Nursing Sem 2 Unit 4

A 30-week-pregnant woman reports low backache and abdominal cramps. Which drug may be prescribed if the client is suspected of having preterm labor? 1 Methylergonovine 2 Mifepristone 3 Calcium gluconate 4 Magnesium sulfate

4 Magnesium sulfate Low backache and abdominal cramps in a pregnant woman may indicate labor; however, labor pains may not be safe if the gestation is not at full term. Magnesium sulfate may be prescribed to prevent preterm labor. Methylergonovine is prescribed to reduce postpartum uterine hemorrhage. Mifepristone may cause an elective termination of pregnancy. Calcium gluconate may be prescribed to reverse magnesium toxicity.

A nurse is teaching breast care to a client who is breastfeeding. Which statement by the client indicates that the teaching has been effective? 1 "I should air-dry my nipples after each feeding." 2 "I should use a mild soap when I wash my breasts." 3 "I'll have to line my breast pads with plastic shields." 4 "I need to take off my bra before I go to bed at night."

1 "I should air-dry my nipples after each feeding." Air-drying nipples after feedings limits irritation and disruption of skin integrity. The application of soap to breast tissue may result in drying and cracking. Plastic liners trap moisture against tissue and may cause skin breakdown. Wearing a brassiere continuously, except while bathing, is recommended for 2 to 3 weeks after delivery to provide support to breast tissue structures.

A client who has been in a coma for 2 months is being maintained on bed rest. At which angle will the nurse place the head of the bed to prevent the effects of shearing force? 1 30 degrees 2 45 degrees 3 60 degrees 4 90 degrees

1 30 degrees Shearing force occurs when two surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and cause this phenomenon. Angles of 45 degrees, 60 degrees, and 90 degrees raise the head of the bed too high, which contributes to the client sliding down in bed.

A client has bright-red erythematosus macules and papules on the skin. What could be the diagnosis? 1 Drug eruption 2 Atopic dermatitis 3 Contact dermatitis 4 Nonspecific eczematous dermatitis

1 Drug eruption Drug eruptions are characterized by bright-red erythematosus macules and papules on the skin, which occur because of an adverse reaction to a drug. Atopic dermatitis is characterized by scaling and excoriation, which occurs due to food allergies, chemicals, or stress. Contact dermatitis manifests as localized eczematous eruption when the skin comes into direct contact with irritants or allergens. Nonspecific eczematous dermatitis results in evolution of lesions from vesicles to weeping papules and plaques.

A client who survived a lightning strike is admitted to the emergency unit. Which interventions could be beneficial for this client's condition? Select all that apply. 1 Administration of diphenhydramine 2 Applying spinal immobilization technique 3 Stabilization of airway, breathing, and circulation 4 Applying ice packs in the axillae and groin and on the neck and head 5 Rapid rewarming in a water bath at a temperature range of 104° F to 108° F (40° C to 42° C) Applying spinal immobilization would reduce spinal cord injury pain.

2 Applying spinal immobilization technique 3 Stabilization of airway, breathing, and circulation Applying spinal immobilization would reduce spinal cord injury pain. Stabilization of airway, breathing, and circulation may be beneficial to prevent respiratory and cardiac arrest. Administration of diphenhydramine would be beneficial in case of bee or wasp stings, not after a lightning strike. Applying ice packs in the axillae and groin and on the neck and head is beneficial for heat stroke victims, not lightning strike victims. Rapid rewarming in a water bath at a temperature range of 104° to 108° degrees Fahrenheit (40° to 42° degrees Celsius) would help clients with cold-related injuries such as hypothermia and frostbite.

Which is a sign of a ruptured ectopic pregnancy in an adolescent? 1 Labor pains 2 Abdominal pain and bleeding 3 Abdominal pain and hypotension 4 Abdominal pain and hypertension

3 Abdominal pain and hypotension An ectopic pregnancy occurs when a fertilized egg implants outside the uterus. Hypotension and abdominal pain indicates that the ectopic pregnancy might have ruptured. Ectopic pregnancy cannot be diagnosed by normal labor pains. Ectopic pregnancy is ruled out if abdominal pain is associated with bleeding or hypertension.

Which neurologic manifestation in a client is associated with hyperthyroidism? 1 Confusion 2 Hearing loss 3 Exophthalmos 4 Slowness of speech

3 Exophthalmos In hyperthyroidism, edema in the extraocular muscles and increased fatty tissue behind the eye leads to exophthalmos. Confusion, hearing loss, and slowness of speech are caused by hypothyroidism.

Which clinical finding occurs due to thinning of the subcutaneous layer? 1 Decreased tone and elasticity 2 Decreased sensory perception 3 Increased risk for hypothermia 4 Increased susceptibility to dry skin

3 Increased risk for hypothermia Thinning of the subcutaneous layer results in increased risk for hypothermia. Degeneration of elastic fibers in the dermis results in decreased tone and elasticity. In the dermis, reduced number and function of nerve endings leads to decreased sensory perception. A decrease in dermal blood flow results in increased susceptibility to dry skin.

A client with a reddish-blue generalized skin alteration is hospitalized. Laboratory findings show an increase in the overall amount of hemoglobin. Which condition might the nurse suspect? 1 Albinism 2 Addison's disease 3 Polycythemia vera 4 Methemoglobinemia

3 Polycythemia vera The generalized reddish-blue skin alteration is occurring due to increased overall hemoglobin and may be associated with polycythemia vera. Albinism may found with decreased pigmentation of the skin due to the genetically determined defect of melanocyte. Addison's disease may be associated with increased melanin production, which may result in a brown skin discoloration. Cyanosis resulting in a blue discoloration of the skin may signify methemoglobinemia.

A nurse is caring for a client who had an open reduction and internal fixation of a femoral neck fracture. The client has a prescription for ambulation with slight weight bearing on the affected extremity. During the physical assessment the nurse identifies that the client has kyphosis and strong upper arm strength. What assistive device does the nurse expect the primary healthcare provider to prescribe for this client? 1 Crutches 2 Quad cane 3 Straight cane 4 A standard walker

4 A standard walker A standard walker can be used by a client with partial weight bearing who has enough upper body strength to lift and move the walker forward. A standard walker with rubber tips is designed for those who need more support than a cane. Kyphosis is an exaggerated angulation of the posterior curve of the thoracic spine; it alters the client's center of gravity, making the use of crutches unsafe. A quad cane requires weight bearing on both legs. Partial weight bearing means that the client may put minimal weight on the affected extremity. A straight cane requires weight bearing on both legs.

A healthcare provider diagnoses acute nonlymphoid leukemia in a 2½-year-old child, and the child is admitted to the hospital. What clinical manifestations of the disease should the nurse expect when assessing the child? Select all that apply. 1 Anorexia 2 Petechiae 3 Irritability 4 Skin pallor 5 Listlessness

All of them! 1 Anorexia 2 Petechiae 3 Irritability 4 Skin pallor 5 Listlessness Anorexia and vague abdominal discomfort occur because of areas of intestinal inflammation. Bleeding tendencies (e.g., petechiae, bleeding gums) occur because of decreased platelets. Irritability results because of the stress of the pathophysiologic changes that occur with the disease. Pallor results because of decreased erythrocytes (anemia). Listlessness and lethargy result because of decreased erythrocytes (anemia).

An adult client sustains partial- and full-thickness burns of the left thigh and left arm. Using the Lund-Browder chart, the nurse calculates the percentage of total body surface area burned. Which percentage will the nurse record? 1 16.5% 2 23.5% 3 28.5% 4 30.5%

1 16.5% According to the Lund-Browder chart the total body surface area is calculated: left thigh = 9.5% and left arm = 7%, which totals 16.5%. The responses 23.5%, 28.5%, and 30.5% are incorrect calculations.

Which statements are true regarding primary dysmenorrhea? Select all that apply. 1 During the luteal phase, F 2-alpha is secreted 2 Anovulatory bleeding that occurs after menarche is painful 3 Primary dysmenorrhea usually appears 2 to 5 months after menarche 4 Pain usually begins at the onset of menstruation and lasts for 8 to 48 hours 5 Excessive release of prostaglandin F 2-alpha decreases the frequency of uterine contractions

1 During the luteal phase, F 2-alpha is secreted 4 Pain usually begins at the onset of menstruation and lasts for 8 to 48 hours Primary dysmenorrhea is a condition associated with the ovulatory cycle. During the luteal phase and subsequent menstrual flow, F 2-alpha is secreted. The pain usually begins at the onset of menstruation and lasts for 8 to 48 hours. Anovulatory bleeding, which is common in the few months or years after menarche, is painless. Primary dysmenorrhea usually appears 6 to 12 months after menarche when ovulation is established. Excessive release of prostaglandin F 2-alpha increases the amplitude and frequency of uterine contractions.

A 15-year-old adolescent is admitted with partial- and full-thickness burns of the arms and upper torso. What are the purposes of administering pain medication by way of the intravenous route rather than the intramuscular route? Select all that apply. 1 Adolescents are afraid of injections. 2 It decreases the risk of tissue irritation. 3 Severe pain is reduced more effectively. 4 Impaired peripheral circulation is bypassed. 5 It provides for more prolonged relief of pain.

2 It decreases the risk of tissue irritation. 3 Severe pain is reduced more effectively. 4 Impaired peripheral circulation is bypassed. Decreasing the risk for tissue irritation can reduce the risk of infection, which is also one of the top care priorities after a burn injury. The medication begins to work in minutes; doses can be controlled. Intramuscular medications are avoided when possible to prevent inadequate absorption of the medication because of damaged tissue. Stating that adolescents are afraid of injections is a generalization that is not necessarily true. The duration of effectiveness of an analgesic is based on its therapeutic level in the body, regardless of what route is used.

Which assessments should a nurse perform in a woman who is prescribed clomiphene? Select all that apply. 1 Allergies to ergot alkaloids 2 Reproductive and uterine status 3 Concomitant use of antidepressants 4 Family stability and economic status 5 Maternal history for estimated gestation

2 Reproductive and uterine status 3 Concomitant use of antidepressants 4 Family stability and economic status The client's reproductive and uterine status should be assessed because clomiphene may result in multiple pregnancies. The concomitant use of antidepressants with clomiphene may cause fertility impairment. Assessing the client's family stability and economic status is essential because this can be a risk factor for multiple pregnancies. Clomiphene is not an ergot alkaloid; therefore, assessing for allergies to ergot alkaloids is not appropriate. Clomiphene is not administered during pregnancy; therefore, assessing the maternal history for estimated gestation of the client is irrelevant.

A client has thin, dark-red vertical lines about 1 to 3 mm long in the nails. Which diseases are associated with this physiologic alteration in the client? Select all that apply. 1 Psoriasis 2 Trichinosis 3 Cardiac failure 4 Diabetes mellitus 5 Bacterial endocarditis

2 Trichinosis 5 Bacterial endocarditis Thin, dark-red vertical lines about 1 to 3 mm long in the nails are associated with trichinosis (parasitic disease) and bacterial endocarditis (infection of the innermost layer of the heart and heart valves). Psoriasis, diabetes mellitus, and cardiac failure are associated with yellow-brown discoloration of the nails.

A male client's laboratory report shows creatine kinase as 175 units/L. Which conditions would the nurse suspect in the client? Select all that apply. 1 Osteomalacia 2 Osteoporosis 3 Muscle trauma 4 Skeletal muscle necrosis 5 Progressive muscular dystrophy

3 Muscle trauma 4 Skeletal muscle necrosis 5 Progressive muscular dystrophy The normal range of creatine kinase in men ranges from 55 to 170 units/L. An elevated creatine kinase level indicates the presence of muscle trauma and progressive muscular dystrophy. Osteomalacia may occur due to elevated serum calcium, serum phosphatase, and alkaline phosphatase levels. Osteoporosis may occur due to elevated serum calcium levels. Elevated levels of lactic dehydrogenase indicate skeletal muscle necrosis.

The primary healthcare provider prescribed imiquimod to a client with a skin infection. What could be the possible condition of the client? 1 Shingles 2 Erysipelas 3 Plantar warts 4 Verucca vulgaris

3 Plantar warts Imiquimod is a topical immunomodulator that stimulates the production of α interferon and other cytokines to enhance cell-mediated immunity. This medication is used for warts, actinic keratoses, and superficial basal cell carcinoma. Topical imiquimod may be used in the treatment of plantar warts, which are caused by a viral infection called the human papilloma virus. Shingles, caused by activation of varicella-zoster virus, is treated with antiviral agents such as acyclovir and famciclovir. Erysipelas is a bacterial infection treated with systemic antibiotics such as penicillin. Verucca vulgaris, also a viral infection, is treated with blistering agents such as cantharidin, keratolytic agents such as salicylic acid, and CO 2 laser destruction.

What is the most important test the nurse should check to determine whether a transplanted kidney is functioning? 1 White blood cell (WBC) cell count 2 Renal ultrasound 3 Serum creatinine level 4 24-hour urinary output

3 Serum creatinine level Serum creatinine concentration measures the kidney's ability to excrete metabolic wastes. Creatinine, a nitrogenous product of protein breakdown, is increased with renal insufficiency. WBC count does not measure kidney function; white blood cells usually are depressed because of immunosuppressive therapy to prevent rejection. WBC count is more valuable for assessing structure than function. Although 24-hour urinary output should be considered, it is not as definitive as the serum creatinine level.

A client has recently developed osteomyelitis. The client's laboratory reports show strains of Escherichia coli. What might be a possible reason for this condition? 1 Sickle cell disease 2 Intravenous drug use 3 Urinary tract infections 4 Joint replacements

3 Urinary tract infections Urinary tract infections, which can be caused by Escherichia coli, can predispose a client to developing osteomyelitis. Sickle cell disease also predisposes clients to osteomyelitis, but Salmonella is the causative microorganism. Intravenous drug use can predispose a client to osteomyelitis by increasing the risk of Salmonella infections. Insertion of indwelling prosthetic devices such as joint replacements can predispose a client to osteomyelitis by increasing the risk of Staphylococcus epidermidis infection.

Which complications does the nurse anticipate in the client who has blue-colored nail beds? 1 Thrombocytopenia 2 Polycythemia vera 3 Methemoglobinemia 4 Cardiopulmonary disease

4 Cardiopulmonary disease A bluish-color to the nail beds is due to an increase in deoxygenated blood that may be due to cardiopulmonary disease. When there is bleeding from the vessels into the tissues, small blue-colored spots are formed (petechiae), which may be due to thrombocytopenia (decreased numbers of platelets). Polycythemia vera is characterized by brown spots on the skin caused by increased melanin production. Methemoglobinemia is a complication in which the mucous membranes appear blue in color due to increased deoxygenated blood in the body.

While assessing the skin of an older adult, the nurse observes that the skin has a dry and uneven color. Which change is responsible for this condition? 1 Decreased subcutaneous fat 2 Decreased extracellular water 3 Decreased proliferation capacity 4 Decreased activity of sebaceous glands

4 Decreased activity of sebaceous glands Dryness and uneven skin color are caused by a decrease in the activity of sebaceous glands. Wrinkling and sagging are due to a decrease in subcutaneous fat. Dry and flaking skin are due to a decrease in extracellular water. The diminished rate of wound healing is due to a decrease in proliferation capacity.

Which integumentary manifestation can be noticed in a client with CD4+ count of 180/mm 3/(200/uL)? 1 Bruises 2 Cyanosis 3 Flushed and dry skin 4 Delayed wound healing

4 Delayed wound healing CD4+ count of less than 200/mm 3 (200/uL) is noticed in immunocompromised conditions such as AIDS. Integumentary manifestations of AIDS include poor wound-healing ability, dry skin, night sweats, and increased susceptibility to skin lesions. Bruises are noticed when the platelet count is decreased. Cyanosis is an integumentary manifestation of respiratory problems. Flushed and dry skin is an integumentary manifestation of metabolic acidosis.

While assessing the skin of a client, the nurse observes weeping papules, fissuring, and lichenification on the client's foot. What could be the possible diagnosis of the client? 1 Drug eruption 2 Atopic dermatitis 3 Contact dermatitis 4 Non-specific eczematous dermatitis

4 Non-specific eczematous dermatitis Weeping papules, fissuring, and lichenification are the clinical signs of non-specific eczematous dermatitis. Bright erythematous macules and papules are seen in clients with drug eruption. Though lichenification is seen in atopic dermatitis, weeping papules and fissuring may not be observed. In contact dermatitis, localized eczematous eruption with well-defined margins is seen.