exam 3 bonus point questions

clinical findings of compartment syndrome

- Pain out of proportion/worsening pain - Pain with passive stretch of compartment - Pain with active flexion of involved muscles - Parasthesia in distribution of affected nerves - Palpation revelas tight compartment

The nurse is performing a skin assessment of a client. Which findings may indicate a risk of skin cancer? Select all that apply. One, some, or all responses may be correct. 1 Lesion 2 Lumps 3 Rashes 4 Bruising 5 Dryness

1,2,3 Lesions on the skin that take a long time to heal may indicate skin cancer. Lumps and rashes on the skin are characteristics of skin cancer. Bruising may indicate a bleeding disorder or injury. Dryness of the skin may be due to excessive bathing and use of harsh soaps

The nurse would assess a client with melanoma for which clinical finding? 1 Firm, nodular lesion with a crusty top 2 Irregularly shaped, pigmented papule 3 Small papule with dry, rough, brown scale 4 Pearly papule with a central crater and waxy border

2. Melanoma is an irregularly shaped, pigmented papule or plaque. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or with a central area of ulceration. Actinic keratosis is a small macule or papule with dry, rough, adherent yellow or brown scale. Basal cell carcinoma is a pearly papule with a central crater and rolled, waxy borders.

Which behavior would the nurse recognize as developmentally atypical in preschoolers? Incorrect1 Thumb sucking during stress 2 Feeling guilty for behaving inappropriately 3 Feeling happy if there is a newborn in the family 4 Curiosity about their surroundings

3 Preschoolers are unlikely to feel happy with the birth of a new baby in the family; they are likely to feel stress and exhibit jealousy. Preschoolers may revert to bed-wetting or thumb sucking during times of stress. Guilt arises in children when they believe that they have not behaved correctly. Preschoolers tend to be curious about their environment.

physiologic change anaerobic metabolism vasodilation increased blood flow increased tissue pressure

clinical finding cyanosis increased edema tense muscle swelling tingling/numbness

Which type of play would the nurse expect of a 5-year-old child while interacting with other children? 1 Team 2 Parallel 3 Initiative 4 Cooperative

4 Cooperative play is typical of 5-year-old children as they learn to share and take turns without becoming frustrated. Team play is typical of older school-aged children who play games with other children and learn to abide by the rules. Parallel play is typical of the toddler age group; toddlers have not yet learned to interact with other toddlers in a social situation. Initiative play does not typify any age group; it is not a recognized term of social play.

Which statement by the client indicates the need for further learning about skin cancer prevention? 1 "I should use sunscreen before going outside." 2 "I should limit sun exposure to between 7 AM and 12 PM." 3 "I should wear a hat and opaque clothing when going out." 4 "I should have regular examinations of precancerous lesions."

2 In prevention of skin cancer, the client should not be out in the sun at midday. This is the time when the sunlight is strongest. Using sunscreen protects a client's skin from the sun's rays. The client should wear a hat and opaque clothing when going out. Going for monthly examination of cancerous and precancerous lesions is recommended.

A 6-month-old infant is to receive scheduled immunizations. The parents ask why two influenza vaccines are given: Haemophilus influenzae type B (Hib) and pneumococcal conjugate vaccine (PCV). Which response by the nurse is appropriate? 1 "PCV prevents influenza." 2 "Hib is given to prevent pneumonia." 3 "Hib and PCV prevent different bacterial diseases." 4 "They are given together to protect against viral and bacterial diseases."

3 Both vaccines protect against bacterial infections. The PCV protects against bacterial pneumonia. The Hib vaccine protects against bacterial infections caused by Haemophilus influenzae type B; these include otitis media, meningitis, epiglottitis, septic arthritis, and sepsis. The PCV conjugate vaccine protects against infections caused by the Streptococcus pneumoniae bacterium (pneumococcal pneumonia).

To implement primary prevention of sexually transmitted infections (STIs) the nurse is counseling an adolescent. Which would be the priority nursing action? 1 Help the adolescent recognize the risk. 2 Provide complete information about STIs. 3 Assess the adolescent's sexual risk behaviors. 4 Educate the adolescent about proper preventive measures

3 The priority step for primary STI prevention is to assess the sexual risk behavior of the adolescent to identify the risk factors and provide appropriate counseling accordingly. With that information in mind, the nurse can then help the adolescent recognize the risk, encourage usage of preventive measures, and provide proper information about STIs.

Which nursing activities are examples of primary prevention? Select all that apply. One, some, or all responses may be correct. 1 Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation 4 Assisting with immunization programs 5 Facilitating a program about the dangers of smoking

4,5 Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention.

The nurse suspects that a client has diabetes mellitus. Which statements made by the client helped the nurse reach this conclusion? Select all that apply. One, some, or all responses may be correct. 1 "I am 65 years old." 2 "I quite often feel thirsty." 3 "I eat food every 2 hours." 4 "I have excessive sweating." 5 "I sometimes experience shortness of breath."

1,2,3 Diabetes mellitus is more common in older clients. Clients with diabetes mellitus may feel excessive thirst due to frequent urination and may also experience excessive hunger. Excessive sweating and respiratory disorders are mostly observed in clients with hyperthyroidism.

Which ages are the most critical for speech development during the preschool years? Select all that apply. One, some, or all responses may be correct. 1 2 years 2 3 years 3 4 years 4 5 years 5 6 years

2,3 The most critical ages for speech development for the preschool-aged client are 3 and 4 years of age. Although critical speech development occurs at the age of 2, this is the toddler, not preschool, stage of development. The ages of 5 and 6 years are not considered critical ages for speech development for the preschool-aged client.

A child with type 1 diabetes is exhibiting deep, rapid respirations; flushed, dry cheeks; abdominal pain with nausea; and increased thirst. Which blood pH and glucose level would the nurse expect the laboratory tests to reveal? 1 7.20 and 60 mg/dL (3.3 mmol/L) 2 7.50 and 60 mg/dL (3.3 mmol/L) 3 7.50 and 460 mg/dL (25.5 mmol/L) 4 7.20 and 460 mg/dL (25.5 mmol/L)

4 A pH of 7.20 and blood glucose level of 460 mg/dL (25.5 mmol/L) are expected values in ketoacidosis; the pH of 7.20 indicates acidosis (metabolic), and the blood glucose level of 460 mg/dL (25.5 mmol/L) is higher than the expected range of 90 to 110 mg/dL (5.0-6.1 mmol/L). Although the blood pH of 7.20 indicates acidosis, the blood glucose of 60 mg/dL (3.3 mmol/L) is less than the expected range of 90 to 110 mg/dL (5.0-6.1 mmol/L), indicating hypoglycemia rather than hyperglycemia. Neither the pH of 7.50 nor the blood glucose value of 60 mg/dL (3.3 mmol/L) is expected with ketoacidosis; with ketoacidosis, the pH is decreased, and the blood glucose level is increased. Although the blood glucose is increased with ketoacidosis, the pH is decreased, not increased; a pH of 7.50 indicates alkalosis.

A client with diabetes mellitus complains of difficulty seeing. Which factor would the nurse suspect as being the cause? 1 Lack of glucose in the retina 2 The growth of new retina blood vessels or "neovascularization" 3 Inadequate glucose supply to rods and cones 4 Destructive effect of ketones on retinal metabolism

2 Proliferative diabetic retinopathy is the growth of new retinal blood vessels, also known as "neovascularization." When retinal blood flow is poor and hypoxia develops, retinal cells secrete growth factors that stimulate the formation of new blood vessels in the eye. These new vessels are thin, fragile, and bleed easily, leading to eye hemorrhage and vision loss. Hemorrhages in the eyes precipitate retinal detachment, resulting in blindness. There is an increase in serum glucose in clients with diabetes mellitus; thickening of the capillary basement membranes can occur, even if the glucose level is maintained within normal limits. Ketones do not affect retinal metabolism; retinopathy is a result of vascular changes, retinal detachment, and hemorrhage within the eye.

The public health nurse is developing a program geared toward primary prevention of domestic violence. Which information would the nurse include in the program for those at high risk? Select all that apply. One, some, or all responses may be correct. 1 Coping skills 2 Social support 3 Care for victims 4 Stress reduction 5 Screening programs

1,2,4 Primary prevention of domestic violence would include programs that prevent abuse from occurring. These would include working with high-risk people to improve coping skills and provide social support and stress reduction techniques. Secondary prevention provides intervention early in abusive relationships including caring for victims and screening programs for at-risk individuals.

Which education would the nurse provide the parents of an infant receiving the first diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) at 2 months of age? 1 Give the baby aspirin if there is pain. 2 Call the clinic if marked drowsiness occurs. 3 Apply ice to the injection site if there is swelling. 4 Provide heat at the injection site if redness occurs.

2 Altered level of consciousness (such as marked drowiness) and seizures are rare but serious complications of the pertussis vaccine. Aspirin should not be given to infants and children because it is associated with Reye syndrome. Infants are sensitive to the application of ice. Heat will cause an extension of the inflammatory response and should be avoided.

Which skin growth would require health care provider follow-up to evaluate for possible skin cancer? Select all that apply. One, some, or all responses may be correct. 1 Mole that is solid black 2 Mole with equal borders 3 Mole that is 12 mm wide 4 Mole of symmetrical size 5 Mole that has not changed

3 Melanomas are detected using the "ABCDE" method: asymmetry, border irregularity, color, diameter, and evolving. A mole that is 12 mm wide would need further assessment by the health care provider. Moles greater than 6 mm in diameter can indicate a melanoma. Moles that are solid black, have equal borders, are symmetrical, and have not changed would not be suspicious for melanoma and can be monitored.

When the international normalized ratio (INR) for a client receiving warfarin for venous thrombosis is 4.6, which action will the nurse take? 1 Administer the scheduled dose of warfarin. 2 Offer the client foods that are high in vitamin K. 3 Notify the health care provider of the laboratory results. 4 Warn the client about risk for spontaneous hemorrhage.

3 The therapeutic level for INR when treating a venous thrombosis is 2 to 3, so the nurse would notify the health care provider and anticipate a decrease in warfarin dosage. Administration of a scheduled warfarin dose would further increase the INR. Although vitamin K can decrease warfarin effectiveness, dietary vitamin K is not used to reverse high INR levels. Although higher INR levels may lead to spontaneous bleeding, an INR of 4.6 would not cause hemorrhage.

Which kind of health service would the nurse offer in a health promotion or primary care program? 1 Home care 2 Immunization 3 Sports medicine 4 Nutrition counseling

4 Health promotion or primary care focuses on improved health outcomes for the entire population. It includes nutrition counseling and health education. Home care is the provision of enabling medically related professional and paraprofessional services and equipment to clients and their families at home. Preventive care is more disease oriented. It focuses on reducing and controlling risk factors for diseases through immunizations and occupational health programs. Sports medicine is a form of restorative care. The goal of this program is to help individuals regain maximum functional status through promotion of independence and self-care.

physiologic change increased edema muscle ischemia tissue necrosis

clinical finding paresthesia severe pain unrelieved with drugs paresis/paralysis

physiologic change increased compartment pressure increased capillary permeability release of histamine increased blood flow to area

clinical findings no change edema increased edema pulses present, pink tissue

Which might an individual experience in Erikson's initiative versus guilt stage? Select all that apply. One, some, or all responses may be correct. 1 Pretends and tries out new roles 2 May develop a superego or a conscience 3 Thrives on his/her accomplishments and praise 4 May develop his/her autonomy by making choices 5 Fantasizes and imagines discovering the environment

1,2,5 In the initiative versus guilt stage, a 3- to 6-year-old child likes to pretend and try out new roles. In this stage, a child may develop a superego or a conscience. Also, a child may fantasize and imagine discovering the environment in this stage. In the industry versus inferiority stage, a 6- to 11-year-old child may thrive on his or her accomplishments and praise. In the autonomy versus sense of shame and doubt stage, a 1- to 3-year-old child may develop his or her autonomy by making choices.

A client is prescribed metformin extended release to control type 2 diabetes mellitus. Which statement made by this client indicates the need for further education? 1 "I will take the medication with food." 2 "I must swallow my medication whole and not crush or chew it." 3 "I will notify my doctor if I develop muscular or abdominal discomfort." 4 "I will stop taking metformin for 24 hours before and after having a test involving dye."

4 Metformin must be withheld for 48 hours before the use of iodinated contrast materials to prevent lactic acidosis. Metformin is restarted when kidney function has returned to normal. Metformin is taken with food to avoid adverse gastrointestinal effects. If crushed or chewed, metformin XL will be released too rapidly and may lead to hypoglycemia. Muscular and abdominal discomfort is a potential sign of lactic acidosis and must be reported to the health care provider.

The parents of a toddler ask the nurse about the importance of play for a child. Which is the best answer for the nurse to provide? 1 The child will develop creative skills later in life. 2 The children will learn and adopt their friends' cultures. 3 There is little evidence that play influences intelligence. 4 Play activities will help release the child's energy surplus.

4 Play activities develop the sensorimotor functions and help release the toddler's energy surplus. Toddlers develop creative skills while engaging in play, because they can experiment and try out their ideas through playful actions that may or may not help currently or later in life. Toddlers learn about different cultural values through play but are not mature enough to adopt them yet. Play stimulates language skills and intellectual development as toddlers learn about colors, shapes, sizes, textures, and the meaning of objects.

Which actions would the nurse expect to take for a client who has compartment syndrome? Select all that apply. One, some, or all responses may be correct. 1 Assisting with splitting the cast 2 Monitoring urine output 3 Evaluating pain using a pain scale 4 Applying splints to the injured part 5 Placing cold compresses to the affected area

1,2,3 Compartment syndrome is increased pressure in a limited space, which compromises the compartmental blood vessels, nerves, and tendons. The cast may be split to reduce the external circumferential pressures. The nurse would assess urine output because the myoglobin released from damaged muscle cells may precipitate and cause obstruction in renal tubules. The nurse would evaluate the pain on a scale from 0 to 10; this helps plan care. Application of external pressure by splints, casts, and dressing to the injured area may worsen the client's symptoms. Application of cold compresses may result in vasoconstriction and exacerbate the symptoms.

Which information would the nurse provide a client about tertiary prevention? Select all that apply. One, some, or all responses may be correct. 1 Focuses on preventing complications of illness 2 Helps clients achieve as high a level of functioning as possible 3 Aims at minimizing the effects of long-term disease or disability 4 Applied when the client is physically and emotionally healthy 5 Activities are aimed at diagnosis and treatment instead of rehabilitation

1,2,3 Tertiary prevention is also known as preventive care because it aims at preventing further disability or reduced functioning in the clients. Even though clients may have developed limitations due to illness or impairment, tertiary prevention helps in achieving as high a level of functioning as possible. Tertiary prevention makes use of interventions that prevent complications and deteriorations to minimize the effects of long-term disease or disability. Tertiary prevention is applied when the client has a defect or disability that is permanent and irreversible. Tertiary prevention activities focus on rehabilitative care instead of diagnosis and treatment.

Which client activities warrant the highest priority for education about health promotion to prevent head and neck cancer? Select all that apply. One, some, or all responses may be correct. 1 Chews tobacco 2 Multiple sex partners 3 Uses condoms when having sex 4 History of alcohol abuse for 5 years 5 Brushes with a soft-bristle toothbrush

1,2,4 Tobacco, alcohol, and human papilloma virus (HPV) are the major causes of neck cancer. The nurse would counsel the client who chews tobacco and educate regarding the importance of oral hygiene. The nurse would advise the client to stop chewing tobacco to reduce the risk of head and neck cancer. The nurse would educate the client with multiple sex partners about protecting against HPV, which is a risk factor for cancer. The nurse would place a high priority on health promotion in a client with a history of alcohol abuse for 5 years because it is 1 of the major risk factors for head and neck cancer. The client should use condoms when having sex with potentially infectious partners to prevent HPV infections that can lead to head and neck cancer. A client should maintain proper oral hygiene by brushing her or his teeth regularly with a soft-bristle brush and flossing.

The nurse is providing instructions about foot care for a client with diabetes mellitus. Which would the nurse include in the instructions? Select all that apply. One, some, or all responses may be correct. 1 Wear shoes when out of bed. 2 Soak the feet in warm water daily 3 Dry between the toes after bathing. 4 Remove corns as soon as they appear. 5 Use a heating pad when the feet feel cold

1,3 Wearing shoes protects the feet from trauma; they should fit well and should be worn over clean socks. Drying between the toes after bathing prevents maceration and skin breakdown, thus maintaining skin integrity. Soaking the feet is contraindicated because it can cause macerations and skin breakdown, which allow a portal of entry for pathogenic organisms. Clients should not self-treat corns, calluses, warts, or ingrown toenails because of the potential for trauma and skin breakdown; these conditions should be treated by a podiatrist. Use of a heating pad, hot water bottle, or hot water is contraindicated because of the potential for burns; diabetic neuropathy, if present, does not allow the client to accurately evaluate the extremes of temperature.

Which would be included in the assessment of a school health promotional program for adolescents? Select all that apply. One, some, or all responses may be correct. 1 Perform a school violence assessment. 2 Assess the sleep pattern of the students. 3 Identify individuals at risk for drug abuse. 4 Explain the need for fluoride supplements to prevent dental caries. 5 Instruct the students about principles of gun safety

1,3,5 During a school educational health promotional program for adolescents, the nurse would perform a school violence assessment. The nurse would try to identify individuals with substance abuse problems and counsel them. The presence of a gun at home may predispose adolescents to a greater incidence of homicide. The nurse would teach about gun safety. The assessment of sleep patterns is done in infants because they have fluctuating sleep patterns. Fluoride supplements for the prevention of dental caries is an important infant issue.

Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. One, some, or all responses may be correct. 1 Encouraging regular dental checkups 2 Facilitating smoking cessation programs 3 Administering influenza vaccines to older adults 4 Teaching the procedure for breast self-examination 5 Referring clients with a chronic illness to a support group

1,4 Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, which would the nurse expect to find? 1 Large area of petechiae 2 Red birthmark that has recently become lighter in color 3 Brown or black mole with red, white, or blue areas 4 Patchy loss of skin pigmentation

3. Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades with time. A patchy loss of skin pigmentation indicates vitiligo

When determining the main difference between type 1 and type 2 diabetes, the nurse recognizes which clinical presentation about type 1? 1 Onset of the disease is slow. 2 Excessive weight is a contributing factor. 3 Complications are not present at the time of diagnosis. 4 Treatment involves diet, exercise, and oral medications

3 Clinical presentation of type 1 diabetes is characterized by acute onset, and there is no time to develop the long-term complications that are common with long-standing disease; 20% of newly diagnosed clients with type 2 diabetes demonstrate complications because the diabetes has gone undetected for an extended period of time. Clinical presentation of type 1 diabetes is rapid, not slow, because pancreatic beta cells are destroyed by an autoimmune process; in type 2 diabetes, the body is still producing some insulin, and the onset of signs and symptoms is slow. In type 1 diabetes, clients are generally lean or have an ideal weight; 80% to 90% of clients with type 2 diabetes are overweight. Type 1 diabetes requires diet control, exercise, and subcutaneous administration of insulin, not oral medications; oral medications are used for type 2 diabetes because some insulin is still being produced.

Which laboratory value would the nurse use to determine whether a client is receiving a therapeutic dose of intravenous heparin? 1 International normalized ratio (INR) is between 2 and 3 2 Prothrombin time (PT) is 2.5 times the control value 3 Activated partial thromboplastin time (APTT) is 70 seconds 4 Activated clotting time (ACT) is in the range of 70 to 120 seconds

3 When a client is receiving intravenous heparin, the APTT should be 1.5 to 2 times the normal APTT of 40 seconds, or 60 to 80 seconds. INR and PT are used to evaluate therapeutic levels of warfarin. The ACT is not commonly used for monitoring of heparin, but ACT increases to a range of 150 to 200 seconds when heparin reaches therapeutic levels.

physiologic change pressure on nerve endings increased tissue pressure decreased tissue perfusion decreased oxygen to tissues increased production of lactic acid

clinical finding pain referred pain to compartment increased edema pallor unequal pulses, flexed posture