Question 1

A nurse is preparing a presentation about behavioral modifications to support weight loss for clients at an obesity clinic. Which of the following points should the nurse include in the teaching plan? Select all that apply.

Accepted Answer

Obesity is a health alteration that may be caused by multiple factors (eg, genetics, diet, pathology, lifestyle choices). Diet and exercise modifications are the main components of weight reduction. However, clients with obesity may also require education and assistance with psychosocial aspects and behavioral modification. Behavioral management includes: Creating a reward system with many small, attainable goals to incentivize positive health behaviors (Option B) Developing health goals unrelated to weight (eg, climbing stairs without shortness of breath) to measure progress regardless of current weight (Option C) Adopting anxiety-reducing diversional activities (eg, reading, meditating, listening to music) as coping mechanisms to reduce stress eating (Option D) Placing visual cues (eg, motivational quotes) throughout the environment as positive reinforcement (Option E) (Option A) Avoiding social activities in a food setting promotes isolation and negative perceptions. Clients who struggle to make healthy choices in these settings should plan ahead for what will be eaten or bring a separate meal. Educational objective: Obesity is a health alteration with multiple causative factors (eg, genetics, diet, pathology, lifestyle choices). Successful behavioral modification is achieved by goal setting, incentivized behavior, diversion, and positive reinforcement.

Question 2

The nurse is teaching general skin care guidelines to a client receiving teletherapy (external beam radiation therapy). Which statements does the client make that indicate proper understanding of the teaching? Select all that apply.

Accepted Answer

Clients receiving teletherapy (external beam radiation therapy) often experience significant effects to the skin of the treatment area. Teaching essential skin care standards to these clients is focused on preventing infection and promoting healing of the affected skin. Key measures of skin care that clients receiving teletherapy should take include: Protect the skin from infection by not rubbing, scratching, or scrubbing (Option B) Wear soft, loose-fitting clothing Use soft, cotton bed sheets and towels Pat skin dry after bathing Avoid applying bandages or tape to the treatment area Cleanse the skin daily by taking a lukewarm shower Use mild soap without fragrance or deodorant Do not wash off any radiation ink markings Use only creams or lotions approved by the health care provider (HCP) Avoid over-the-counter creams, oils, ointments, or powders unless specifically recommended by the HCP as they can worsen any irritation Shield the skin from the effects of the sun during and after treatment Avoid tanning beds and sunbathing Wear a broad-brimmed hat, long sleeves, and long pants when outside Use a sunscreen that is SPF 30 or higher Avoid extremes in skin temperature Avoid heating pads and ice packs (Option A) Maintain a cool, humid environment for comfort Educational objective: The client receiving teletherapy is taught measures to implement to protect the skin from infection and promote healing. Recommended skin care measures include taking a lukewarm shower daily, avoiding rubbing or scratching the skin, using only approved lotions, shielding the skin from the effects of the sun, and avoiding extremes in temperature.

Question 3

A client with throat cancer receives radiation therapy to the head and neck. Which strategies are appropriate to increase oral intake? Select all that apply.

Accepted Answer

Radiation therapy to the head and neck can decrease a client's oral intake due to the development of mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth). These adverse side effects affect speech, taste, and ability to swallow and can have a significant impact on the client's nutritional status. The nurse teaches the client to: Avoid irritants such as spicy, acidic, dry, or crumbly foods; coffee; and alcohol (Option A). Consume supplemental nutritional drinks (eg, Ensure), which are often easier to swallow (Option C). Use artificial saliva to manage xerostomia and the production of thick saliva due to altered salivary gland function (Option E). Sipping water throughout the day is equally effective and less expensive. (Option B) Topical anesthetics (eg, lidocaine) have been found to increase comfort and improve oral intake in clients with mucositis due to radiation therapy. (Option D) Clients on radiation therapy need to maintain more frequent (eg, before and after meals, at bedtime) oral hygiene (eg, using soft toothbrush, rinsing with baking soda solution) due to the drying effects of mucositis. Educational objective: Radiation therapy to the head and neck can cause mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth), leading to decreased nutrition. Care includes avoiding irritants, consuming supplements, using artificial saliva or sipping water, and performing frequent oral hygiene.

Question 4

The nurse is reinforcing teaching to a client with a hiatal hernia.  Which statement by the client indicates that further teaching is needed?

Accepted Answer

11ecbb05_c9c8_9884_b433_a51e89410d55_MD0009_00 Hiatal hernia is a group of medical conditions characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to a weakness in the diaphragm. Although hiatal hernias may be asymptomatic, many people experience heartburn, chest pain, dysphagia, and shortness of breath when the abdominal organs move into the chest. Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward movement of abdominal organs. Clients with hiatal hernias who are obese are often encouraged to lose excess weight by performing light activities (eg, short walks) because obesity increases abdominal pressure. However, nurses should teach clients to avoid activities that promote straining (eg, weight lifting), which increases abdominal pressure (Option D). (Options A and B) Sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches (15 cm) reduces upward movement of the hernia and decreases the risk of gastric reflux. (Option C) If symptoms of hiatal hernias are uncontrolled with home management (eg, weight loss, diet modification, positioning after meals), surgical revision of the diaphragm may be required to prevent organ movement. Educational objective: Hiatal hernia is characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to diaphragmatic weakness. Nurses educating clients with hiatal hernias about symptom management should instruct them to avoid activities that increase abdominal pressure (eg, weight lifting), sleep with the head of the bed elevated, and remain upright for several hours after meals.

Question 5

A client diagnosed with head and neck cancer has developed mouth sores related to external radiation therapy. The nurse teaches the client to use which of the following oral hygiene practices? Select all that apply.

Accepted Answer

Oral mucositis, inflammation or ulceration of the oral mucosa, results from chemotherapy or radiation therapy. Oral hygiene practices that minimize oral mucositis and promote comfort include the following: Cleansing the mouth with normal saline after meals and at bedtime to promote oral health Use of a soft-bristle toothbrush to decrease gum irritation Application of prescribed viscous lidocaine HCl (Xylocaine) to alleviate oral pain Use of water-soluble lubricating agents to moisten mouth tissues that may become dry due to therapy Avoidance of hot liquids and spicy/acidic foods, which can cause oral discomfort (Option E) Clients with mucositis should avoid antiseptic mouthwashes with alcohol as they are irritating to mucous membranes. (Option F) Administration of palifermin (Kepivance), a recombinant human keratinocyte growth factor, prevents oral mucositis in clients diagnosed with hematologic malignancies. However, it does not help with pain. Viscous lidocaine HCl (Xylocaine) alleviates the oral pain caused by mucositis. Educational objective: Measures to minimize oral mucositis from chemoradiotherapy include rinsing the mouth with normal saline, brushing with a soft-bristle toothbrush, using a water-soluble lubricating agent, avoidance of hot liquids and spicy/acidic foods, and application of prescribed viscous lidocaine.

Question 6

A nurse is caring for a client who developed paralytic ileus after a stroke. The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent. Which prescription does the nurse question?

Accepted Answer

Paralytic ileus is characterized by temporary paralysis of a portion of the bowel, which affects peristalsis and bowel motility. Signs and symptoms include abdominal discomfort, distension, and nausea/vomiting. Risk factors for paralytic ileus include: Abdominal surgery Perioperative medications (eg, anesthesia, analgesics) Immobility (eg, stroke) To prevent further abdominal distension and resulting nausea, the client should remain NPO. Nasogastric tube to wall suction may be necessary to decompress the stomach (Option C). IV fluid and electrolyte replacement (eg, normal saline) may be necessary to correct losses that occur from nasogastric suction (Option B). Nausea can be treated with prescribed antiemetics (eg, ondansetron, promethazine) (Option D). (Option A) The client should not take medications by mouth (due to NPO status), and opioid medications should be avoided as they prolong paralytic ileus. Instead, non-opioid IV analgesics (eg, ketorolac, ibuprofen, acetaminophen) should be administered as prescribed if the client is in pain. Educational objective: Opioid medications can worsen constipation and paralytic ileus and therefore should be avoided in high-risk clients (eg, stroke, post abdominal surgery).

Question 7

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites.  Which assessment finding indicates that the albumin has been effective?

Accepted Answer

Ascites is the accumulation of fluid in the peritoneal space that often occurs in clients with liver cirrhosis. Ascitic fluid increases abdominal pressure, resulting in weight gain, abdominal distension and discomfort, and shortness of breath. Paracentesis (ie, needle insertion through the abdomen into the peritoneum to remove ascitic fluid) is often performed to reduce symptoms of ascites. However, clients undergoing paracentesis must be monitored closely for hypotension as changes in abdominal pressure often result in systemic vasodilation. Clients may receive IV albumin (a colloid) after paracentesis, which increases intravascular oncotic pressure resulting in increased intravascular fluid volume. Albumin administration prevents hypotension and tachycardia by mitigating hemodynamic changes associated with paracentesis (Option D). (Options A and C) Decreased abdominal circumference and improved respiratory effort occur in clients with ascites after ascitic fluid is removed via paracentesis. Albumin does not directly reduce ascitic fluid volume. (Option B) Asterixis (ie, flapping hand tremors during arm extension) occurs due to elevated blood ammonia levels. Lactulose is commonly used to treat asterixis as it promotes ammonia excretion. Albumin does not affect ammonia excretion. Educational objective: Clients undergoing paracentesis to alleviate symptoms related to ascites are at risk for hypotension due to changes in abdominal pressure. IV albumin increases intravascular fluid volume and may be used to prevent hypotension associated with paracentesis.

Question 8

Which of the following diets would place a client at the highestrisk for macrocytic anemia?

Accepted Answer

Megaloblastic anemia is caused by vitamin B₁₂ or folic acid deficiency. Vitamin B₁₂ deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B₁₂ is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B₁₂ only if they accidentally contain animal particles. Natural sources of vitamin B₁₂ include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B₁₂ as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B₁₂. Individuals who practice any form of vegetarianism are at risk for vitamin B₁₂ deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B₁₂ supplement is recommended when dietary intake is inadequate. (Option A) Lacto-ovo-vegetarian - eggs, milk, and milk products are included, but no meat is consumed. (Option B) Lacto-vegetarian - milk and milk products are included in the diet; eggs and meats are excluded. (Option C) Macrobiotic - whole grains, vegetables, fruits, and seaweeds are emphasized; fish and seafood may be included in the diet up to several times a week. Educational objective: Individuals who follow a plant-based diet, especially vegans, are at risk for vitamin B₁₂ deficiency and the resulting macrocytic anemia.

Question 9

The family practice clinic nurse is conducting client intake histories. Which client findings or histories indicate a need for heightened concern that the client may have cancer? Select all that apply.

Accepted Answer

Unintentional weight loss of >10% of usual weight (in non-obese clients) requires evaluation and could indicate underlying cancer. Nausea, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss (Option D). The warning signs of cancer can be remembered with the acronym CAUTION: Change in bowel or bladder habitsA sore that does not healUnusual bleeding or discharge from a body orificeThickening or a lump in the breast or elsewhereIndigestion or difficulty in swallowingObvious change in a wart or moleNagging cough or hoarseness (Option C) Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging cough or hoarseness (Option C) Although 99% of breast cancers are found in women, men can also develop breast cancer, especially if risk factors, such as past chest radiation, are present. Later signs of breast cancer include a newly retracted nipple or an orange-peel appearance of the breast tissue (peau d'orange) caused by the plugging of dermal lymph drainage (Option E). breast cancer (Option A) BPH is caused by hormonal changes related to aging. Growth is not related to cancer. (Option B) Lipomas are benign, fatty masses and rarely become malignant. They are subcutaneous, have a soft doughy feel, and are mobile and asymptomatic. Masses that are hard and fixed, not soft and mobile, usually indicate malignancy. Lipomas Educational objective: Signs of potential cancer include unplanned weight loss, nagging cough/hoarseness, and dimpled skin (orange peel) on the breast. Hard, fixed masses, non-healing ulcers, and changing moles may also indicate malignancy and require further workup.

Question 10

A graduate nurse (GN) is caring for a client with acute appendicitis who is awaiting surgery. Which action by the GN would require the precepting nurse to intervene?

Accepted Answer

11ecbb05_c9c5_3d22_b433_73335da1f3f4_MD0009_00 Appendicitis is inflammation of the appendix often resulting from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. Appendicitis is often treated surgically via removal of the appendix (ie, appendectomy). Nurses caring for clients with appendicitis should avoid interventions that increase intestinal blood circulation, gut motility, or appendiceal intraluminal pressure. The application of heat to the abdomen (eg, heating pad, warm blanket) increases intestinal circulation and the risk for appendiceal perforation (Option C). (Option A) Pain and nausea may be managed with prescribed IV analgesics (eg, morphine) and antiemetics. (Option B) NPO status and vomiting contribute to dehydration, which frequently requires continuous IV fluids (eg, normal saline) to maintain fluid and electrolyte balance. (Option D) Food and drink increase gastric motility, thereby increasing circulation to the appendix and risk of perforation. The nurse should teach the client about remaining NPO before surgery. Educational objective: Appendicitis is an inflammation of the appendix that often requires surgical treatment. Nurses caring for clients with appendicitis should avoid applying heat to the abdomen as this increases appendiceal swelling and the risk of appendix perforation, which is a medical emergency.

Question 11

The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? Select all that apply.

Accepted Answer

NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet high in fiber-rich foods (eg, fruits, vegetables, legumes, whole grains) improves stool elimination, which helps prevent constipation and decreases the risk of colorectal cancer (Options A and E). Fiber-rich foods tend to have a low glycemic load (less sugar per serving) and are nutrient dense, yet they have lower caloric density. Clients may also experience increased satiety as fiber absorbs water and produces fullness. This may help reduce caloric intake, improve blood glucose control, and promote weight loss (Options B and C). Fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of dietary cholesterol that enters the bloodstream. Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis. A high intake of fiber-rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery disease and stroke (Option D). Educational objective: Dietary fiber increases stool bulk and makes stool softer and easier to pass. A fiber-rich diet helps prevent constipation; decreases risk of colorectal cancer; promotes weight loss; improves blood glucose control; and decreases serum cholesterol levels, which reduces the risk of coronary artery disease and stroke.

Question 12

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms?

Accepted Answer

Hematocrit (Hct) is the percentage of red blood cells (RBCs) in a volume of whole blood. Hct and hemoglobin (Hgb) values are related (approximately 3 x Hgb = Hct); when one value is decreased, the other is also. This client likely has hemoglobin of 7 g/dL (70 g/L) (normal, 13.2-17.3 g/dL [132-173 g/L] for males and 11.7-15.5 g/dL [117-155 g/L] for females). Hgb is a component of the RBC that carries oxygen to the body's tissues. A decrease in Hgb decreases oxygen-carrying capacity and transport to tissues. RBCs may be 100% saturated with oxygen at rest, but desaturation may occur with increased activity and oxygen demand in the presence of decreased Hct and Hgb. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia. (Option A) Brain natriuretic peptide (BNP) >100 pg/mL (100 pmol/L) is considered elevated and indicates ventricular stretch (heart failure) as the cause of the dyspnea. This client has normal BNP levels, making heart failure an unlikely cause. (Option C) The leukocyte count is decreased (normal, 4,000-11,000/mm³ [4.0-11.0 x 10⁹/L]). Leukocytes play a role in protecting the body from disease. (Option D) The platelet count is decreased (normal, 150,000-400,000/mm³ [150-400 x 10⁹/L]). Platelets play a role in blood clotting. Educational objective: Hemoglobin is a component of red blood cells that carries oxygen to the body's tissues. In the presence of decreased hematocrit and hemoglobin, decreased oxygen-carrying capacity and transport occur. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia.

Question 13

The nurse assesses for cancer risk factors during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply.

Accepted Answer

11ecbb05_c9c9_34c5_b433_6f38cbdfddab_MD0009_00 Esophageal cancer is a rare, rapidly growing malignancy of the esophageal lining with a low 5-year survival rate. Squamous cell carcinoma usually develops in the upper part of the esophagus, whereas adenocarcinoma usually develops in the lower part. Major risk factors include smoking (eg, cigarettes, pipe, cigars) and excessive alcohol consumption (ie, approximately >15 drinks/week for men, >8 drinks/week for women) (Options A and C). Barrett esophagus is also a significant risk factor for esophageal cancer; this condition occurs when the distal portion of the esophagus develops precancerous changes. Obesity (which allows stomach acid to flow upward into the esophagus due to increased abdominal pressure) and uncontrolled gastroesophageal reflux disease contribute to the development of Barrett esophagus; they are both closely linked with esophageal cancer (Options B and D). (Option E) Consumption of salty foods is not associated with an increased risk of esophageal cancer but increases the risk of gastric cancer. Dietary factors that may increase a client's risk of esophageal cancer include high intake of nitrosamine-containing foods (eg, pickled foods, beer), frequent ingestion of extremely hot beverages (thermal injury), and deficient intake of fruits and vegetables. Educational objective: Esophageal cancer is a rapidly growing malignancy of the esophageal lining. Risk factors for esophageal cancer include smoking, excessive alcohol consumption, obesity, and gastroesophageal reflux disease.

Question 14

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.

Accepted Answer

11ecbb05_c9c7_6003_b433_cfea7293d7ef_MD0009_00 Peptic ulcer disease (PUD) is characterized by ulceration of the protective layers (ie, mucosa) of the esophagus, stomach, and/or duodenum. Mucosal "breaks" allow digestive enzymes and stomach acid to digest underlying tissues, leading to potential gastrointestinal bleeding and perforation. Risk factors for PUD include gastrointestinal Helicobacter pylori infections, genetic predisposition, chronic NSAID (eg, aspirin, ibuprofen, naproxen) use, stress, and diet and lifestyle choices. Nurses educating clients with PUD about ulcer prevention should focus on modifiable risk factors: NSAIDs: Chronic use of NSAIDs can damage the gastric mucosa and delay ulcer healing (Option A). Caffeine: Cola, tea, and coffee should be avoided as they stimulate stomach acid secretion (Option B). Smoking: Tobacco increases secretion of stomach acid and delays ulcer healing (Option C). Alcohol: Alcohol should be avoided as it stimulates stomach acid secretion and impairs ulcer healing (Option D). Meal timing: Eating multiple small meals throughout the day or eating shortly before sleeping may actually worsen PUD by increasing stomach acid secretion. (Option E) Evidence does not support the standard elimination of specific foods from the diet in clients with PUD. However, clients should avoid foods that exacerbate their symptoms. Educational objective: Peptic ulcer disease (PUD) is a gastrointestinal illness caused by breaks in the gastrointestinal mucosa, leading to ulcer formation. To reduce ulcer formation risk, clients with PUD should be instructed to stop smoking; avoid chronic NSAID use; avoid meals or snacks before sleeping; and limit alcohol and caffeine consumption.

Question 15

A nurse is evaluating the teaching of weight reduction strategies to a client with obesity. Which of the following statements indicate that the client understands the teaching? Select all that apply.

Accepted Answer

Clients aiming to achieve a healthy weight must take a multifaceted approach to eating and implement lifestyle changes. The nurse can assist clients with these changes by helping them form realistic and consistent modifications. Effective strategies include: Eliminating sugar-containing beverages (eg, soda, juice, alcohol) to decrease non-nutritive caloric intake Setting realistic goals to maintain motivation and prevent frustration and abandoned efforts; 1-2 lb (0.45-0.91 kg) per week is a healthy, realistic goal (Option B). Planning healthy meals and keeping nutritious snacks readily available to decrease likelihood of poor dietary choices (eg, fast food, vending machines) (Option C) Eating small, frequent meals to decrease hunger and tendency to overeat Exercising about 30-60 minutes daily to promote weight reduction. Even small changes (eg, parking further away, using stairs instead of the elevator) can have long-term benefits (Option E). Getting adequate sleep (usually about 7-9 hours/night); sleep deprivation is associated with weight gain and obesity. (Option A) Juice contains high amounts of natural sugar and is not an appropriate alternative for soda. (Option D) Skipping meals for caloric reduction has been shown to increase the tendency to overeat at subsequent meals. Educational objective: To promote effective weight loss, the nurse teaches the client to eliminate sugar-containing beverages; aim to lose about 1-2 lb (0.45-0.91 kg) per week; eat small, frequent meals; incorporate daily exercise with increasing intensity; and get about 7-9 hours of sleep per night.

Question 16

An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3 hours.  Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion?

Accepted Answer

The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started (Option D). (Options A and B) Hypotension is a sign of a transfusion reaction and is not expected. Bedrest is not required, but the client should be assisted if out of bed during a transfusion to prevent falls. Educational objective: An acute hemolytic transfusion reaction is a life-threatening reaction caused primarily by blood incompatibility. If it occurs, the transfusion should be stopped and a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. Asking the client to void prior to starting the transfusion helps ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion.

Question 17

A 78-year-old client recovering from a hip fracture tells the home health nurse, "I haven't had much of an appetite lately and have been really tired. I'm worried I'm not eating enough." Which question is the priority for the nurse to ask?

Accepted Answer

Malnutrition occurs when there is insufficient nutrient intake to meet body needs and relates to multiple factors (eg, poor diet, chronic illness, physical or cognitive impairments). Malnutrition may impair critical physiologic processes (eg, organ and immune system function, wound healing) and can have rapid and potentially lethal implications. Therefore, nurses should frequently assess clients for malnutrition, particularly those at increased risk (eg, advanced age, altered functional status). Assessing for malnutrition involves collecting dietary data (eg, 24-hour diet recall), laboratory values (eg, albumin or prealbumin), physical measurements (eg, BMI), and history of recent weight loss (Option C). Reports of weight loss, especially unintentional, are critical findings often indicative of malnutrition. In addition, weight loss of ≥5% in 1 month or ≥10% in 6 months may indicate serious conditions (eg, cancer, tuberculosis, failure to thrive). (Option A) Impaired functional status may contribute to a client's malnutrition. The nurse should prioritize assessing for the presence of malnutrition before assessment of contributing factors. (Option B) Assessment of psychologic factors (eg, depression, loneliness) is important to determine possible reasons for malnutrition but should be performed only after determining the extent of malnutrition. (Option D) Meal frequency, eating habits, and recent diet changes are possible contributing factors leading to malnutrition that should be assessed after determining malnutrition risk. Educational objective: Malnutrition occurs when nutrient intake is insufficient for body requirements. Nurses evaluating clients for malnutrition should first assess for unintentional weight loss, an important indicator of malnourishment. Afterwards, contributing factors of malnutrition (eg, functional status, mood alteration, diet) should be evaluated.

Question 18

The public health nurse identifies which of the following clients as being at high risk for developing colorectal cancer? Select all that apply.

Accepted Answer

Colorectal cancer is the third most common cancer and the second leading cause of cancer deaths affecting both genders equally. Various risk factors for colorectal cancer include: Personal or family (first-degree relative) history of colorectal cancer/polyps Personal history of inflammatory bowel disease, Crohn's disease, or ulcerative colitis History of hereditary non-polyposis colorectal cancer (Lynch syndrome) Lifestyle factors such as obesity, a diet high in red meat, cigarette smoking, and alcohol consumption (Option D) Eating fruits, vegetables, and grains may decrease colorectal cancer risk but diets high in fat and low in fiber increase this risk. Educational objective: Medical risk factors for colorectal cancer include a personal or family history of inflammatory bowel disease. Lifestyle risk factors include a history of obesity, a diet high in red meat, cigarette smoking, and alcohol consumption.

Question 19

Which client is at greatest risk for pulmonary embolism?

Accepted Answer

Death from pulmonary embolism is often attributed to a missed diagnosis. Early identification of risk factors (eg, venous stasis, hypercoagulability of blood, endothelial damage) can have a positive effect on client outcome. This postoperative client is at greatest risk due to the presence of the following 4 risk factors: Abdominal cesarean section surgery (endothelial damage) Engorged pelvic vessels from pregnancy (venous stasis, hypercoagulability of blood) Inactivity/immobility ≥6 hours related to positioning during surgery and the immediate postoperative period and epidural anesthesia (venous stasis) Postpartum state (hypercoagulability of blood) (Option B) In atrial fibrillation, stasis and turbulence of blood increases risk of thrombus formation. Once mobilized, emboli can get trapped in blood vessels causing ischemia. Smaller vasculature and increased blood flow in the brain increases the probability of a stroke, rather than PE. This client has 1 risk factor and is not at greatest risk for PE. (Option C) The presence of a subdural hematoma does not pose a significant risk for PE unless the client has been immobile. Many clients with subdural hematomas are asymptomatic and walking. This client is not at greatest risk for PE. (Option D) Any acute medical illness (eg, pneumonia) can predispose a client to PE from inflammation and the client's relative immobility. However, this risk is lower than the risk for PE from major surgery. Educational objective: Death from pulmonary embolism (PE) is often attributed to a missed diagnosis. Nurses must recognize any condition or situation that predisposes a client to venous stasis, hypercoagulability of blood, and endothelial damage, as these factors increase the risk for PE.

Question 20

A nurse is screening clients at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? Select all that apply.

Accepted Answer

Cancer is a growth of abnormal cells in an organ system that may impair the organ's function and spread throughout the body. Many cancers are invasive and life threatening if allowed to reach late stages of development. However, cancer is often difficult to identify early as the client may be asymptomatic or have only vague symptoms. Nurses should screen clients for and immediately report warning signs of cancer, which can be remembered with the mnemonic CAUTION: Change in bowel or bladder habits (Option E) A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere (Option C) Indigestion or difficulty in swallowing that does not go away Obvious change in a wart or mole (Option D) Nagging cough or hoarseness (Option A) A productive cough that is annual and seasonal, particularly occurring in the winter, may indicate chronic bronchitis. The nagging cough found in clients with lung cancer is persistent, rather than seasonal. (Option B) A client report of occasional indigestion after specific triggers (eg, high-fat or spicy food, caffeine) may indicate gastroesophageal reflux disease. However, indigestion that is persistent or chronic indigestion may indicate cancer. Educational objective: Warning signs of cancer for nurses to monitor include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or a lump in the breast or elsewhere, indigestion or difficulty swallowing, any obvious change in a wart or mole, and nagging cough or hoarseness (mnemonic: CAUTION).

Exam 1: Adult Health

A nurse is preparing a presentation about behavioral modifications to support weight loss for clients at an obesity clinic. Which of the following points should the nurse include in the teaching plan? Select all that apply.

The nurse is teaching general skin care guidelines to a client receiving teletherapy (external beam radiation therapy) . Which statements does the client make that indicate proper understanding of the teaching? Select all that apply.

A client with throat cancer receives radiation therapy to the head and neck. Which strategies are appropriate to increase oral intake? Select all that apply.

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed?

A client diagnosed with head and neck cancer has developed mouth sores related to external radiation therapy. The nurse teaches the client to use which of the following oral hygiene practices? Select all that apply.

A nurse is caring for a client who developed paralytic ileus after a stroke. The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent. Which prescription does the nurse question?

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective?

Which of the following diets would place a client at the highestrisk for macrocytic anemia?

The family practice clinic nurse is conducting client intake histories. Which client findings or histories indicate a need for heightened concern that the client may have cancer? Select all that apply.

A graduate nurse (GN) is caring for a client with acute appendicitis who is awaiting surgery. Which action by the GN would require the precepting nurse to intervene?

The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? Select all that apply.

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms?

The nurse assesses for cancer risk factors during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply.

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.

A nurse is evaluating the teaching of weight reduction strategies to a client with obesity. Which of the following statements indicate that the client understands the teaching? Select all that apply.

A 78-year-old client recovering from a hip fracture tells the home health nurse, "I haven't had much of an appetite lately and have been really tired. I'm worried I'm not eating enough." Which question is the priority for the nurse to ask?

The public health nurse identifies which of the following clients as being at high risk for developing colorectal cancer? Select all that apply.

Which client is at greatest risk for pulmonary embolism?

A nurse is screening clients at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? Select all that apply.