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

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

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

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

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

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

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

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

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

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

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

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

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

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Rationale: Ketones are a byproduct of fat metabolism. When this process occurs to the
extreme, it is termed ketoacidosis. “Glucose,” “glucagon,” and “lactic dehydrogenase”
are incorrect.
Test-Taking Strategy: Knowledge of the pathophysiology of glucose metabolism is
needed to answer this question. Remember that ketones are a byproduct of fat
metabolism. If this question was difficult, review the physiological process of fat
breakdown.
PTS: 1
DIF: Level of Cognitive Ability: Understanding
REF: Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for
positive outcomes (8th ed.). St. Louis: Saunders.
OBJ: Client Needs: Physiological Integrity
TOP: Content Area: Adult Health/Endocrine
MSC: Integrated Process: Nursing Process—Assessment
23. The client with diabetes mellitus is being tested to determine long-term diabetic control.
Which of the following results would the nurse expect to see if the client’s long-term
control is within acceptable limits?
1. Glycosylated hemoglobin of 6%
2. Fasting blood glucose level of 150 mg/dL
3. Presence of ketones in the urine
4. Presence of albumin in the urine
ANS: 1
Rationale: This measurement of glycosylated hemoglobin (Hb A1c) detects glucose
binding on the red blood cell (RBC) membrane and is expressed as a percentage. It
measures glucose for the life of the RBC, which is 120 days. The fasting blood glucose
level should be lower than 130 mg/dL. The urine should be free of both ketones and
urine.
Test-Taking Strategy: Specific knowledge of the effects of an increased blood glucose
level in the body is necessary to answer this question. Noting the words “long-term” will
direct you to “glycosylated hemoglobin of 6%.” Review the alterations in normal
physiology that occur with diabetes mellitus if you had difficulty with this question.
PTS: 1
DIF: Level of Cognitive Ability: Analyzing
REF: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ: Client Needs: Physiological Integrity
TOP: Content Area: Adult Health/Endocrine
MSC: Integrated Process: Nursing Process—Assessment

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

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

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