NCLEX Practice from Evolve

The nurse is counseling the parents of a 12-year-old child with Duchenne muscular dystrophy about problems that may develop during adolescence. What body system does the nurse expect will be affected?

Cardiopulmonary Muscle degeneration is advanced in the adolescent with Duchenne muscular dystrophy. The disease process involves the diaphragm, auxiliary muscles of respiration, and the heart, resulting in life-threatening respiratory infections and heart failure. Central nervous system function is not affected by Duchenne muscular dystrophy; nor is the integumentary system. Nutritional problems related to the gastrointestinal system are less significant than cardiopulmonary problems.

A pregnant woman with a history of heart disease visits the prenatal clinic toward the end of her second trimester. Which intervention does the nurse anticipate will be part of this client's care plan?

Prophylactic antibiotics at the time of birth Prophylactic antibiotics are given to clients with heart disease to reduce their risk for bacterial endocarditis. A vaginal birth, with a shortened second stage and an assisted birth involving forceps or vacuum extraction, is preferred. The data do not indicate which class of heart disease the client has; if it is class I and there is no cardiac decompensation, activities may be restricted; however, bed rest is not necessary. Increasing the dosages of the client's cardiac medications may or may not be necessary; dosages are based on each individual's response to the stress imposed by pregnancy.

A nurse is caring for an infant whose vomiting is intractable. Which complication is most likely to occur?

Excessive vomiting causes an increased loss of hydrogen ions (hydrochloric acid), leading to metabolic alkalosis, an excess of base bicarbonate. Acidosis is caused by retention of hydrogen ions and a loss of base bicarbonate, which is more likely to occur with diarrhea. Hypokalemia, not hyperkalemia, will occur. With the loss of chloride ions, hyponatremia is more likely to occur.

After 2 weeks of radiation therapy for cancer of the breast a client experiences some erythema over the area being irradiated. The area is sensitive but not painful. The client states that she has been using tepid water and a soft washcloth when cleansing the area and applying an ice pack three times a day. What does the nurse conclude from this information?

Further teaching on skin care is necessary. Extremes of temperature should be avoided; ice constricts blood vessels, interfering with circulation. Continued application of cold is contraindicated because it may cause tissue damage. Erythema is an expected reaction; however, pain, vesicle formation, or sloughing of tissue requires intervention.

A nurse identifies that clients with cancer often lose weight and may become cachectic. What common response do clients with cancer experience, regardless of the site of the cancer that accounts for this weight loss?

Tumor necrosis factor affects the satiety center. Macrophages release tumor necrosis factor (TNF), which crosses the blood-brain barrier and affects the satiety center, causing anorexia. Depression does not occur in all clients with cancer, and when it does, it does not necessarily cause anorexia. Decreased saliva impeding chewing and swallowing is not a commonality associated with all clients with cancer; it may occur in clients who receive treatment to the head and neck. Nutrients not being absorbed through the gastrointestinal mucosa is not a commonality associated with all clients with cancer; it may occur in clients who receive treatment that affects the gastrointestinal tract.

A client at 37 weeks' gestation is brought to the emergency department because of sudden abdominal pain. Abruptio placentae is suspected, and the client is transferred to the birthing unit. What should the nurse assess the client for?

Uterine tenderness and increased fetal activity When the placenta initially separates, the fetus may become hyperactive as a response to acute hypoxia; the uterus is tender because of the accumulation of blood at the abrupted placental site. If bleeding occurs, it is dark red or port wine colored and usually does not clot. The uterus generally enlarges because of an accumulation of blood at the placental site. It is difficult to assess a client for concealed hemorrhage; the fetus must first be assessed for fetal heart tones to determine viability, not for increases or decreases in the heart rate.

A client who is in labor is admitted 30 hours after her membranes ruptured. Which condition is this client at increased risk for?

chorioamnionitis The risk of developing chorioamnionitis (intra-amniotic infection) is increased with prolonged rupture of the membranes; foul-smelling fluid is a sign of infection