Adult Health
Developed by
Dare Domico, RN, DSN
Revised by Jill Ray
Integumentary Disorders
Practice Question 1
A client returns the clinic for follow-up treatment
following a skin biopsy of a suspicious lesion
performed 1 week ago. The biopsy report indicates
that the lesion is a melanoma. The nurse
understands that which of the following describes
a characteristic of this type of a lesion?
1. Melanoma is the most common type of skin cancer.
2. Melanoma is often precipitated by pruritus.
3. Melanoma is highly metastatic
4. Melanoma is characterized by local invasion
Practice Question 1
A client returns to the clinic for follow-up treatment following a
skin biopsy of a suspicious lesion performed 1 week ago.
The biopsy report indicates that the lesion is a melanoma.
The nurse understands that which of the following
describes a characteristic of this type of a lesion?
1. Melanoma is the most common type of skin cancer. Basal
cell is the most common type.
2. Melanoma is often precipitated by pruritus. Can be part of
the assessment findings for skin cancer.
3. Melanoma is highly metastatic highly metastatic – survival
dependent upon early dx and tx.
4. Melanoma is characterized by local invasion can
metastasize to the brain, lungs, bone, liver, skin….
Practice Question 2
Which lesion best represents Basal Cell
Cancer?
2.
1.
3.
4.
Practice Question 2
Which lesion best represents Basal Cell
Cancer? 1. Basal Cell
2. Mole
4. Melanoma
3. Squamous Cell
Basal Cell:
 Waxy border
 Papule
 Red, central crater
 Metastasis rare
Squamous Cell:
 oozing, bleeding, crusting lesion
 Potentially metastatic
 Larger tumors higher risk metastasis.
Melanoma:
Irregular, circular, bordered lesion
Hues of tan, black, blue
Rapid infiltration into tissue, rapid metastasis.
Practice Question 3
A client has a superficial skin tear to the
arm. The nurse applies which best
type of dressing?
1.Dry sterile dressing
2.Wet-to-dry dressing
3.Gelfoam sponge dressing
4.Semipermeable film dressing
A client has a superficial skin tear to the arm. The
nurse applies which best type of dressing?
1. Dry sterile dressing stick to the wound
2. Wet-to-dry dressing not necessary
3. Gelfoam sponge dressing type of enzyme
dressing used to tx necrotic tissue
4.Semipermeable film dressing Opsite, duoderm. Allow tissues to heal
underneath.
Practice Question 4
A client who is being evaluated for thermal
burn injuries to the arms and legs complains
of thirst. Which action by the nurse is most
appropriate?
1. Give the client small glasses of clear liquids.
2. Keep the client NPO.
3. Allow the client to have full liquids.
4 Order the client a full meal with extra liquids.
Practice Question 4
A client who is being evaluated for thermal burn
injuries to the arms and legs complains of thirst.
Which action by the nurse is most appropriate?
1. Give the client small glasses of clear liquids.
2. Keep the client NPO. Maintain NPO because burn
injuries freq. cause paralytic ileus. Fluids could
cause vomiting because of the effect of the burn
injury on GI fx. Oral care to alleviate thirst is OK
3. Allow the client to have full liquids.
4 Order the client a full meal with extra liquids.
Note that 1,3, and 4 are similar choices.
Practice Question 5
In the burn unit, a client has partial thickness and full
thickness burns over 50% of his body. The nurse
has an order for silver sulfadiazine (Silvadene
cream). The safest and most therapeutic way of
applying this mediation is with a sterile:
1. Tongue blade
2. 4 by 4 gauze pad
3. gloved hand
4. 4 by 4 soaked in sterile saline
In the burn unit, a client has partial thickness and full
thickness burns over 50% of his body. The nurse has an
order for silver sulfadiazine (Silvadene cream). The
safest and most therapeutic way of applying this
mediation is with a sterile:
1. Tongue blade rough surface would be abrasive to the
injured skin, and it is too small to be practical for use…
2. 4 by 4 gauze pad the dry gauze pad would stick to the
injured skin
3. gloved hand allows for better contact and
control of the amt of pressure being applied to
the burn area. Allows the nurse to feel the
surface blisters without breaking them.
4.
4 by 4 soaked in sterile saline OK – but the gloved hand
allows for more precise application and minimal injury
to the tissue.
Practice Question 6
A client is NPO and has a NG tube in place
after suffering bilateral burns to the legs.
The nurse determines that the client’s GI
status is least satisfactory if which of the
following is noted on assessment?
1. Gastric pH of 3
2. Presence of hypoactive bowel sounds
3. GI drainage that is guaiac negative
4. Absence of abdominal discomfort
Practice Question 6
A client is NPO and has a NG tube in place after suffering bilateral burns to the
legs. The nurse determines that the client’s GI status is least satisfactory if
which of the following is noted on assessment?
1. Gastric pH of 3 gastric pH should be maintained at 7
or greater using prescribed antacids and histamine
h2 receptor-blocking agents. Lowered pH in the
absence of fd or tube feedings can lead to erosion of
the gastric lining and ulcer development. (Note that
normal gastric pH is 1.5-3.5)
2. Presence of hypoactive bowel sounds expected as
client is NPO and has suffered burn injury
3. GI drainage that is guaiac negative normal finding –
means that it is negative for blood
4. Absence of abdominal discomfort WNL
Practice Question 7
A client is admitted to the emergency
department following a burn injury in a
house fire. The skin on the client’s trunk
is tan, dry, and hard. The skin is
edematous but is not very painful. The
nurse interprets that this client's burn
should be classified as
1. Superficial thickness burn
2. Superficial partial thickness
3. Deep partial thickness
4. Full thickness
Practice Question 7
A client is admitted to the emergency department
following a burn injury in a house fire. The skin
on the client’s trunk is tan, dry, and hard. The
skin is edematous but is not very painful. The
nurse interprets that this client's burn should be
classified as
1. Superficial thickness burn these burns are
painful
2. Superficial partial thickness these burns are
painful
3. Deep partial thickness wound surface red, dry,
with white areas in deeper areas.
4. Full thickness involve epidermis, dermis, and
some subcutaneous fat. Some nerve endings
damaged – may be insensitive to touch with
little or no pain.
Superficial
Thickness burn
Injury to the upper third of the
dermis – bld supply to dermis is
intact.
Mild to severe erythema (pin
to red)
Skin blanches with pressure
Burn painful, tingling, eased by
cooling
Discomfort lasts about 48 hrs –
heals in 3-5 days
No scarring and skin grafts not
required.
Superficial Partial-thickness Burn
•Injury deeper into
dermis, bld supply
reduced
•Large blisters may cover
an extensive area
•Edema present
•Mottled pin to red base, broken epidermis, with wet, shiny,
weeping surface
•Burn painful, sensitive to cold air
•Heals 0-21 days with no scarring, minor pigment changes
possible
•Grafts may be needed
Deep Partial-thickness Burn
Deep Partial-thickness Burn
•Extends into dermis
•Blister formation usu not seen because dead
tissue is thick and sticks to underlying viable
dermis
•Wound surface is red and dry with white areas
in deeper parts
•May/may not blanch, edema is moderate
•Con convert to full thickness if complications
•Heals in 3-6 weeks, scar results, skin graft may
be necessary
Full-thickness Burn
• Involves injury and destruction
of the epidermis ad the dermis;
wound will not heal by reepithelializaion, grafting may be
required
• Appears as a dry, hard, leathery
eshcar (burn crust or dead tissue
that must slough off or be
removed form the wound before
healing can occur
•Appears as a waxy white, deep
red, yellow, brown, black
•Injured are appears dry
•Edema present under eschar
•Sensation reduced or absent because of nerve ending damage
•Healing takes weeks to months and dependent on adequ bld supply
•Must remove eschar and split-or full-thickness skin grafting
•Scarring and wound contractures likely
Deep full-thickness
• Extends beyond the
skin into underlying
fascia and tissues,
damage to the
muscle, bone,
tendons
• Injured area appears
black and sensation is
completely absent
•Eschar is hard and
inelastic
•Healing takes months
and grafts are required
•Mortality rates are higher for children younger than 4
•Debilitating disorders (cardiac, respiratory, endocrine, renal disorders occur
and hinder healing)
•Mortality rate is higher with preexisting disorder.
Practice Question 8
A nurse is monitoring the fluid balance of the
client with a burn injury. The nurse
determines that the client is less than
adequately hydrated if which of the following
is noted during assessment.?
1. Urine output of 40 ml/hour.
2. Urine that is pale yellow.
3. Urine specific gravity of 1.032
4. Urine pH of 6.
A nurse is monitoring the fluid balance of the
client with a burn injury. The nurse determines
that the client is less than adequately hydrated
if which of the following is noted during
assessment.?
1. Urine output of 40 ml/hour. 30ml/hr is WNL, 40 is OK
2. Urine that is pale yellow. Pale urine is normal –
would be dark and concentrated if not well hydrated
3. Urine specific gravity of 1.032 (1.016-1.022)
4. Urine pH of 6. OK – urine pH of 6 is adequate (4.5-8
WNL). Do not monitor urine pH to assess hydration.
Practice Question 9
A home care nurse visits an older client who was
discharged from the hospital following diagnostic
testing. The client complains of chronic dry skin
and episodes of pruritus. Which of the following
measures would the nurse provide to the client to
alleviate this discomfort?
1. Take baths twice daily using a dilute solution of
vinegar and water.
2. Avoid the use of astringents on the skin
3. Avoid the use of emollients on the skin
4. Purchase a dehumidifier for the home.
A home care nurse visits an older client who was discharged from the
hospital following diagnostic testing. The client complains of
chronic dry skin and episodes of pruritus. Which of the following
measures would the nurse provide to the client to alleviate this
discomfort?
1.
Take baths twice daily using a dilute solution of vinegar
and water. Warm bath or shower per day for 15-20
min with warm water and a mild soap followed
immediately by the application of an emollient to
prevent evaporation of water form the hydrated
epidermis.
2. Avoid the use of astringents on the skin avoid
alcohol, astringents, or other drying agents to the
skin. tend to have a drying affect on the skin
3. Avoid the use of emollients on the skin need to incr
use of emollients
4. Purchase a dehumidifier for the home. A dehumidifier
would further dry room air.
Practice Question 10
The evening nurse reviews the nursing documentation
in the client’s chart and notes that the day nurse
has documented that he client has a stage 2
pressure ulcer (decubitus) in the sacral area.
Which of the following would the nurse expect to
note on assessment of the client’s sacral area?
1. Intact skin
2. Partial-thickness skin loss of the epidermis
3. Deep, crater-like appearance
4. Presence of sinus tracts
Practice Question 10
The evening nurse reviews the nursing documentation
in the client’s chart and notes that the day nurse
has documented that he client has a stage 2
pressure ulcer (decubitus) in the sacral area.
Which of the following would the nurse expect to
note on assessment of the client’s sacral area?
1. Intact skin
2. Partial-thickness skin loss of the epidermis
3. Deep, crater-like appearance
4. Presence of sinus tracts
Classification of Pressure Ulcers
I
Nonblanchable erythema of the intact skin.
II
Partial-thickness skin loss involving
epidermis and /or dermis.
III
Full-thickness skin loss involving damage
or necrosis of subcutaneous tissue that
may extend down to but not through
underlying fascia.
Full-thickness skin loss with extensive
destruction; tissue necrosis; or damage to
muscle, bone, or supporting structures.
IV
Stage I
(no skin loss)
Stage II
(Shallow crater – involves epidermis
and/or dermis)
Stage III
(Full thickness involving
damage/necrosis of subc. Tissue. Does
not extend down through underlying
fascia)
Stage III or IV
Stage IV
Full thickness skin loss with extensive
destruction; tissue necrosis; or damage to
muscle, bone, or supporting structures.
Oncology
Practice Question 11
The nurse recognizes which of the following
conditions as an oncological emergency? Select
all that apply.
1. Cardiac tamponade
2. Leukopenia
3. Syndrome of inappropriate ADH
4. Hypercalcemia
5. Hypophosphatemia
6. Tumor lysis syndrome
The nurse recognizes which of the following conditions as an
oncological emergency? Select all that apply.
1. Cardiac tamponade could result from direct pressure
from a tumor, complication from chemo (decrease
platelets increase chances of hemorrhage)
2. Leukopenia
3. Syndrome of inappropriate ADH tumors can produce,
secrete, or stimulate substances that mimic ADH
hormone – low serum Na levels result and can lead to
seizures, coma, death
4. Hypercalcemia late manifestation of extensive
malignancy
5. Hypophosphatemia
6. Tumor lysis syndrome large quantities of tumor cells
are destroyed rapidly. Can lead to renal failure.
Practice Question 12
The nurse is giving discharge instructions to
a client with cancer who is taking
doxorubicin (Adriamycin). What is
important to tell the client.
1. Avoid folic acid intake.
2. Increase intake of oral fluids.
3. Report symptoms of dyspnea.
4. Report symptoms of hematuria.
Practice Question 12
The nurse is giving discharge instructions to a client
with cancer who is taking doxorubicin (Adriamycin).
What is important to tell the client?
1. Avoid folic acid intake.
2. Increase intake of oral fluids.
3. Report symptoms of dyspnea. This
medication can cause cardio toxicity,
cardiomyopathy, EKG changes. CHF (dyspnea,
tachycardia, peripheral edema) and myocardial
toxicity are potential adverse reactions.
4. Report symptoms of hematuria.
Practice Question 13
A client had a modified radical mastectomy of the left breast.
What would be important for the nurse to include in a
discharge teaching plan? (Select all that apply)
1. Avoid any needle sticks in the left arm.
2. Avoid abduction & external rotation of left arm.
3. Begin pendulum arm swings & full ROM immediately.
4. Elevate left arm on pillows to prevent edema.
5. Have all blood pressure readings taken on the right arm.
6. Massage wound site with essential oils once incision has
healed.
A client had a modified radical mastectomy of the left breast. What would be
important for the nurse to include in a discharge teaching plan? (Select all that
apply)
1. Avoid any needle sticks in the left arm.
2. Avoid abduction & external rotation of left arm. Gradual
abduction and external rotation of the affected arm is
encouraged. May be more comfortable elevating the arm.
3. Begin pendulum arm swings & full ROM immediately. These
activities are started after the incision has healed.
4. Elevate left arm on pillows to prevent edema.
5. Have all blood pressure readings taken on the right arm.
6. Massage wound site with essential oils once incision has
healed. No indication for this
Postoperative Mastectomy
• Gradual abduction and external rotation of the
affected arm is encouraged.
• Avoid activities that might lead to the development
of lymphedema
• Begin finger, wrist, and hand exercises to facilitate
muscle contraction and to help prevent edema.
• Active exercises, such as pendulum swings and wall
climbing are started after the incision has healed
Practice Question 14
A client has developed stomatitis while receiving
chemotherapy. What would be an appropriate
intervention to suggest for the pain associated with
the stomatitis?
1. Use lemon-flavored glycerin swabs
2. Apply antacid coating solutions and viscous
lidocaine
3. Brush oral plaques off with a soft toothbrush.
4. Have client swish mouth with weak hydrogen
peroxide solution
Practice Question 14
A client has developed stomatitis while receiving chemotherapy.
What would be an appropriate intervention to suggest for the
pain associated with the stomatitis?
1. Use lemon-flavored glycerin swabs could cause pain
2. Apply antacid coating solutions and viscous lidocaine
Antacids, Benadryl, and viscous lidocaine have been
mixed in equal proportions to use as a component of
oral care.
3. Brush oral plaques off with a soft toothbrush. could
cause pain
4. Have client swish mouth with weak hydrogen peroxide
solution
Practice Question 15
A client with breast cancer is being treated with
external radiation therapy. What will be important for
the nurse to teach the client regarding skin care of the
area?
1. Use mild soap and do not rub with abrasive
materials.
2. Do not use any lotions on the area being
treated.
3. Expose the area to sunshine to maximize
healing.
4. Wear clothing and bras that support the area.
A client with breast cancer is being treated with
external radiation therapy. What will be important for
the nurse to teach the client regarding skin care of the
area?
1. Use mild soap and do not rub with abrasive materials.
Skin being tx is fragile and easily damaged. Mild soap
and thorough rinsing with warm water.
2. Do not use any lotions on the area being treated. A
hydrophilic moisture lotion can be used if the skin
becomes dry.
3. Expose the area to sunshine to maximize healing. The
area cannot be exposed to sun
4. Wear clothing and bras that support the area. Clothing
should be loose and nonbinding.
Practice Question 16
Which of the following is a priority nursing
intervention for a client with a vaginal radium
implant?
1. Clamp and drain the Foley catheter at intervals.
2. Provide a high residue diet.
3. Place the client in a semiprivate room.
4. Raise the head of the bed no more than 20
degrees.
Which of the following is a priority nursing
intervention for a client with a vaginal radium
implant?
1. Clamp and drain the Foley catheter at intervals.
2. Provide a high residue diet. Good idea – maintain
optimal GI fx. Note that “4” is the BEST choice but
that this is appro.
3. Place the client in a semiprivate room. No - Private
room, private bath
4. Raise the head of the bed no more than 20
degrees. Once the implant is in place, important
to keep in the exact location. HOB only raised
slightly if at all after placement.
Practice Question 17
The client is hospitalized for insertion of an internal
cervical radiation implant. While giving care, the
nurse finds the radiation implant in the bed. The
initial action by the nurse is to
1. Call the MD
2. Pick up the implant with gloved hands and
flush it down the toilet
3. Reinsert the implant into the vagina
immediately
4. Pick up the implant with long handled
forceps and place it in a lead container
Practice Question 17
The client is hospitalized for insertion of an internal
cervical radiation implant. While giving care, the
nurse finds the radiation implant in the bed. The
initial action by the nurse is to
1. Call the MD yes, but initial action is “4”
2. Pick up the implant with gloved hands and flush it
down the toilet do not touch the implant
3. Reinsert the implant into the vagina immediately
inappro action.
4. Pick up the implant with long handled forceps and
place it in a lead container Key word is “initial”
action.
Practice Question 18
The nurse is caring for a client experiencing
Hematologic toxicity as a result of
chemotherapy. The nurse develops a plan of
care for the client. The nurse plans to
1. Restrict all visitors
2. Restrict fluid intake
3. Insert an indwelling urinary catheter to
prevent skin breakdown
4. Restrict fresh fruits and vegetables in the
diet
Practice Question 18
The nurse is caring for a client experiencing Hematologic toxicity
as a result of chemotherapy. The nurse develops a plan of
care for the client. The nurse plans to
1. Restrict all visitors eliminate this choice because of the
term “all”. The client is protected from persons with
known infections.
2. restrict fluid intake unrealistic to restrict fluids in
chemotherapy client who is at risk for fluid and electrolyte
imbalance. Need to encourage fluids.
3. Insert an indwelling urinary catheter to prevent skin
breakdown risk of infection, other noninvasive measures
can be used if indicated
4. Restrict fresh fruits and vegetables in the diet
immunocompromised client needs a low-bacteria diet.
Includes avoiding fresh fruits and vegetables and thorough
cooking of all foods.
Practice Question 19
The client is diagnosed with benign prostatic hyperplasia and is
scheduled for transrectal ultrasound and drawing of a
prostate-specific antigen level. The client says to the nurse,
“ I can’t remember. Can you tell me again why I need these
tests to be done?” The nurse responds knowing that the
tests
1. Help to rule out the presence of cancer
2. Specifically predict the course of benign prostatic
hyperplasia
3. Pinpoint the likelihood of developing urinary
obstruction
4. Give an indication of whether intermittent selfcatheterization is needed.
The client is diagnosed with benign prostatic hyperplasia and is
scheduled for transrectal ultrasound and drawing of a
prostate-specific antigen level. The client says to the nurse,
“ I can’t remember. Can you tell me again why I need these
tests to be done?” The nurse responds knowing that the
tests
1. Help to rule out the presence of cancer
2. Specifically predict the course of benign prostatic
hyperplasia
3. Pinpoint the likelihood of developing urinary
obstruction
4. Give an indication of whether intermittent selfcatheterization is needed.
diagnostic test do not predict the course of a disease –
likelihood of developing complications (i.e. obstruction)
Practice Question 20
A nurse is reviewing the lab results of a client
with leukemia and notes that the absolute
neutrophil count is decreased. The nurse
interprets that the client is at risk for
1. Infection
2. Bleeding
3. Anemia
4. Dehydration
Practice Question 20
A nurse is reviewing the lab results of a client
with leukemia and notes that the absolute
neutrophil count is decreased. The nurse
interprets that the client is at risk for
1. Infection
2. Bleeding platelets are low
3. Anemia H/H low
4. Dehydration SG of urine can evaluate; skin
turgor; Serum Na can suggest hydration status
Practice Question 21
The client with cancer is receiving chemotherapy
and develops thrombocytopenia. The nurse
identifies which intervention as the highest
priority in the nursing plan of care?
1. Ambulation 3 times daily
2. Monitoring temperature
3. Pad side rails and sharp corners of the bed and
furniture
4. Monitoring for pathological fractures
The client with cancer is receiving chemotherapy and develops
thrombocytopenia. The nurse identifies which intervention as the
highest priority in the nursing plan of care?
1. Ambulation 3 times daily important in the plan of
care but not related directly to thrombocytopenia
2. Monitoring temperature monitoring for infection,
important esp if dealing with a leukemia pt – not
the best choice for a pt with thrombocytopenia.
3. Pad side rails and sharp corners of the bed and
furniture thrombocytopenia indicates a decr in
number of platelets in circulating blood – client is
at risk of bleeding.
4. Monitoring for pathological fractures important in
the plan of care but not related directly to
thrombocytopenia
Practice Question 22
A nurse is caring for the 25-year-old client will undergo bilateral
orchidectomy for testicular cancer. Which of the following
statements by the nurse would be most helpful in exploring
the client's concerns about loss of reproductive ability?
1. “Has the doctor told you that you will not be able to have
children?”
2. “You must be sad that you won't be able to have children
after surgery.”
3. “Do you feel that the doctor has told you all you need to
know about the upcoming surgery?”
4. “Share with me any concerns about how this surgery will
affect you in the future.”
Practice Question 22
A nurse is caring for the 25-year-old client will undergo bilateral
orchidectomy for testicular cancer. Which of the following
statements by the nurse would be most helpful in exploring
the client's concerns about loss of reproductive ability?
1. “Has the doctor told you that you will not be able to have
children?” yes/no
2. “You must be sad that you won't be able to have children
after surgery.” yes/no
3. “Do you feel that the doctor has told you all you need to
know about the upcoming surgery?” yes/no
4. “Share with me any concerns about how this
surgery will affect you in the future.”
Endocrine
Pituitary Gland
Hypopituitarism
• Decr secretion of:
–
–
–
–
•
growth hormone,
gonadotropic hormones,
thyroid-stimulating hormone,
adrenocorticotropic hormone, antidiuretic hormone
Hyperpituitarism
• Incr secretion of
– Growth hormone
– Other pituitary hormones may also
be involved…can see Cushing’s
syndrome
•
–
–
–
–
–
–
–
–
–
–
Assessment:
– Obesity (GH, TSH)
– Decr CO (GH, ADH)
– Infertility, sexual dysfx
(gonadotropins, ACTH)
– Fatigue, low BP (TSH, ADH, ACTH,
GH)
•
Tx
– Emotional support
– Hormone replacement
– education
Assessment
•
Large hands/feet
Thickening /protrusion of the jaw
Arthritic changes
Visual disturbances
Diaphoresis
Oily, rough skin
Organomegaly
Hypertension
Dysphagia
Deepening of the voice
Tx
–
–
–
–
Emotional support
Frequ skin care
Pain management for joint pain
Prepare for
radiation/hypophysectomy if planned
Syndrome of Inappropriate ADH(SIADH) vs
Diabetes Insipidus
Diabetes Insipidus
• Decr secretion of ADH (opposes Diuresis –
decre secretion would mean that the body
would loose large quantities of fluid via
the u/o)
• Assessment:
– Polyuria (4-24 L/day), Polydipsia,
Dehydration
–
–
–
•
Inability to concentrate urine (sg 1.006 or
lower)
Fatigue, muscle pain, weakness, h/a
Postural hypotension, tachycardia
Tx:
–
–
–
–
–
–
–
–
Monitor v/s and neuro and CV status
Safety: postural hypotension
Monitor electrolytes
Monitor I/O, wt, serum osmolality, urine
s.g.
Restrict foods, liqu that produce diuresis
Diabinese
Pitressin, desmopressin acetate
Medic alert bracelet
SIADH
• Incr secretion of ADH (the body would
retain fluid)
• Assessment:
– s/s fluid volume overload
–
–
–
–
•
LOC changes
Wt gain, anorexia, nausea, vomiting
Hyponatremia (dilutional)
Hypertension, tachycardia
Tx
–
–
–
–
–
–
–
Monitor v/s
Safety: altered LOC
I/O, daily wt
Monitor electrolytes, serum/urine
osmolality,
Restrict fluid intake
Adm diuretics and IV fluids
Demeclocycline
Adrenal Gland
Addison’s disease
• Hyposecretion of adrenal cortex
hormones
• Assessment:
– Lethargy, fatigue, muscle
weakness
– GI disturbances
– Wt loss
– Menstrual changes/impotence
– Hypoglycemia, hyponatremia
– Hyperkalemia
– Hypercalcemia
– Postural hypotension
– Hyperpigmentation of skin
• Cushing’s disease
• Hypersecretion of glucocorticoids
• Assessment:
–
–
–
–
–
–
–
–
–
–
Muscle wasting, weakness
Moon face, buffalo hump
Truncal obesity, thin extremities
Wt gain
Hirsutism (females)
Hyperglycemia, hypernatremia
Hypokalemia, hypocalcemia
Hypertension
Fragile skin that easily bruises
Reddish-purple striae on the abd
and upper thighs
Thyroid Gland
Hypothyroidism
• Decr secretion of T3 and T4
• Decr rate of body metabolism
• Assessment:
– Lethargy
– Weakness, muscle aches,
paresthesias
– Intolerance to cold
– Wt gain
– Dry skin, hair loss
– Bradycardia
– Constipation
– Generalized puffiness/edema around
the eyes and face (myxedema)
– Forgetfulness/loss of memory
– Menstrual distrubances
– Cardiac enlargement, CHF
– Perhaps goiter
Hyperthyroidism
• Incr secre of T3 and T4
• Incr rate of body metabolism
• Graves’ Disease common cause/Toxic
diffuse goiter
• Assessment :
–
–
–
–
–
–
–
–
–
–
–
Enlarged thyroid
Palpitations, cardiac dysrhthmias
Exophthalmos
Hypertension
Heat intolerance
Diaphoresis
Wt loss
Diarrhea
Smooth, soft skin, hair
Nervousness/fine tremors if hands
Personality changes such as
irritability/agitation/mood swings
Parathyroid Gland
Hypoparathyroidism
• Decr secr of parathyroid hormone
(causes decrease in Ca and incr in
phosphorus)
• Assessment
– s/s of tetany
– Hypocalcemia/
hyperphosphatemia
– Numbness/tingling in the face
– Muscle cramps/abd cramps
– Positive Trousseau’s sign (carpal
spasm) or Chvostek’s sign (facial
spasm)
– Hypotension
– Anxiety, irritability, depression
Hyperparathyroidism
• Hypersecr of Parathyroid
hormone (incr in Ca levels, decr in
phos)
• Assessment:
– Hypercalcemia,
hypophosphatemia
– Fatigue, muscle weakness
– Skeletal pain/tenderness
– Bone deformities/pathological
fractures
– Anorexia, nausea, vomiting,
epigastric pain
– Wt loss
– Constipation
– Hypertension
– Cardiac dysrhthmias
– Renal stones
Practice Question 23
The ER nurse planning care for a client with a
diagnosis of hyperglycemic hyperosmolar
nonketotic syndrome knowing that the
hyperglycemia results from
1. increased use of glucose
2. increased production of glucose.
3. overproduction of insulin
4. Over hydration
Practice Question 23
The ER nurse planning care for a client with a
diagnosis of hyperglycemic hyperosmolar
nonketotic syndrome knowing that the
hyperglycemia results from
1. increased use of glucose this would cause
hypoglycemia
2. increased production of glucose. Note that the
stem asks for the cause of the hyperglycemia
3. overproduction of insulin this would cause
hypoglycemia
4. Over hydration these pts suffer from dehydration
Diabetic Ketoacidosis vs Hyperglycemic Hyperosmolar
Nonketotic Syndrome
DKA
• Complication of Type I DM
• Occurs with severe insulin
deficiency
• Clinical manifestations:
hyperglycemia, dehydration,
ketosis, acidosis
• Tx:
– restore bld volume,
– tx dehydration,
– tx hyperglycemia,
– correct electrolyte imbalance
• Monitor potassium levels
HHNS
• Extreme hyperglycemia without
ketosis or acidosis
• Occurs most often in individuals
with Type II DM
• Ketosis and acidosis do not occur
• Clinical manifestations: CNS
alterations, dehydration or
electrolyte loss
• Tx:
– Similar to DKA
– Fluid replacement, correct
electrolyte imbalance,
– Administer insulin
– Rehydration alone may
decrease glucose levels
Practice Question 24
The client with diabetes has been instructed in the
dietary exchange system. The client ask if bacon is
allowed in the diet. Which response is most
appropriate?
1. “Bacon is much too high in fat.”
2. “Bacon is not allowed.”
3. “One strip of bacon may be eaten if one
teaspoon of butter is omitted.”
4. “Bacon may be eaten if you eliminate one meat
item from your diet.”
Practice Question 24
The client with diabetes has been instructed in the
dietary exchange system. The client ask if bacon is
allowed in the diet. Which response is most
appropriate?
1. “Bacon is much too high in fat.”
2. “Bacon is not allowed.”
3. “One strip of bacon may be eaten if one
teaspoon of butter is omitted.”
4. “Bacon may be eaten if you eliminate one meat
item from your diet.”
Practice Question 25
A client with type 1 diabetes reports recurrent
episodes of hypoglycemia with exercising. Which
statement by the client indicates an inadequate
understanding of the peak action of NPH insulin &
exercise? “The best time for me to exercise is
1. in the afternoon.”
2. after I eat.”
3. after breakfast.”
4. after my morning snack.”
Practice Question 25
A client with type 1 diabetes reports recurrent
episodes of hypoglycemia with exercising. Which
statement by the client indicates an inadequate
understanding of the peak action of NPH insulin &
exercise? “The best time for me to exercise is
1. in the afternoon.” NPH insulin peaks in 6-14
hours.
2. after I eat.”
3. after breakfast.”
4. after my morning snack.”
Practice Question 26
A client with type 1 diabetes reports vomiting &
diarrhea with no food intake or medications for
36 hours. Which additional statement indicates a
need for further teaching? “I need to
1. stop my insulin.”
2. increase my fluid intake.”
3. call the physician because of these symptoms.”
4. monitor my blood glucose every 3 to 4 hours.”
Practice Question 26
A client with type 1 diabetes reports vomiting &
diarrhea with no food intake or medications for
36 hours. Which additional statement indicates a
need for further teaching? “I need to
1. stop my insulin.” Type I DM need to
maintain routine schedule of insulin
administration unless prescribed
otherwise by MD. Note that BG often
increases with stress/illness.
2. increase my fluid intake.” should do this
3. call the physician because of these symptoms.”
should do this
4. monitor my blood glucose every 3 to 4 hours.”
should do this
Practice Question 27
A client with diabetes has a glycosylated
hemoglobin A1C level of 9%. Based on this test
result, the nurse plans to teach the client about
the need to
1. avoid infection.
2. take in adequate fluids.
3. prevent hyperglycemia.
4. prevent hypoglycemia.
Practice Question 27
A client with diabetes has a glycosylated
hemoglobin A1C level of 9%. Based on this test
result, the nurse plans to teach the client about
the need to
1. avoid infection.
2. take in adequate fluids.
3. prevent hyperglycemia. Goal for pt with DM is
less than 7.5 %. This value provides an estimate
of BGL for the prior 3-4 months.
4. prevent hypoglycemia.
Pt without DM value should be 4-6%.
Practice Question 28
A nurse is providing instructions to a client newly
diagnosed with diabetes regarding insulin
administration. A mixture of NPH and regular insulin is
ordered. Sequence the following steps of this
procedure:
1. inject air equal to the amount of NPH insulin into the
vial of NPH insulin.
2. inject air equal to the amount of regular insulin into
the vial of regular insulin
3. draw up the correct dosage of regular insulin
4. draw up the correct dosage of NPH insulin
1, 2, 3, 4
Practice Question 29
A nurse is providing home care instructions to a
client with a diagnosis of Addison’s disease. Which
statement by the client indicates a need for
further instructions? “I need
1. to wear a Medic Alert bracelet.”
2. to take daily medications for a limited period of
time.”
3. an increased dose of glucocorticoid medication
during stressful minor illnesses.”
4. to purchase a travel kit that contains cortisone.”
Practice Question 29
A nurse is providing home care instructions to a
client with a diagnosis of Addison’s disease. Which
statement by the client indicates a need for
further instructions? “I need
1. to wear a Medic Alert bracelet.” true
2. to take daily medications for a limited period of
time.” chronic disease will take meds from now
on…
3. an increased dose of glucocorticoid true
medication during stressful minor illnesses.”
4. to purchase a travel kit that contains cortisone.”
true
Practice Question 30
A client has returned to the unit following a
thyroidectomy complaining of tingling
sensations around the mouth and in the
fingers. The nurse would next assess the
results of which serum lab study?
1. Sodium
2. Potassium
3. Calcium
4. Magnesium
Practice Question 30
A client has returned to the unit following a
thyroidectomy complaining of tingling
sensations around the mouth and in the
fingers. The nurse would next assess the results
of which serum lab study?
1. Sodium
2. Potassium
3. Calcium because of accidental damage to the
parathyroid which regulates CA levels.
4. Magnesium
Practice Question 31
Which medication will the nurse have available
for emergency treatment of tetany in the
client who has had a thyroidectomy?
1. Calcium chloride
2. Potassium chloride
3. Magnesium sulfate
4. Sodium bicarbonate
Practice Question 31
Which medication will the nurse have available
for emergency treatment of tetany in the
client who has had a thyroidectomy?
1. Calcium chloride supplemental Ca is
indicated if s/s of tetany develop.
2. Potassium chloride
3. Magnesium sulfate
4. Sodium bicarbonate
Practice Question 32
A nurse is preparing to care for a client
following parathyroidectomy. The nurse
plans care anticipating which postoperative
order?
1.
2.
3.
4.
Place flat with head and neck immobilized.
Rectal temps only until discharge.
Maintain endotracheal tube for 24 hours.
Continuous mist of room air or oxygen.
Practice Question 32
A nurse is preparing to care for a client following
parathyroidectomy. The nurse plans care
anticipating which postoperative order?
1. Place flat with head and neck immobilized. Do not
need to immobilize the neck.
2. Rectal temps only until discharge. Oral, axillary
temps are OK
3. Maintain endotracheal tube for 24 hours. Not
necessarily intubated.
4. Continuous mist of room air or oxygen. Humidity
will asst to decr postop inflammation.
Practice Question 33
A nurse is caring for a client admitted to the
emergency room with diabetic ketoacidosis
(DKA). In the acute phase the priority
nursing action is to prepare to
1. administer regular insulin IV.
2. administer 5% dextrose IV.
3. correct the acidosis.
4. apply an electrocardiogram monitor.
Practice Question 33
A nurse is caring for a client admitted to the
emergency room with diabetic ketoacidosis
(DKA). In the acute phase the priority
nursing action is to prepare to
1. administer regular insulin IV.
2. administer 5% dextrose IV.
3. correct the acidosis. True
4. apply an electrocardiogram monitor.
Probably true
Practice Question 34
A nurse is preparing the bedside for a
postoperative parathyroidectomy client.
The nurse ensures that which medical
equipment is at the bedside?
1. Underwater seal chest drainage.
2. Tracheotomy set.
3. Intermittent gastric suction.
4. Cardiac monitor.
Practice Question 34
A nurse is preparing the bedside for a
postoperative parathyroidectomy client.
The nurse ensures that which medical
equipment is at the bedside?
1. Underwater seal chest drainage.
2. Tracheotomy set. Surgery very close to
trachea. Postop swelling could close the
airway and create the need for
Tracheostomy.
3. Intermittent gastric suction.
4. Cardiac monitor.
Practice Question 35
The nurse is assessing a client with syndrome of
inappropriate antidiuretic hormone (SIADH). What
would the nurse expect to find on the laboratory
values?
1. Serum sodium=150 mEq/L and low urine
osmolality.
2. Serum potassium=5 mEq/L and low serum
osmolality.
3. Serum sodium=120 mEq/L and low serum
osmolality.
4. Serum potassium=3mEq/L and high serum
osmolality.
Practice Question 35
The nurse is assessing a client with syndrome of inappropriate
antidiuretic hormone (SIADH). What would the nurse
expect to find on the laboratory values?
1. Serum sodium=150 mEq/L and low urine osmolality.
2. Serum potassium=5 mEq/L and low serum osmolality.
3. Serum sodium=120 mEq/L and low serum osmolality. SIADH
causes the body to retain water. The serum sodium will be
low (dilutional hyponatremia) and the serum osmolality will
be low. Note Na levels are 135-145.
4. Serum potassium=3mEq/L and high serum osmolality.
Syndrome of Inappropriate ADH
(SIADH)
• Excessive Antidiuretic Hormone (ADH) is
released.
• ADH hormone opposes diuresis – which
means that water is retained even when the
plasma (serum) osmolality is normal.
• As a result of extracellular fluid expansion,
serum osmolality decreases.
• Na levels decline because of the excess fluid
volume.
Practice Question 36
A client has been receiving vasopressin therapy
for treatment of diabetes insipidus. What
will the nurse evaluate to assist in
determining the therapeutic response to this
medication?
1. Urine specific gravity
2. Blood glucose
3. Vital signs
4. Oxygen saturation levels
Practice Question 36
A client has been receiving vasopressin therapy for
treatment of diabetes insipidus. What will the
nurse evaluate to assist in determining the
therapeutic response to this medication?
1. Urine specific gravity vasopressin alleviates
polyuria by incr ADH secretion. Urine SG
will incr as the urine is less dilute and will
return to WNL
2. Blood glucose
3. Vital signs
4. Oxygen saturation levels
Gastrointestinal
Practice Question 37
A nurse is caring for a client following a cholecystectomy
via an abdominal incision. What is the best position for
this client?
1. Side-lying position, to prevent aspiration.
2. Semi-fowler’s position, to facilitate breathing.
3. Supine, to decrease strain on the incision line.
4. Prone, to reduce nausea.
A nurse is caring for a client following a cholecystectomy
via an abdominal incision. What is the best position for
this client?
1. Side-lying position, to prevent aspiration.
2. Semi-fowler’s position, to facilitate breathing. Note
that the incision for this procedure is high on the
abdomen and postop pain/discomfort can hinder
respirations (lung expansion)
3. Supine, to decrease strain on the incision line.
4. Prone, to reduce nausea.
Practice Question 38
When teaching a client with hepatitis C who is
receiving interferon and ribavirin therapy,
the nurse encourages the client to eat
1. small frequent meals, high in carbohydrates.
2. small frequent meals, high in proteins.
3. 3 well balanced meals daily, high in
carbohydrates.
4. 3 well balanced meals daily, but with
minimal fluid intake.
When teaching a client with hepatitis C who is
receiving interferon and ribavirin therapy, the nurse
encourages the client to eat
1. small frequent meals, high in carbohydrates. Small
frequ meals are recommended because of the
drug’s s/e of nausea, vomiting, fatigue.
2. small frequent meals, high in proteins.
3. 3 well balanced meals daily, high in carbohydrates.
4. 3 well balanced meals daily, but with minimal fluid
intake.
Practice Question 39
The nurse is caring for a client who has a bleeding
duodenal ulcer. Which of the following
assessment data would indicate gastric
perforation?
1. Increasing abdominal distention and rigid abdomen
2. Decreasing hemoglobin and hematrocrit with bloody
stools.
3. Diarrhea with increased bowel sounds and
hypovolemia.
4. Decreasing blood pressure with tacycardia and
disorientation.
The nurse is caring for a client who has a bleeding
duodenal ulcer. Which of the following assessment
data would indicate gastric perforation?
1. Increasing abdominal distention and rigid
abdomen Perforation is characterized by incr
distention and a “board-like” abdomen.
2. Decreasing hemoglobin and hematrocrit with
bloody stools. May be seen with hemorrhage
3. Diarrhea with increased bowel sounds and
hypovolemia. May be seen with hemorrhage
4. Decreasing blood pressure with tacycardia and
disorientation. May be seen with hemorrhage
Practice Question 40
Which of the following interventions has the
highest priority for a client following a
esophagogastroduodenoscopy?
1. Assessing for the return of the gag reflex.
2. Giving warm gargles for a sore throat.
3. Monitoring complaints of heartburn.
4. Monitoring the temperature.
Which of the following interventions has the
highest priority for a client following a
esophagogastroduodenoscopy?
1. Assessing for the return of the gag reflex.
ABC’s
2. Giving warm gargles for a sore throat.
Psychosocial
3. Monitoring complaints of heartburn.
4. Monitoring the temperature. Important but
would be a later complication