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

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Elsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.Silvestri: Saunders Comprehensive Review forthe NCLEX-RN®Examination, 5thEditionAdult HealthTestBankMULTIPLE CHOICE1.The nurse reviews the health record of a client with melasma. The nurse wouldanticipate that this client will exhibit:1.Skin that is uniformly dark in color2.Very pale skin with little pigmentation3.Patches of skin that have loss of pigmentation4.Blotchy brown macules across the cheeks and foreheadANS:4Rationale:Melasma is a condition caused by hormonal influences on melaninproduction andis noted by the appearance of blotchy brown macules across the cheeksand forehead. “Skin that is uniformly dark in color” describes vitiligo. “Very pale skinwith little pigmentation” and “patches of skin that have loss of pigmentation” refer tonormal variations in skin color.Test-Taking Strategy:To answer this question correctly, you must be familiar with thevarious terms used when discussing skin structures and functions. “Skin that isuniformly 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:1DIF:Level of Cognitive Ability: UnderstandingREF:Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management forpositive outcomes (8th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/IntegumentaryMSC:Integrated Process: Nursing Process—Assessment2.The client with cellulitis of the lower leg has had cultures done on the affected area. Thenurse reviewing the results of the culture report interprets that which of the followingorganisms is not part of the normal flora of the skin?1.Escherichia coli2.Candida albicans3.Staphylococcus aureus4.Staphylococcus epidermidisANS:1

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.2Rationale:E.coliis normally found in the intestines and is a common source ofinfection of wounds and the urinary system.C.albicans,S.aureus, andS.epidermisarepart of the normal flora of the skin.Test-Taking Strategy:To answer this question correctly, you must be familiar with thenormal microorganisms that inhabit the skin. Note that the question asks for theorganism that is not part of normal flora. Remember thatE.coliis normally found in theintestines. Review basic skin structures if you had difficulty with this question.PTS:1DIF:Level of Cognitive Ability: UnderstandingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/IntegumentaryMSC:Integrated Process: Nursing Process—Assessment3.The client complains of chronic pruritus. Which of the following diagnoses would thenurse expect to support this client’s complaint?1.Anemia2.Renal failure3.Hypothyroidism4.Diabetes mellitusANS:2Rationale:Clients with renal failure often have pruritus, or itchy skin. This is because ofimpaired clearance of waste products by the kidneys. The client who is markedly anemicis likely to have pale skin. Hypothyroidism may lead to complaints of dry skin. Clientswith diabetes mellitus are at risk for skin infections and skin breakdown.Test-Taking Strategy:Focus on the subject, chronic pruritus. Remember that clientswith renal failure often experience this problem. If this question was difficult, review thecommon causes of pruritus.PTS:1DIF:Level of Cognitive Ability: UnderstandingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/IntegumentaryMSC:Integrated Process: Nursing Process—Assessment4.A client being seen in an ambulatory clinic for an unrelated complaint has a butterflyrash noted across the nose. The nurse interprets that this finding is consistent with earlymanifestations of which of the following disorders?1.Hyperthyroidism2.Pernicious anemia

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.33.Cardiopulmonary disorders4.Systemic lupus erythematosus (SLE)ANS:4Rationale: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 anemiais exhibited by pale skin. Severe cardiopulmonary disorders may lead to clubbing of thefingers.Test-Taking Strategy:To answer this question accurately, you must be familiar with theimpact of systemic conditions on the skin. Remember that SLE causes a characteristicbutterfly rash. If this question was difficult, review the disorders identified in the optionsand the associated skin conditions that occur in each disorder.PTS:1DIF:Level of Cognitive Ability: UnderstandingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/IntegumentaryMSC:Integrated Process: Nursing Process—Assessment5.The nurse notes that the older adult client has a number of bright, ruby-colored, roundlesions scattered on the trunk and thighs. The nurse correctly interprets the finding asalterations in blood vessels of the skin and defines them as:1.Purpura2.Venous star3.Cherry angioma4.Spider angiomaANS:3Rationale:A cherry angioma occurs with increasing age and has no clinical significance.Itis noted by the appearance of small, bright, ruby-colored round lesions on the trunkand/or extremities. Purpura results from hemorrhage into the skin. A venous star resultsfrom increased pressure in veins, usually in the lower legs, and has an irregularly shapedbluish center with radiating branches. Spider angiomas have a bright red center, withlegs that radiate outward. These are commonly seen in those with liver disease orvitamin B deficiency, although they can occur occasionally without underlyingpathology.Test-Taking Strategy:To answer this question accurately, you must be familiar with thevarious alterations in vascularity that can occur in the skin. Note the relationship of thewords “ruby”in the question and “cherry”in the correct option. If you had difficultywith this question, review the various skin alterations identified in each of the options.PTS:1

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.4DIF:Level of Cognitive Ability: UnderstandingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/IntegumentaryMSC:Integrated Process: Nursing Process—Assessment6.The client has been diagnosed with paronychia. The nurse understands that this is adisorder of the:1.Nails2.Hair follicles3.Pilosebaceous glands4.Epithelial layer of skinANS:1Rationale:Paronychia is a fungal infection that is most often caused byCandidaalbicans. This results in inflammation of the nail fold, with separation of the fold fromthe nail plate. The area is generally tender to touch, with purulent drainage. Disorders ofthe hair follicles include folliculitis, furuncles, and carbuncles. Disorders of thepilosebaceous glands include acne vulgaris and seborrheic dermatitis. There are a varietyof disorders involving the epithelial skin.Test-Taking Strategy:To answer this question accurately, you must be familiar with avariety of skin disorders and their causes. Remember that paronychia is a nail disorder.If this question was difficult, review the characteristics of paronychia.PTS:1DIF:Level of Cognitive Ability: UnderstandingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/IntegumentaryMSC:Integrated Process: Nursing Process—Assessment7.The client is diagnosed with a full-thickness burn. The nurse understands that which ofthe following structural areas of the skin is involved?1.Epidermis only2.Epidermis and deeper dermis3.Epidermis and upper layer of dermis4.Epidermis, entire dermis, and epithelial portion of subcutaneous fatANS:4Rationale:A full-thickness burn involves the epidermis, entire dermis, and epithelialportion of subcutaneous fat layer. “Epidermis only” describes a superficial burn.“Epidermis and deeper dermis” describes a partial-thickness burn, and “epidermis, entire

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.5dermis, and epithelial portion of subcutaneous fat” describes a deep partial-thicknessburn.Test-Taking Strategy:To answer this question accurately, you must be familiar with theclassification of burn depth and the associated skin structures affected. Noting the words“full-thickness”will direct you to “epidermis, entire dermis, and epithelial portion ofsubcutaneous fat.” If this question was difficult, review the types of burn injuries.PTS:1DIF:Level of Cognitive Ability: UnderstandingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/IntegumentaryMSC:Integrated Process: Nursing Process—Assessment8.A client who suffered carbon monoxide poisoning from working on an automobile in aclosed garage has a carbon monoxide level of 15%. The nurse would anticipateobserving which sign or symptom?1.Coma2.Flushing3.Dizziness4.TachycardiaANS:2Rationale:The signs and symptoms worsen as the carbon monoxide level rises in thebloodstream. Impaired visual acuity occurs at 5% to 10%, whereas flushing andheadache are seen at 11% to 20%. Nausea and impaired dexterity appear at levels of21% to 30%, and a 31% to 40% level is accompanied by vomiting, dizziness, andsyncope. Levels of 41% to 50% cause tachypnea and tachycardia, and those higher than50% result in coma and death.Test-Taking Strategy:Knowledge of the various manifestations of carbon monoxidepoisoning is needed to answer this question. Remember that flushing is noted at levels of11% to 20%. If you had difficulty with this question, review the manifestationsassociated with carbon monoxide poisoning.PTS:1DIF:Level of Cognitive Ability: AnalyzingREF:Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management forpositive outcomes (8th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/IntegumentaryMSC:Integrated Process: Nursing Process—Assessment9.A client is admitted to the hospital with cellulitis of the lower leg. The nurse wouldanticipate which of the following therapies to be prescribed?

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.61.Intermittent heat lamp treatments2.Alternating hot and cold compresses3.Warm compresses to the affected area4.Cold compresses to the affected areaANS:3Rationale:Warm compresses may be used to decrease the discomfort, erythema, andedema that accompany cellulitis. Definitive treatment includes antibiotic therapy afterappropriate cultures have been done. Other supportive measures are also used to managesuch symptoms as fatigue, fever, chills, headache, or myalgia. Heat lamps are not usedbecause 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 toheat and cold therapy to answer this question. Eliminate “alternating hot and coldcompresses” and “cold compresses to the affected area” first, because cold therapywould 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 thataccompanies cellulitis. If you had difficulty with this question, review the treatmentassociated with cellulitis.PTS:1DIF:Level of Cognitive Ability: AnalyzingREF: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 IntegrityTOP:Content Area: Adult Health/IntegumentaryMSC:Integrated Process: Nursing Process—Planning10.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 toexamine the right breast, the nurse would tell the client to place a pillow:1.Under the left scapula2.Under the left shoulder3.Under the right shoulder4.Under the small of the backANS:3Rationale:The nurse would instruct the client to lie down and place a towel or pillowunder the shoulder on the side of the breast to be examined. If the right breast is to beexamined, 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 theback” are incorrect.

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.7Test-Taking Strategy:Use the process of elimination, and visualize this procedure. Thiswill direct you to “under the right shoulder.” If you are unfamiliar with the procedure forperforming BSE, review this important self-examination.PTS:1DIF:Level of Cognitive Ability: ApplyingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Health Promotion and MaintenanceTOP:Content Area: Adult Health/OncologyMSC:Integrated Process: Teaching and Learning11.The nurse would identify that which of the following foods should be increased in thediet to help decrease the risk of cancer development?1.Bacon2.Broccoli3.Bologna4.Broiled beefANS:2Rationale:Broccoli is acruciferous vegetable, which is helpful in reducing the risk ofcancer. Other cruciferous vegetables are cauliflower, Brussels sprouts, and cabbage. Redmeat (“bacon”) and meats with nitrites (“bologna” and “broiled beef”) can increase therisk of developing cancer.Test-Taking Strategy:Remember that options that are comparable or alike are not likelyto be correct. With this in mind, note that each incorrect option lists a meat, whereas thecorrect choice is a cruciferous vegetable. Review dietary risk factors for cancer if youhad difficulty with this question.PTS:1DIF:Level of Cognitive Ability: ApplyingREF:Nix, S. (2009). Williams’ basic nutrition and diet therapy (13th ed.).St. Louis:Mosby.OBJ:Client Needs: Health Promotion and MaintenanceTOP:Content Area: Adult Health/OncologyMSC:Integrated Process: Nursing Process—Implementation12.The nurse would include which of the following in a list of themosthelpful foods forthe vegan client wishing to increase foods high in vitamin A?1.Peas2.Carrots3.Potatoes4.Green beansANS:2

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.8Rationale:Foods that are high in vitamin A include carrots, green leafy vegetables, andyellow vegetables. The other vegetables are high in vitamins but do not necessarily havethe highest amount of vitamin A.Test-Taking Strategy:Note the strategic words “most helpful.” To answer this questionaccurately, 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:1DIF:Level of Cognitive Ability: ApplyingREF:Peckenpaugh, N. (2010). Nutrition essentials and diet therapy (11th ed.).St.Louis: Saunders.OBJ:Client Needs: Health Promotion and MaintenanceTOP:Content Area: Adult Health/OncologyMSC:Integrated Process: Nursing Process—Implementation13.According to the American Cancer Society, fecal occult blood testing should be doneannually after the age of _____ years.1.302.403.504.60ANS:3Rationale:Fecal occult blood testing for colorectal cancer should be done annually forboth 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 therecommendations for cancer screening published by the American Cancer Society. Thiswould allow you to eliminate each of the incorrect options easily. Review these cancerprevention guidelines.PTS:1DIF:Level of Cognitive Ability: ApplyingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Health Promotion and MaintenanceTOP:Content Area: Adult Health/OncologyMSC:Integrated Process: Nursing Process—Implementation14.A 27-year-old female client is undergoing evaluation of lumps in her breasts. Indetermining whether the client could have fibrocystic breast disorder, the nurse shouldask the client whether the breast lumps seem to become more prominent or troublesomeat which of the following times?1.After menses2.Before menses

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.93.During menses4.At any time, regardless of the menstrual cycleANS:2Rationale:The nurse assesses the client with fibrocystic breast disorder for worseningof symptoms (breast lumps, painful breasts, and possible nipple discharge) before theonset of menses. This is associated with cyclical hormone changes. Therefore “aftermenses,” “during menses,” and “at any time, regardless of the menstrual cycle” areincorrect.Test-Taking Strategy:Note the strategic words “more prominent or troublesome.” Thisimplies that there is a predictable variation in symptoms. Use knowledge of the effectsof hormonal variations to select the correct option. Review fibrocystic breast disorder ifyou had difficulty with this question.PTS:1DIF:Level of Cognitive Ability: ApplyingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/OncologyMSC:Integrated Process: Nursing Process—Assessment15.The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor.Which of the following is themostcharacteristic manifestation of cancer at this site?1.Frequent diarrhea2.Crampy gas pains3.Flat, ribbon-like stools4.Dull abdominal pain exacerbated by walkingANS:4Rationale:Characteristic symptoms of right colon tumors include vague, dull,abdominal pain exacerbated by walking, and dark red-or mahogany-colored bloodmixed in the stool. The symptoms described in the other options are associated with leftcolon tumors.Test-Taking Strategy:Knowledge regarding the signs of right and left colon tumors isrequired to answer this question. Note, however, that “crampy gas pains” and “dullabdominal pain exacerbated by walking” describe different patterns of pain. This maysuggest to you that one of the two is correct. If you are not familiar with the differencesbetween right and left colon tumors, review this content.PTS:1DIF:Level of Cognitive Ability: UnderstandingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.10OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/OncologyMSC:Integrated Process: Nursing Process—Assessment16.A client has undergone abdominal perineal resection for a bowel tumor. The nurseinterprets that the client’s colostomy is beginning to function if which of the followingsigns is noted?1.Absent bowel sounds2.The passage of flatus3.Blood drainage from the colostomy4.The client’s ability to tolerate foodANS:2Rationale:Following abdominal perineal resection, a colostomy should begin tofunction within 72 hours after surgery, although it may take up to 5 days. The nurseshould monitor for a return of peristalsis by listening for bowel sounds and checking forthe passage of flatus. Absent bowel sounds indicate that peristalsis has not returned. Theclient 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 strategicwords should assist in eliminating “absent bowel sounds.” Knowledge of generalpostoperative 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 postoperativecare of a client following abdominal perineal resection if you had difficulty with thisquestion.PTS:1DIF:Level of Cognitive Ability: AnalyzingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/OncologyMSC:Integrated Process: Nursing Process—Assessment17.A nurse assessing a postoperative ureterostomy client will interpret that the stoma hasnormal characteristics if the stoma is:1.Dry2.Pale3.Dark-colored4.Red and moistANS:4Rationale:Following ureterostomy, the stoma should be red and moist. A dry stomamay indicate fluid volume deficit. A pale stoma may indicate an inadequate vascular

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.11supply. Any darkness or duskiness of the stoma may mean loss of vascular supply andmust be corrected immediately to prevent necrosis.Test-Taking Strategy:Knowledge of normal stoma characteristics is needed to answerthis question. Remember that a red and moist stoma is an expected finding. If you haddifficulty with this question, review expected and unexpected findings followingureterostomy.PTS:1DIF:Level of Cognitive Ability: AnalyzingREF:Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management forpositive outcomes (8th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/RenalMSC:Integrated Process: Nursing Process—Assessment18.The nurse monitoring the oncological client for early signs of vena cava syndromewould include assessment for which of the following?1.Cyanosis2.Arm edema3.Periorbital edema4.Mental status changesANS:3Rationale:Vena cava syndrome occurs when the superior vena cava is compressed orobstructed by tumor growth. Early signs and symptoms generally occur in the morningand include edema of the face, especially around the eyes, and client complaints oftightness of a shirt or blouse collar. As the compression worsens, the client experiencesedema 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 withvena cava syndrome and its manifestations. Note the strategic word “early” in thequestion. This will assist in directing you to the correct option. If you are unfamiliarwith vena cava syndrome, review the signs of this oncological emergency.PTS:1DIF:Level of Cognitive Ability: AnalyzingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/OncologyMSC:Integrated Process: Nursing Process—Assessment19.The nurse understands that which of the following hormones is directly responsible formaintaining the free or unbound portion of serum calcium within normal limits?1.Thyroid hormone2.Parathyroid hormone

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.123.Follicle-stimulating hormone4.Adrenocorticotropic hormoneANS:2Rationale:Parathyroid hormone is responsible for maintaining serum calcium andphosphorous levels within normal range. Thyroid hormone is responsible formaintaining a normal metabolic rate in the body. Follicle-stimulating hormone andadrenocorticotropic hormone are produced by the anterior pituitary gland. They areresponsible for growth and maturation of the ovarian follicle and stimulation of theadrenal glands, respectively.Test-Taking Strategy:Basic knowledge of physiology associated with the parathyroidgland is needed to answer this question. This gland is responsible for maintaining theimportant balance of calcium and phosphorus in the body. Review the function of theparathyroid gland if you had difficulty with this question.PTS:1DIF:Level of Cognitive Ability: UnderstandingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/EndocrineMSC:Integrated Process: Nursing Process—Assessment20.The client with an endocrine disorder complains of weight loss and diarrhea, and saysthat he can “feel his heart beating in his chest.” The nurse interprets that which of thefollowing glands ismostlikely responsible for these symptoms?1.Thyroid2.Pituitary3.Parathyroid4.Adrenal cortexANS:1Rationale:The thyroid gland is responsible for a number of metabolic functions in thebody, including metabolism of nutrients (such as fats and carbohydrates). Increasedmetabolic function places a demand on the cardiovascular system for a higher cardiacoutput. Thus, a client with increased activity of the thyroid gland exhibits weight lossfrom higher metabolic rate and increased pulse rate.Test-Taking Strategy:Use knowledge of the function of the thyroid gland to answer thisquestion. Remember that the thyroid gland is responsible for metabolic function. Thiswill assist in directing you to “thyroid.” If you had difficulty answering this question,review the function of the thyroid gland.PTS:1DIF:Level of Cognitive Ability: Understanding

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.13REF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/EndocrineMSC:Integrated Process: Nursing Process—Assessment21.The client is experiencing an episode of hypoglycemia. The nurse understands that thephysiological mechanism that should take place to combat this decrease in the bloodglucose level is:1.Decreased cortisol release2.Increased insulin secretion3.Decreased epinephrine release4.Increased glucagon secretionANS:4Rationale:Glucagon is secreted from the alpha cells in the pancreas in response todeclining blood glucose levels. At the same time, hypoglycemia triggers increasedcortisol release, increased epinephrine release, and decreased secretion of insulin.“Decreased cortisol release,” “increased insulin secretion,” and “decreased epinephrinerelease” are not physiological mechanisms that take place to combat the decrease in theblood glucose level.Test-Taking Strategy:To answer this question accurately, you must be familiar withhow each of the hormones listed is affected by blood glucose levels. Thinking about thepathophysiology of hypoglycemia will direct you to “increased glucagon secretion.” Ifthis question was difficult, review this physiological mechanism.PTS:1DIF:Level of Cognitive Ability: UnderstandingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/EndocrineMSC:Integrated Process: Nursing Process—Assessment22.The client with diabetes experiences breakdown of fats for conversion to glucose. Thenurse determines that this response is occurring if the client has elevated levels of whichof the following substances?1.Glucose2.Ketones3.Glucagon4.Lactic dehydrogenaseANS:2

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.14Rationale:Ketones are a byproduct of fat metabolism. When this process occurs to theextreme, it is termedketoacidosis. “Glucose,” “glucagon,” and “lactic dehydrogenase”are incorrect.Test-Taking Strategy:Knowledge of the pathophysiology of glucose metabolism isneeded to answer this question. Remember that ketones are a byproduct of fatmetabolism. If this question was difficult, review the physiological process of fatbreakdown.PTS:1DIF:Level of Cognitive Ability: UnderstandingREF:Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management forpositive outcomes (8th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/EndocrineMSC:Integrated Process: Nursing Process—Assessment23.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-termcontrol is within acceptable limits?1.Glycosylated hemoglobin of 6%2.Fasting blood glucose level of 150 mg/dL3.Presence of ketones in the urine4.Presence of albumin in the urineANS:1Rationale:This measurement of glycosylated hemoglobin (Hb A1c) detects glucosebinding on the red blood cell (RBC) membrane and is expressed as a percentage. Itmeasures glucose for the life of the RBC, which is 120 days. The fasting blood glucoselevel should be lower than 130 mg/dL. The urine should be free of both ketones andurine.Test-Taking Strategy:Specific knowledge of the effects of an increased blood glucoselevel in the body is necessary to answer this question. Noting the words “long-term” willdirect you to “glycosylated hemoglobin of 6%.” Review the alterations in normalphysiology that occur with diabetes mellitus if you had difficulty with this question.PTS:1DIF:Level of Cognitive Ability: AnalyzingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/EndocrineMSC:Integrated Process: Nursing Process—Assessment

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TestBankElsevier items and derived items © 2011, 2008, 2005, 2002 by Saunders, an imprint of Elsevier Inc.1524.The nurse is caring for a client with a dysfunctional thyroid gland and is concerned thatthe client will exhibit signs of thyroid storm. Which of the following is an early indicatorof this complication?1.Hyperreflexia2.Constipation3.Bradycardia4.Low-grade temperatureANS:1Rationale:Clinical manifestations of thyroid storm include a fever as high as 106°F,hyperreflexia, abdominal pain, diarrhea, dehydration rapidly progressing to coma, severetachycardia, extreme vasodilation, hypotension, atrial fibrillation, and cardiovascularcollapse.Test-Taking Strategy:To answer this question correctly, you must be familiar with theclinical manifestations of thyroid storm. This condition is a rare but potentially fatalhypermetabolic state. Remembering the description of thyroid storm will direct you tothe correct option. If you are unfamiliar with thyroid storm, review this content.PTS:1DIF:Level of Cognitive Ability: AnalyzingREF:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:patient-centered collaborative care (6th ed.).St. Louis: Saunders.OBJ:Client Needs: Physiological IntegrityTOP:Content Area: Adult Health/EndocrineMSC:Integrated Process: Nursing Process—Assessment25.The client is undergoing an oral glucose tolerance test. The nurse interprets that theclient’s results are not compatible with diabetes mellitus if the glucose level is lowerthan which of the following cutoff values after 120 minutes (2 hours)?1.80 mg/dL2.110 mg/dL3.140 mg/dL4.160 mg/dLANS:3Rationale:The normal reference values for oral glucose tolerance tests are lower than140 mg/dL at 120 minutes; lower than 200 mg/dL at 30, 60, and 90 minutes; and lowerthan 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 thenormal values for this screening test for diabetes. Think about the physiology associatedwith diabetes mellitus and the procedure for this test to answer correctly. Noting thewords “not compatible with diabetes mellitus” will assist in answering correctly. Reviewthis test if you had difficulty with this question.

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