Skip to content
Exam Guides

Saunders Comprehensive Review for the NCLEX-RN Examination, 5th Edition Test Bank

Stay ahead of the curve with Saunders Comprehensive Review for the NCLEX-RN Examination, 5th Edition Test Bank, a structured guide covering all the essential topics you need.

Preview 16 of 430 pages

See the first 16 pages exactly as they appear in the document.

  1. Page 1
    Read page 1 as text

    Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. Silvestri: Saunders Comprehensive Review for the NCLEX - RN® Examination, 5 th Edition Adult Health Test Bank MULTIPLE CHOICE 1. The nurse reviews the health record of a client with melasma. The nurse would anticipate that this client will exhibit: 1. Skin that is uniformly dark in color 2. Very pale skin with little pigmentation 3. Patches of skin that have loss of pigmentation 4. Blotchy brown macules across the cheeks and forehead ANS : 4 Rationale : Melasma is a condition caused by hormonal influences on melanin production and is noted by the appearance of blotchy brown macules across the cheeks and forehead. “Skin that is uniformly dark in color” describes vitiligo. “Very pale skin with little pigmentation” and “patches of skin that have loss of pigmentation” refer to normal variations in skin color. Test - Taking Strategy: To answer this question correctly, you must be familiar with the various terms used when discussing skin structures and functions. “Skin that is uniformly dark in color” describes vitiligo. “Very pale skin with little pigmentation” and “patches of skin that have loss of pigmentation” refer to normal variations in skin color. Review the description of melasma if you had difficulty with this question. PTS: 1 DIF : Level of Cognitive Ability: Understanding REF: Black, J., & Hawks, J. (2009). Medical - surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Integumentary MSC: Integrated Process: Nursing Process — Assessment 2. The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture report interprets that which of the following organisms is not part of the normal flora of the skin? 1. Escherichia coli 2. Candida albicans 3. Staphylococcus aureus 4. Staphylococcus epidermidis ANS : 1

  2. Page 2
  3. Page 3
    Read page 3 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 2 Rationale : E . coli is normally found in the intestines and is a common source of infection of wounds and the urinary system. C . albicans , S . aureus , and S . epidermis are part of the normal flora of the skin. Test - Taking Strategy: To answer this question correctly, you must be familiar with the normal microorganisms that inhabit the skin. Note that the question asks for the organism that is not part of normal flora. Remember that E . coli is normally found in the intestines. Review basic skin structures if you had difficulty with this question. PTS: 1 DIF : Level of Cognitive Ability: Understanding REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Integumentary MSC: Integrated Process: Nursing Process — Assessment 3. The client complains of chronic pruritus. Which of the following diagnoses would the nurse expect to support this client’s complaint? 1. Anemia 2. Renal failure 3. Hypothyroidism 4. Diabetes mellitus ANS : 2 Rationale : Clients with renal failure often have pruritus, or itchy skin. This is because of impaired clearance of waste products by the kidneys. The client who is markedly anemic is likely to have pale skin. Hypothyroidism may lead to complaints of dry skin. Clients with diabetes mellitus are at risk for skin infections and skin breakdown. Test - Taking Strategy: Focus on the subject, chronic pruritus. Remember that clients with renal failure often experience this problem. If this question was difficult, review the common causes of pruritus. PTS: 1 DIF : Level of Cognitive Ability: Understanding REF: Ignataviciu s, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Integumentary MSC: Integrated Process: Nursing Process — Assessment 4. A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders? 1. Hyperthyroidism 2. Pernicious anemia

  4. Page 4
    Read page 4 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 3 3. Cardiopulmonary disorders 4. Systemic lupus erythematosus (SLE) ANS : 4 Rationale : An early sign of SLE is the appearance of a butterfly rash across the nose. Hyperthyroidism often leads to moist skin and increased perspiration. Pernicious anemia is exhibited by pale skin. Severe cardiopulmonary disorders may lead to clubbing of the fingers. Test - Taking Strategy: To answer this question accurately, you must be familiar with the impact of systemic conditions on the skin. Remember that SLE causes a characteristic butterfly rash. If this question was difficult, review the disorders identified in the options and the associated skin conditions that occur in each disorder. PTS: 1 DIF : Level of Cognitive Ability: Understanding REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Integumentary MSC: Integrated Process: Nursing Process — Assessment 5. The nurse notes that the older adult client has a number of bright, ruby - colored, round lesions scattered on the trunk and thighs. The nurse correctly interprets the finding as alterations in blood vessels of the skin and defines them as: 1. Purpura 2. Venous star 3. Cherry angioma 4. Spider angioma ANS : 3 Rationale : A cherry angioma occurs with increasing age and has no clinical significance. It is noted by the appearance of small, bright, ruby - colored round lesions on the trunk and/or extremities. Purpura results from hemorrhage into the skin. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Spider angiomas have a bright red center, with legs that radiate outward. These are commonly seen in those with liver disease or vitamin B deficiency, although they can occur occasionally without underlying pathology. Test - Taking Strategy: To answer this question accurately, you must be familiar with the various alterations in vascularity that can occur in the skin. Note the relationship of the words “ruby” in the question and “cherry” in the correct option. If you had difficulty with this question, review the various skin alterations identified in each of the options. PTS: 1

  5. Page 5
    Read page 5 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 4 DIF : Level of Cognitive Ability: Understanding REF: I gnatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Integumentary MSC: Integrated Process: Nursing Process — Assessment 6. The client has been diagnosed with paronychia. The nurse understands that this is a disorder of the: 1. Nails 2. Hair follicles 3. Pilosebaceous glands 4. Epithelial layer of skin ANS : 1 Rationale : Paro nychia is a fungal infection that is most often caused by Candida albicans . This results in inflammation of the nail fold, with separation of the fold from the nail plate. The area is generally tender to touch, with purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. There are a variety of disorders involving the epithelial skin. Test - Taking Strategy: To answer this question accurately, you must be familiar with a variety of skin disorders and their causes. Remember that paronychia is a nail disorder. If this question was difficult, review the characteristics of paronychia. PTS: 1 DIF : Level of Cognitive Ability: Understanding REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Integumentary MSC: Integrated Process: Nursing Process — Assessment 7. The client is diagnosed with a full - thickness burn. The nurse understands that which of the following structural areas of the skin is involved? 1. Epidermis only 2. Epidermis and deeper dermis 3. Epidermis and upper layer of dermis 4. Epidermis, entire dermis, and epithelial portion of subcutaneous fat ANS : 4 Rationale : A full - thickness burn involves the epidermis, entire dermis, and epithelial portion of subcutaneous fat layer. “Epidermis only” describes a superficial burn. “Epidermis and deeper dermis” describes a partial - thickness burn, and “epidermis, entire

  6. Page 6
    Read page 6 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 5 dermis, and epithelial portion of subcutaneous fat” describes a deep partial - thickness burn. Test - Taking Strategy: To answer this question accurately, you must be familiar with the classification of burn depth and the associated skin structures affected. Noting the words “full - thickness” will direct you to “epidermis, entire dermis, and epithelial portion of subcutaneous fat.” If this question was difficult, review the types of burn injuries. PTS: 1 DIF : Level of Cognitive Ability: Understanding REF: Ignatavicius, D., & Workman, M . (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Integumentary MSC: Integrated Process: Nursing Process — Assessment 8. A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse would anticipate observing which sign or symptom? 1. Coma 2. Flushing 3. Dizziness 4. Tachycardia ANS : 2 Rationale : The signs and symptoms worsen as the carbon monoxide level rises in the bloodstream. Impaired visual acuity occurs at 5% to 10%, whereas flushing and headache are seen at 11% to 20%. Nausea and impaired dexterity appear at levels of 21% to 30%, and a 31% to 40% level is accompanied by vomiting, dizziness, and syncope. Levels of 41% to 50% cause tachypnea and tachycardia, and those higher than 50% result in coma and death. Test - Taking Strategy: Knowledge of the various manifestations of carbon monoxide poisoning is needed to answer this question. Remember that flushing is noted at levels of 11% to 20%. If you had difficulty with this question, review the manifestations associated with carbon monoxide poisoning. PTS: 1 DIF : Level of Cognitive Ability: Analyzing REF: Black, J., & Hawks, J. (2009). Medical - surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Integumentary MSC: Integrated Process: Nursing Process — Assessment 9. A client is admitted to the hospital with cellulitis of the lower leg. The nurse would anticipate which of the following therapies to be prescribed?

  7. Page 7
    Read page 7 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 6 1. Intermittent heat lamp treatments 2. Alternating hot and cold compresses 3. Warm compresses to the affected area 4. Cold compresses to the affected area ANS : 3 Rationale : Warm compresses may be used to decrease the discomfort, erythema, and edema that accompany cellulitis. Definitive treatment includes antibiotic therapy after appropriate cultures have been done. Other supportive measures are also used to manage such symptoms as fatigue, fever, chills, headache, or myalgia. Heat lamps are not used because of the risk of burns, and moist heat is most useful in treating this disorder. Test - Taking Strategy: Use knowledge of the disease process and concepts related to heat and cold therapy to answer this question. Eliminate “alternating hot and cold compresses” and “cold compresses to the affected area” first, because cold therapy would cause vasoconstriction rather than vasodilation. Choose correctly between “intermittent heat lamp treatments” and “warm compresses to the affected area,” knowing that moist heat decreases the discomfort, erythema, and edema that accompanies cellulitis. If you had difficulty with this question, review the treatment associated with cellulitis. PTS: 1 DIF : Level of Cognitive Ability: Analyzing REF: Monahan, F., Sands, J., Marek, J., Neighbors, M., & Green, C. (2007). Phipps' medical - surgical nursing: health and illness perspectives (8th ed.). St. Louis: Mosby. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Integumentary MSC: Integrated Process: Nursing Process — Planning 10. The nurse has instructed the client in the correct technique for breast self - examination (BSE). For a portion of the examination, the client will lie down. If the client were to examine the right breast, the nurse would tell the client to place a pillow: 1. Under the left scapula 2. Under the left shoulder 3. Under the right shoulder 4. Under the small of the back ANS : 3 Rationale : The nurse would instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the right breast is to be examined, the pillow would be placed under the right shoulder, and vice versa. Therefore “under the left scapula,” “under the left shoulder,” and “under the small of the back” are incorrect.

  8. Page 8
    Read page 8 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 7 Test - Taking Strategy: Use the process of elimination, and visualize this procedure. This will direct you to “under the right shoulder.” If you are unfamiliar with the procedure for performing BSE, review this important self - examination. PTS: 1 DIF : Level of Cognitive Ability: Applying REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Health Promotion and Maintenance TOP: Content Area: Adult Health/Oncology MSC: Integrated Process: Teaching and Learning 11. The nurse would identify that which of the following foods should be increased in the diet to help decrease the risk of cancer development? 1. Bacon 2. Broccoli 3. Bologna 4. Broiled beef ANS : 2 Rationale : Broccoli is a cruciferous vegetable, which is helpful in reducing the risk of cancer. Other cruciferous vegetables are cauliflower, Brussels sprouts, and cabbage. Red meat (“bacon”) and meats with nitrites (“bologna” and “broiled beef”) can increase the risk of developing cancer. Test - Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. With this in mind, note that each incorrect option lists a meat, whereas the correct choice is a cruciferous vegetable. Review dietary risk factors for cancer if you had difficulty with this question. PTS: 1 DIF : Level of Cognitive Ability: Applying REF: Nix, S. (2009). Williams’ basic nutrition and diet therapy (13th ed.). St. Louis: Mosby. OBJ: Client Needs: Health Promotion and Maintenance TOP: Content Area: Adult Health/Oncology MSC: Integrated Process: Nursing Process — Implementation 12. The nurse would include which of the following in a list of the most helpful foods for the vegan client wishing to increase foods high in vitamin A? 1. Peas 2. Carrots 3. Potatoes 4. Green beans ANS : 2

  9. Page 9
    Read page 9 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 8 Rationale : Foods that are high in vitamin A include carrots, green leafy vegetables, and yellow vegetables. The other vegetables are high in vitamins but do not necessarily have the highest amount of vitamin A. Test - Taking Strategy: Note the strategic words “most helpful.” To answer this question accurately, you must be aware of the type of foods that are naturally high in vitamin A. Remember that carrots are high in vitamin A. If you had difficulty with this question, review foods that are in this vitamin group. PTS: 1 DIF : Level of Cognitive Ability: Applying REF: Peckenpaugh, N. (2010). Nutrition essentials and diet therapy (11th ed.). St. Louis: Saunders. OBJ: Client Needs: Health Promotion and Maintenance TOP: Content Area: Adult Health/Oncology MSC: Integrated Process: Nursing Process — Implementation 13. According to the American Cancer Society, fecal occult blood testing should be done annually after the age of _____ years. 1. 30 2. 40 3. 50 4. 60 ANS : 3 Rationale : Fecal occult blood testing for colorectal cancer should be done annually for both men and women after the age of 50 years. The other options are incorrect. Test - Taking Strategy: To answer this question correctly, you must be familiar with the recommendations for cancer screening published by the American Cancer Society. This would allow you to eliminate each of the incorrect options easily. Review these cancer prevention guidelines. PTS: 1 DIF : Level of Cognitive Ability: Applying REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Health Promotion and Maintenance TOP: Content Area: Adult Health/Oncology MSC: Integrated Process: Nursing Process — Implementation 14. A 27 - year - old female client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask the client whether the breast lumps seem to become more prominent or troublesome at which of the following times? 1. After menses 2. Before menses

  10. Page 10
    Read page 10 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 9 3. During menses 4. At any time, regardless of the menstrual cycle ANS : 2 Rationale : The nurse assesses the client with fibrocystic breast disorder for worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Therefore “after menses,” “during menses,” and “at any time, regardless of the menstrual cycle” are incorrect. Test - Taking Strategy: Note the strategic words “more prominent or troublesome.” This implies that there is a predictable variation in symptoms. Use knowledge of the effects of hormonal variations to select the correct option. Review fibrocystic breast disorder if you had difficulty with this question. PTS: 1 DIF : Level of Cognitive Ability: Applying REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Oncology MSC: Integrated Process: Nursing Process — Assessment 15. The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor. Which of the following is the most characteristic manifestation of cancer at this site? 1. Frequent diarrhea 2. Crampy gas pains 3. Flat, ribbon - like stools 4. Dull abdominal pain exacerbated by walking ANS : 4 Rationale : Char acteristic symptoms of right colon tumors include vague, dull, abdominal pain exacerbated by walking, and dark red - or mahogany - colored blood mixed in the stool. The symptoms described in the other options are associated with left colon tumors. Test - Taking Strategy: Knowledge regarding the signs of right and left colon tumors is required to answer this question. Note, however, that “crampy gas pains” and “dull abdominal pain exacerbated by walking” describe different patterns of pain. This may suggest to you that one of the two is correct. If you are not familiar with the differences between right and left colon tumors, review this content. PTS: 1 DIF : Level of Cognitive Ability: Understanding REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders.

  11. Page 11
    Read page 11 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 10 OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Oncology MSC: Integrated Process: Nursing Process — Assessment 16. A client has undergone abdominal perineal resection for a bowel tumor. The nurse interprets that the client’s colostomy is beginning to function if which of the following signs is noted? 1. Absent bowel sounds 2. The passage of flatus 3. Blood drainage from the colostomy 4. The client’s ability to tolerate food ANS : 2 Rationale : Following abdominal perineal resection, a colostomy should begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should monitor for a return of peristalsis by listening for bowel sounds and checking for the passage of flatus. Absent bowel sounds indicate that peristalsis has not returned. The client would remain NPO until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy. Test - Taking Strategy: Note the strategic words “beginning to function.” These strategic words should assist in eliminating “absent bowel sounds.” Knowledge of general postoperative measures will assist in eliminating “the client’s ability to tolerate food.” Focus on the subject of the question to make your final selection. Review postoperative care of a client following abdominal perineal resection if you had difficulty with this question. PTS: 1 DIF : Level of Cognitive Ability: Analyzing REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Oncology MSC: Integrated Process: Nursing Process — Assessment 17. A nurse assessing a postoperative ureterostomy client will interpret that the stoma has normal characteristics if the stoma is: 1. Dry 2. Pale 3. Dark - colored 4. Red and moist ANS : 4 Rationale : Following ureterostomy, the stoma should be red and moist. A dry stoma may indicate fluid volume deficit. A pale stoma may indicate an inadequate vascular

  12. Page 12
    Read page 12 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 11 supply. Any darkness or duskiness of the stoma may mean loss of vascular supply and must be corrected immediately to prevent necrosis. Test - Taking Strategy: Knowledge of normal stoma characteristics is needed to answer this question. Remember that a red and moist stoma is an expected finding. If you had difficulty with this question, review expected and unexpected findings following ureterostomy. PTS: 1 DIF : Level of Cognitive Ability: Analyzing REF: Black, J., & Hawks, J. (2009). Medical - surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Renal MSC: Integrated Process: Nursing Process — Assessment 18. The nurse monitoring the oncological client for early signs of vena cava syndrome would include assessment for which of the following? 1. Cyanosis 2. Arm edema 3. Periorbital edema 4. Mental status changes ANS : 3 Rationale : Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs. Test - Taking Strategy: To answer this question accurately, you must be familiar with vena cava syndrome and its manifestations. Note the strategic word “early” in the question. This will assist in directing you to the correct option. If you are unfamiliar with vena cava syndrome, review the signs of this oncological emergency. PTS: 1 DIF : Level of Cognitive Ability: Analyzing REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Oncology MSC: Integrated Process: Nursing Process — Assessment 19. The nurse understands that which of the following hormones is directly responsible for maintaining the free or unbound portion of serum calcium within normal limits? 1. Thyroid hormone 2. Parathyroid hormone

  13. Page 13
    Read page 13 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 12 3. Follicle - stimulating hormone 4. Adrenocorticotropic hormone ANS : 2 Rationale : Parathyroid hormone is responsible for mainta ining serum calcium and phosphorous levels within normal range. Thyroid hormone is responsible for maintaining a normal metabolic rate in the body. Follicle - stimulating hormone and adrenocorticotropic hormone are produced by the anterior pituitary gland. They are responsible for growth and maturation of the ovarian follicle and stimulation of the adrenal glands, respectively. Test - Taking Strategy: Basic knowledge of physiology associated with the parathyroid gland is needed to answer this question. This gland is responsible for maintaining the important balance of calcium and phosphorus in the body. Review the function of the parathyroid gland if you had difficulty with this question. PTS: 1 DIF : Level of Cognitive Ability: Understanding REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Endocrine MSC: Integrated Process: Nursing Process — Assessment 20. The client with an endocrine disorder complains of weight loss and diarrhea, and says that he can “feel his heart beating in his chest.” The nurse interprets that which of the following glands is most likely responsible for these symptoms? 1. Thyroid 2. Pituitary 3. Parathyroid 4. Adrenal cortex ANS : 1 Rationale : The thyroid gland is responsible for a number of metabolic functions in the body, including metabolism of nutrients (such as fats and carbohydrates). Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. Thus, a client with increased activity of the thyroid gland exhibits weight loss from higher metabolic rate and increased pulse rate. Test - Taking Strategy: Use knowledge of the function of the thyroid gland to answer this question. Remember that the thyroid gland is responsible for metabolic function. This will assist in directing you to “thyroid.” If you had difficulty answering this question, review the function of the thyroid gland. PTS: 1 DIF : Level of Cognitive Ability: Understanding

  14. Page 14
    Read page 14 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 13 REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Endocrine MSC: Integrated Process: Nursing Process — Assessment 21. The client is experiencing an episode of hypoglycemia. The nurse understands that the physiological mechanism that should take place to combat this decrease in the blood glucose level is: 1. Decreased cortisol release 2. Increased insulin secretion 3. Decreased epinephrine release 4. Increased glucagon secretion ANS : 4 Rationale : Glucagon is secreted from the alpha cells in the pancreas in response to declining blood glucose levels. At the same time, hypoglycemia triggers increased cortisol release, increased epinephrine release, and decreased secretion of insulin. “Decreased cortisol release,” “increased insulin secretion,” and “decreased epinephrine release” are not physiological mechanisms that take place to combat the decrease in the blood glucose level. Test - Taking Strategy: To answer this question accurately, you must be familiar with how each of the hormones listed is affected by blood glucose levels. Thinking about the pathophysiology of hypoglycemia will direct you to “increased glucagon secretion.” If this question was difficult, review this physiological mechanism. PTS: 1 DIF : Level of Cognitive Ability: Understanding REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Endocrine MSC: Integrated Process: Nursing Process — Assessment 22. The client with diabetes experiences breakdown of fats for conversion to glucose. The nurse determines that this response is occurring if the client has elevated levels of which of the following substances? 1. Glucose 2. Ketones 3. Glucagon 4. Lactic dehydrogenase ANS : 2

  15. Page 15
    Read page 15 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 14 Rationale : Ketones are a byproduct of fat metabolism. W hen this process occurs to the extreme, it is termed ketoacidosis . “Glucose,” “glucagon,” and “lactic dehydrogenase” are incorrect. Test - Taking Strategy: Knowledge of the pathophysiology of glucose metabolism is needed to answer this question. Remember that ketones are a byproduct of fat metabolism. If this question was difficult, review the physiological process of fat breakdown. PTS: 1 DIF : Level of Cognitive Ability: Understanding REF: Black, J., & Hawks, J. (2009). Medical - surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Endocrine MSC: Integrated Process: Nursing Process — Assessment 23. The client with diabetes mellitus is being tested to determine long - term diabetic control. Which of the following results would the nurse expect to see if the client’s long - term control is within acceptable limits? 1. Glycosylated hemoglobin of 6% 2. Fasting blood glucose level of 150 mg/dL 3. Presence of ketones in the urine 4. Presence of albumin in the urine ANS : 1 Rationale : This measurement of glycosylated hemoglobin (Hb A 1c ) detects glucose binding on the red blood cell (RBC) membrane and is expressed as a percentage. It measures glucose for the life of the RBC, which is 120 days. The fasting blood glucose level should be lower than 130 mg/dL. The urine should be free of both ketones and urine. Test - Taking Strategy: Specific knowledge of the effects of an increased blood glucose level in the body is necessary to answer this question. Noting the words “long - term” will direct you to “glycosylated hemoglobin of 6%.” Review the alterations in normal physiology that occur with diabetes mellitus if you had difficulty with this question. PTS: 1 DIF : Level of Cognitive Ability: Analyzing REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Endocrine MSC: Integrated Process: Nursing Process — Assessment

  16. Page 16
    Read page 16 as text

    Test Bank Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc. 15 24. The nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit signs of thyroid storm. Which of the following is an early indicator of this complication? 1. Hyperreflexia 2. Constipation 3. Bradycardia 4. Low - grade temperature ANS : 1 Rationale : Clinical manifestations of thyroid storm include a fever as high as 106 ° F, hyperreflexia, abdominal pain, diarrhea, dehydration rapidly progressing to coma, severe tachycardia, extreme vasodilation, hypotension, atrial fibrillation, and cardiovascular collapse. Test - Taking Strategy: To answer this question correctly, you must be familiar with the clinical manifestations of thyroid storm. This condition is a rare but potentially fatal hypermetabolic state. Remembering the description of thyroid storm will direct you to the correct option. If you are unfamiliar with thyroid storm, review this content. PTS: 1 DIF : Level of Cognitive Ability: Analyzing REF: Ignatavicius, D., & Workman, M. (2010). Medical - surgical nursing: patient - centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Endocrine MSC: Integrated Process: Nursing Process — Assessment 25. The client is undergoing an oral glucose tolerance test. The nurse interprets that the client’ s results are not compatible with diabetes mellitus if the glucose level is lower than which of the following cutoff values after 120 minutes (2 hours)? 1. 80 mg/dL 2. 110 mg/dL 3. 140 mg/dL 4. 160 mg/dL ANS : 3 Rationale : The normal reference values for oral glucose tolerance tests are lower than 140 mg/dL at 120 minutes; lower than 200 mg/dL at 30, 60, and 90 minutes; and lower than 115 mg/dL in the fasting state. The other values are not part of the reference ranges. Test - Taking Strategy: To answer this question correctly, you must be familiar with the normal values for this screening test for diabetes. Think about the physiology associated with diabetes mellitus and the procedure for this test to answer correctly. Noting the words “not compatible with diabetes mellitus” will assist in answering correctly. Review this test if you had difficulty with this question.

414 more pages in the full document

Unlock it once and it stays in your library, ready to chat with or turn into flashcards.

Unlock the full document

More Nursing study materials

See all

Study this document with CramX

Once it is in your library, every tool can work from it.