Ati med surg iii exam mdc 2
Ati med surg iii exam mdc 2
Total Questions : 49
Showing 10 questions Sign up for moreA nurse is providing discharge education to a client diagnosed with fluid volume excess (FVE) due to liver failure. Which of the following meal options should the nurse recommend for the client?
Explanation
A. Baked chicken breast: Baked chicken breast is a low-sodium, high-protein option that helps prevent fluid retention. Protein is necessary for liver function and healing, and low sodium is essential to managing FVE. It is the best choice for this client.
B. Bowl of ice cream: Ice cream is high in sodium and sugar, which can worsen fluid retention. Excess sodium intake can further exacerbate FVE, making ice cream an inappropriate choice for a client with liver failure.
C. Canned soup: Canned soups often contain high sodium levels, which can increase fluid retention in clients with FVE. Sodium exacerbates edema and ascites, which are common concerns in liver failure.
D. Spaghetti with commercial red sauce: Commercial red sauces typically have high sodium content, which can contribute to fluid retention. Reducing sodium is essential in FVE to manage symptoms effectively.
A nurse is providing care for an older adult client who has diabetes insipidus (DI). The nurse should monitor the client for which of the following neurologic effects?
Explanation
A. Dilute urine: In diabetes insipidus the kidneys are unable to concentrate urine, leading to the excretion of dilute urine. While this is a characteristic of DI, it is not specifically a neurologic effect.
B. Poor skin turgor: Poor skin turgor is a sign of dehydration, which can occur in DI due to excessive urine output. It is a physical finding related to fluid balance rather than a neurologic effect, though it should still be monitored as part of overall care.
C. Hypotension: Hypotension can occur as a result of dehydration due to fluid loss in DI. While this can be a concern, it is a cardiovascular issue rather than a neurologic effect. Monitoring blood pressure is important but it does not address neurologic complications.
D. Ataxia: Ataxia is a neurologic symptom that can result from dehydration and electrolyte imbalances in DI. Severe dehydration can lead to changes in electrolyte levels, which can affect brain function, causing neurologic symptoms like ataxia. This is the most relevant neurologic effect to monitor.
A nurse is reviewing the medical record of a client who has been on levothyroxine for several months. Which of the following findings indicates a therapeutic response to the medication?
Explanation
A. Increase in hours of sleep per night: While improved sleep might occur with levothyroxine, it is not an indicator of therapeutic response. The key response is normalization of thyroid function.
B. Decrease in level of thyroxine (T4): A decrease in T4 levels suggests inadequate thyroid hormone replacement. Levothyroxine should normalize T4 levels, so a decrease would indicate suboptimal treatment.
C. Increase in weight: Weight gain is a symptom of hypothyroidism and is not a sign of a therapeutic response. Proper treatment with levothyroxine should help stabilize weight or prevent further gain.
D. Decrease in level of thyroid stimulating hormone (TSH): A decrease in TSH indicates that the thyroid hormone levels are normalizing. Levothyroxine therapy should reduce TSH levels as the thyroid function improves.
A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?
Explanation
A. Serum T4: In primary hypothyroidism, serum T4 levels are typically low because the thyroid is underactive. Therefore, an elevation of serum T4 would indicate hyperthyroidism not primary hypothyroidism.
B. Serum T3: Serum T3 levels are usually low in primary hypothyroidism as well. T3 is the active thyroid hormone, and its production is reduced when the thyroid gland is not functioning properly.
C. Thyroid stimulating hormone (TSH): In primary hypothyroidism, TSH levels are elevated. The pituitary gland produces more TSH to stimulate the thyroid gland to produce more thyroid hormones, but the thyroid is not responding effectively.
D. Free T4: Free T4 refers to the unbound, active form of thyroxine. In primary hypothyroidism, the free T4 levels would be decreased because the thyroid gland is not producing sufficient amounts of this active hormone.
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?
Explanation
A. Hypolipidemia: Hypolipidemia is not typically associated with acute pancreatitis. In fact hyperlipidemia can be a contributing factor in some cases of pancreatitis, making hypolipidemia an unlikely finding.
B. COPD: Chronic obstructive pulmonary disease is a chronic inflammatory lung disease that obstructs airflow from the lungs. While it is a significant health condition, there is no direct association between COPD and the development of acute pancreatitis.
C. Diabetes mellitus: Diabetes mellitus can occur as a complication of pancreatitis due to pancreatic damage affecting insulin production. However, it is not a primary risk factor for acute pancreatitis itself.
D. Gallstones: Gallstones are a leading cause of acute pancreatitis. They can block the pancreatic duct, leading to inflammation and damage to the pancreas. The nurse should anticipate a history of gallstones in clients with acute pancreatitis.
A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which the following laboratory findings indicate a therapeutic effect of the medication?
Explanation
A. Blood urea nitrogen (BUN) 15 mg/dL: BUN levels are not a direct indicator of the therapeutic effect of desmopressin in diabetes insipidus. While BUN can indicate hydration status, it does not specifically reflect the effectiveness of desmopressin.
B. Urine specific gravity 1.015: A urine specific gravity of 1.015 indicates that the kidneys are concentrating urine appropriately, which is the desired effect of desmopressin in diabetes insipidus. This shows that the medication is improving the kidney's ability to retain water.
C. Serum sodium 146 mEq/L: A serum sodium of 146 mEq/L is elevated, indicating dehydration or hypernatremia, which is a common concern in diabetes insipidus. Desmopressin should help lower sodium levels by promoting water retention, so this value suggests inadequate therapeutic effect.
D. Blood glucose 80 mg/dL: Blood glucose levels are not directly affected by desmopressin, which is used to treat the symptoms of diabetes insipidus. While normal blood glucose levels are important, they do not indicate the success of desmopressin therapy for this condition.
A nurse is providing education to a client who needs a cholecystectomy due to a build-up of calculi or gallstones. Which of the following is the best response from the nurse to explain what caused this problem?
Explanation
A. The gallbladder has become inflamed due to a build-up of gallstones that are blocking the common bile duct: Gallstones can form when bile becomes too concentrated, leading to inflammation and blockage of the common bile duct. This blockage causes pain and potential infection.
B. The gallbladder became infected by a virus and needs to be removed: While infections can occur in the gallbladder (e.g., cholecystitis), they are typically due to bacterial infections, not viral ones. The primary issue in this case is the presence of gallstones causing inflammation.
C. The gallbladder is no longer working: The gallbladder may still function to some extent, but the presence of gallstones can disrupt its ability to properly release bile, leading to symptoms that require surgical intervention.
D. The gallbladder has become inflamed due to the cholesterol in the gallstones: While cholesterol can be a component of gallstones, gallstones can also contain other substances like bile pigments. The focus should be on the stones blocking bile flow and causing inflammation.
A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following responses from the nurse best explains how a person can become infected with the virus?
Explanation
A. "Coming into contact with infected blood, such as from that of a dirty needle, can cause you to become infected with hepatitis C": Hepatitis C is primarily transmitted through contact with infected blood. This can occur via sharing needles, transfusions, or any procedure that involves exposure to contaminated blood.
B. "Eating contaminated food or water from an infected source can cause you to become infected with hepatitis C": Hepatitis C is not transmitted through contaminated food or water. Unlike hepatitis A and E, it is not transmitted via the gastrointestinal route.
C. "Coming into contact with an infected person's bodily fluids, such as saliva, can cause you to become infected with hepatitis C": Hepatitis C is not spread through casual contact or bodily fluids like saliva, sweat, or urine. It is primarily bloodborne.
D. "Consuming a large amount of alcohol at one time can cause you to become infected with hepatitis C": While alcohol can worsen liver damage in people already infected with hepatitis C, it does not cause the infection.
A nurse is caring for a client who is newly diagnosed with hyperthyroidism and reports dry eyes and sensitivity to light. The nurse notes that the client's eyes have a bulging appearance. Which of the following should the nurse include in the client's plan of care?
Explanation
A. "These are unusual symptoms. I will ask the provider for an ophthalmology referral.": Bulging eyes are a common symptom of hyperthyroidism, they do not immediately require a referral. Symptomatic management is a more immediate priority.
B. "Exposure to sunlight will help to strengthen your eyes.": Sunlight exposure can worsen sensitivity to light and does not address the dry eyes or discomfort caused by hyperthyroidism. Dim lighting is more appropriate.
C. "Surgery will be necessary to correct the damage to your eyes.": Surgery is not typically required to treat the eye symptoms of hyperthyroidism. Conservative treatments like eye drops and managing light sensitivity are more appropriate first steps.
D. "Eye drops and dim lighting can improve your symptoms.": Using eye drops helps relieve dryness, and dim lighting can reduce light sensitivity, which are effective measures for managing eye symptoms in hyperthyroidism.
A nurse is planning care for a client who has hyperthyroidism and is receiving radioactive iodine (radioiodine). Which of the following statements by the nurse regarding special precautions is appropriate?
Explanation
A. "You will need to remain at the hospital for the entire time the radioiodine is radioactive.": The client typically only needs to stay in the hospital for a short period after receiving radioactive iodine, not for the entire duration. Most of the radioactivity is eliminated through urine and bodily fluids over time.
B. "A low fiber diet will be necessary.": A low fiber diet is not specifically required for clients receiving radioactive iodine. Some clients may experience gastrointestinal symptoms such as diarrhea, and a low fiber diet could worsen this.
C. "Additional immunizations will be needed for full protection.": Radioactive iodine therapy targets the thyroid gland and does not inherently impact the immune system in a way that would necessitate additional immunizations for protection against common infections.
D. "You will need to use a bathroom separate from other household members.": This is an appropriate precaution. Radioactive iodine can be excreted in urine, and using a separate bathroom helps reduce exposure to others, especially in the first few days after treatment.
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