N434 Exam 3 Questions

A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to

a. emphasize the positive outcomes of a bone marrow transplant.

b. discuss the need for adequate insurance to cover post-HSCT care.

c. ask the patient whether there are any questions or concerns about HSCT.

d. explain that a cure is not possible with any other treatment except HSCT.
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A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to

a. emphasize the positive outcomes of a bone marrow transplant.

b. discuss the need for adequate insurance to cover post-HSCT care.

c. ask the patient whether there are any questions or concerns about HSCT.

d. explain that a cure is not possible with any other treatment except HSCT.
c. ask the patient whether there are any questions or concerns about HSCT.
Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation?

a. The patient has type 1 diabetes.

b. The patient has metastatic lung cancer.

c. The patient has a history of chronic hepatitis C infection.

d. The patient is infected with the human immunodeficiency virus.
b. The patient has metastatic lung cancer.
Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation?

a. Postural hypotension

b. Recurrent tachycardia

c. Knee and hip joint pain

d. Increased serum creatinine
c. Knee and hip joint pain
A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone). Which assessment data will be of most concern to the nurse?

a. The blood glucose is 144 mg/dL.

b. There is a nontender axillary lump.

c. The patient's skin is thin and fragile.

d. The patient's blood pressure is 150/92.
b. There is a nontender axillary lump. --> potential malignancy such as lymphoma
The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider?

a. The urine output is 900 to 1100 mL/hr.

b. The patient's central venous pressure (CVP) is decreased.

c. The patient has a level 7 (0 to 10 point scale) incisional pain.

d. The blood urea nitrogen (BUN) and creatinine levels are elevated.
b. The patient's central venous pressure (CVP) is decreased. --> suggests hypovolemia
The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider?

a. Heart rate

b. Urine output

c. Creatinine clearance

d. Blood urea nitrogen (BUN) level
b. Urine output
The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement?

a. "I will make an appointment to see the doctor every year."

b. "I will stop taking the prednisone if I experience a dry cough."

c. "I will not worry if I feel a little short of breath with exercise."

d. "I will call the health care provider right away if I develop a fever."
d. "I will call the health care provider right away if I develop a fever." --> could indicate infection or acute rejection
Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patient's skin rash?

a. The donor T cells are attacking the patient's skin cells.

b. The patient's antibodies are rejecting the donor bone marrow.

c. The patient is experiencing a delayed hypersensitivity reaction.

d. The patient will need treatment to prevent hyperacute rejection.
a. The donor T cells are attacking the patient's skin cells. --> graft vs host disease
The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

a. "After a couple of years, it is likely that I will be able to stop taking the cyclosporine."

b. "If I develop an acute rejection episode, I will need to have other types of drugs given IV."

c. "I need to be monitored closely because I have a greater chance of developing malignant tumors."

d. "The drugs are given in combination because they inhibit different ways the kidney can be rejected."
a. "After a couple of years, it is likely that I will be able to stop taking the cyclosporine." --> will need to take for life
An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time?

a. The patient restricts salt to treat prehypertension.

b. The patient drinks 3 to 4 quarts of fluids every day.

c. The patient has many concerns about the effects of cyclosporine.

d. The patient has a glass of grapefruit juice every day for breakfast.
d. The patient has a glass of grapefruit juice every day for breakfast.
A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Administration of immunosuppressant medications b. Insertion of an arteriovenous graft for hemodialysis c. Placement of the patient on the transplant waiting list d. A blood draw for human leukocyte antigen (HLA) matchinga. Administration of immunosuppressant medicationsThe charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplantc. A patient who is recovering from an anaphylactic reaction to a bee sting --> no increased exposure to infection from this patientA nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor cross matching are positive d. Panel of reactive antibodies (PRA) percentage is lowc. Results of patient-donor cross matching are positive --> contraindication to kidney transplantationA patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan? a. Transplant of the donated cells is painful because of the nerves in the tissue lining the bone. b. Donor bone marrow cells are transplanted through an incision into the sternum or hip bone. c. The transplant procedure takes place in a sterile operating room to minimize the risk for infection. d. Hospitalization will be required for several weeks after the stem cell transplant procedure is performed.d. Hospitalization will be required for several weeks after the stem cell transplant procedure is performed. --> strict protective isolation to prevent infection for 2-4 weeks after HSCTA patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hoursc. Serum sodium level of 120 mg/dL --> hyponatremia is most important finding to reportFamily members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best? a. "This type of monitoring system is complex and it is managed by skilled staff." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."b. "The monitoring system helps show whether blood flow to the brain is adequate." --> short & simple explanationAdmission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 154/68, pulse 56, respirations 12 b. Blood pressure 134/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30a. Blood pressure 154/68, pulse 56, respirations 12 --> Cushing's triad - indicate ICP has increasedWhen a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.c. decorticate posturing.The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Blood pressure b. Oxygen saturation c. Intracranial pressure d. Hemoglobin and hematocritc. Intracranial pressureAn unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Refer the family members to the hospital counseling service to deal with their anxiety. d. Call the family's pastor or spiritual advisor to take them to the chapel while care is given.b. Allow the family to stay with the patient and briefly explain all procedures to them.A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing. b. Position the patient with knees and hips flexed. c. Keep the head of the bed elevated to 30 degrees. d. Cluster nursing interventions to provide rest periods.c. Keep the head of the bed elevated to 30 degrees.A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.b. Check the drainage for glucose content. --> if drainage is CSF, will test positive for glucoseWhich action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI). d. Arrange to admit the patient to the neurologic unit for 24 hours of observation.b. Provide discharge instructions about monitoring neurologic status.A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Prepare the patient for craniotomy. c. Initiate high-dose barbiturate therapy. d. Type and crossmatch for blood transfusion.b. Prepare the patient for craniotomy. --> need to remove hematomaThe nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours d. Apply cold packs intermittently to face.b. Insert nasogastric tube to low suction. --> rhinorrhea may indicate dural tear with CSF leakage -- NG tube decreases risk for infectionsA college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Short-term memory b. Muscle coordination c. Glasgow Coma Scale d. Pupil reaction to lighta. Short-term memoryWhich statement by a 40-year-old patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache."b. "I am going to drive home and go to bed."After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. cluster nursing activities to allow longer rest periods. b. turn and reposition the patient side to side every 2 hours. c. position the bed flat and log roll to reposition the patient. d. perform range-of-motion (ROM) exercises every 4 hours.d. perform range-of-motion (ROM) exercises every 4 hours. --> prevents complications of immobilityA 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.a. Encourage family members to remain at the bedside.A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.b. Report the BP and ICP to the health care provider.After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.b. Ensure that the patient's neck is in neutral position.A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a. Administer IV 5% hypertonic saline. b. Draw blood for arterial blood gases (ABGs). c. Send patient for computed tomography (CT). d. Administer acetaminophen (Tylenol) 650 mg orally.a. Administer IV 5% hypertonic saline. --> hyponatremia may be causing cerebral edemaAfter the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 c. A 40-year-old patient who lost consciousness for a few seconds after a fall d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to lightd. A 50-year-old patient whose right pupil is 10 mm and unresponsive to lightThe nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? a. Complaint of severe headache b. Large contusion behind left ear c. Bilateral periorbital ecchymosis d. Temperature of 101.4° F (38.6° C)d. Temperature of 101.4° F (38.6° C) --> basillar skull fracture = risk for meningitisAfter evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? a. Pulse 102 beats/min b. Temperature 101.6° F c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hgb. Temperature 101.6° F --> indicates need for antibiotics or removal of monitorWhich information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 25 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia at 128 beats/minutec. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg --> should be 20-40 mmHgThe nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse? a. The apical pulse is slightly irregular. b. The patient complains of a headache. c. The patient is more difficult to arouse. d. The blood pressure (BP) increases to 140/62 mm Hg.c. The patient is more difficult to arouse.Which finding for a patient who has a head injury should the nurse report immediately to the health care provider? a. Intracranial pressure is 16 mm Hg when patient is turned. b. Pale yellow urine output is 1200 mL over the last 2 hours. c. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg. d. Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours.b. Pale yellow urine output is 1200 mL over the last 2 hours. --> indicates diabetes insipidus may be developingA patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order for collaborative intervention should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.d. Swab the nasopharyngeal mucosa for cultures. --> need culture before antibiotics can be startedA patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Elevate the head of the bed 20 degrees. b. Restrict oral fluids to 1000 mL daily. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.b. Restrict oral fluids to 1000 mL daily. --> need increased fluidsA 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.c. The patient reports that symptoms began with a severe headache. --> sudden onset headache is typical of subarachnoid hemorrhage & aspirin is contraindicatedA 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructionsd. Difficulty comprehending instructionsA 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.d. tissue plasminogen activator (tPA) infusion. --> suggests acute ischemic strokeA female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.a. ask questions that the patient can answer with "yes" or "no."For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.a. risk for injury related to denial of deficits and impulsiveness.A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.a. Apply intermittent pneumatic compression stockings. --> risk for blood clotsA 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.c. assist the patient into a chair. --> should be uprightSeveral weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.b. Assist the patient onto the bedside commode every 2 hours. --> regular voiding scheduleWhich stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.c. The patient's usual blood pressure (BP) is 170/94 mm Hg.A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).d. The patient has atrial fibrillation and takes warfarin (Coumadin).A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scand. Noncontrast computed tomography (CT) scanWhich information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).b. The patient's blood pressure (BP) is 90/50 mm Hg. --> needs to be higher than 90 to maintain perfusionAfter receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduleda. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed --> tPA needs to be infused within first few hrs after stroke symptoms to be effectiveWhich laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassiumc. AmylaseWhich assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Abdominal tenderness and guarding d. Muscle twitching and finger numbnessd. Muscle twitching and finger numbness --> hypocalcemiaThe nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.d. alcohol consumption.The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) a. at bedtime. b. in the morning. c. with each meal. d. for abdominal pain.c. with each meal.When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.c. Check the calcium level in the chart. --> risk for hypocalcemia, data indicates Trousseau's signA 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.d. Abdominal pain is decreased. --> will decrease release of pancreatic enzymes into pancreas & decrease painWhich assessment finding is of most concern for a 46-year-old woman with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal massd. Palpable abdominal mass --> may indicate pancreatic abscessThe nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance.a. maintaining normal respiratory function.The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority? a. Offer psychologic support for depression. b. Offer high-calorie, high-protein dietary choices. c. Administer prescribed opioids to relieve pain as needed. d. Teach about the need to avoid scratching any pruritic areas.c. Administer prescribed opioids to relieve pain as needed.Which statement by a 50-year-old female patient indicates to the nurse that further assessment of thyroid function may be necessary? a. "I notice my breasts are tender lately." b. "I am so thirsty that I drink all day long." c. "I get up several times at night to urinate." d. "I feel a lump in my throat when I swallow."d. "I feel a lump in my throat when I swallow." --> goiterWhich question will provide the most useful information to a nurse who is interviewing a patient about a possible thyroid disorder? a. "What methods do you use to help cope with stress?" b. "Have you experienced any blurring or double vision?" c. "Have you had a recent unplanned weight gain or loss?" d. "Do you have to get up at night to empty your bladder?"c. "Have you had a recent unplanned weight gain or loss?"A 61-year-old female patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for _____ levels. a. calcitonin b. catecholamine c. thyroid hormone d. parathyroid hormoned. parathyroid hormoneDuring the physical examination of a 36-year-old female, the nurse finds that the patient's thyroid gland cannot be palpated. The most appropriate action by the nurse is to a. palpate the patient's neck more deeply. b. document that the thyroid was nonpalpable. c. notify the health care provider immediately. d. teach the patient about thyroid hormone testing.b. document that the thyroid was nonpalpable. --> thyroid is frequently nonpalpableWhich laboratory value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland or with the thyroid gland? a. Thyroxine (T4) level b. Triiodothyronine (T3) level c. Thyroid-stimulating hormone (TSH) level d. Thyrotropin-releasing hormone (TRH) levelc. Thyroid-stimulating hormone (TSH) level --> low TSH level indicates it's caused by decreased anterior pituitary secretion of TSHWhich action by a new registered nurse (RN) caring for a patient with a goiter and possible hyperthyroidism indicates that the charge nurse needs to do more teaching? a. The RN checks the blood pressure on both arms. b. The RN palpates the neck thoroughly to check thyroid size. c. The RN lowers the thermostat to decrease the temperature in the room. d. The RN orders nonmedicated eye drops to lubricate the patient's bulging eyes.b. The RN palpates the neck thoroughly to check thyroid size.A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate? a. "Because you have diabetes, you would not be a candidate for a heart transplant." b. "The choice of a patient for a heart transplant depends on many different factors." c. "Your heart failure has not reached the stage in which heart transplants are needed." d. "People who have heart transplants are at risk for multiple complications after surgery."b. "The choice of a patient for a heart transplant depends on many different factors." --> coping skills, family support, & motivation to follow post-transplant regiment need to be considered as wellWhich finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? a. Dry palpebral and oral mucosa b. Crackles at bilateral lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 daysc. Temperature 100.8° F (38.2° C) --> can indicate infection