352 exam 2

Colchicine 1200 mcg orally is prescribed for client with gout. Each tablet contains 0.6 mg. How many tablets should the nurse administer? Record your answer using a whole number

2

A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis?

1-Urinary retention 2-Gastric hyperacidity 3-Rebound tenderness-CORRECT 4-Increased lower bowel motility Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix.

An adolescent displaying low self-esteem complains of inflamed, red, and painful lesions on his forehead. What condition does he have?

1-Varicoceles 2-Acne vulgaris-CORRECT 3-Open comedones 4-Closed comedones Acne vulgaris is a common skin problem that adolescents experience. It is an inflammatory manifestation to the proliferation of Propionibacterium acnes. A varicocele is a collection of elongated and twisted superficial veins near the spermatic cord, superior to the testicle. Comedones are noninflammatory lesions.

A 6-year-old child who has colicky abdominal pain and guarding, as well as nausea, anorexia, and a low-grade fever, is admitted to the pediatric unit. During the admission assessment, a nurse palpates the abdomen and elicits pain in the right lower quadrant. Based on these findings, the child is at greatest risk for which pathophysiological condition?

1-Viral infection 2-Inflamed appendix-CORRECT 3-Irritable bowel 4-Parasitic infestation The child has classic signs and symptoms of an inflamed appendix. The symptoms are caused by inflammation and altered gastrointestinal function. The general symptoms may be seen in children with viral infections, irritable bowel, and parasitic infestations. However, abdominal guarding and pain in right lower quadrant specifies a more specific condition, appendicitis.

A client who is diagnosed with a duodenal ulcer asks, "Now that I have an ulcer, what comes next?" What is the nurse's best response?

1-"Most peptic ulcers heal with medical treatment."-CORRECT 2-"Clients with peptic ulcers have pain while eating." 3-"Early surgery is advisable, especially after the first attack." 4-"If ulcers are untreated, cancer of the stomach can develop." Treatment with medications, rest, diet, and stress reduction relieves symptoms, heals the ulcer, and prevents complications and recurrence. Clients with duodenal ulcers have pain after eating and especially at night; gastric ulcers cause pain during or close to eating. Surgery may be done after multiple recurrences and for treating complications. Perforation, pyloric obstruction, and hemorrhage, not cancer, are major complications.

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor?

1-"My blood type is A positive." 2-"I smoke one pack of cigarettes a day."-CORRECT 3-"I have been overweight most of my life." 4-"My blood pressure has been high lately." Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. While blood type O is more frequently associated with duodenal ulcer, type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.

A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis will the nurse most likely observe written in the medical record?

1-Botulism 2-Bell palsy-CORRECT 3-Trigeminal neuralgia 4-Guillain-Barré syndrome Bell palsy is a cranial nerve disorder characterized by inflammation of the facial nerve on one side of the face. Botulism is a type of polyneuropathy caused by food poisoning due to Clostridium botulinum that can be fatal. Trigeminal neuralgia is a cranial nerve disorder characterized by pain in the distribution of the trigeminal nerve. Guillain-Barré syndrome is an acute, rapidly progressing, potentially fatal polyneuritis.

A client returns from a radical neck dissection with a tracheotomy and two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention?

1-Cloudy wound drainage 2-Poor gag reflex 3-Decreased urinary output 4-Restlessness with dyspnea-CORRECT The client is at risk for airway obstruction; restlessness and dyspnea indicate hypoxia. Cloudy drainage may indicate infection, which is not an immediate postoperative complication. Loss of the gag reflex is unimportant. The pharyngeal opening is sutured closed and a tracheal stoma is formed; the trachea is anatomically separate from the esophagus. Decreased urinary output needs to be monitored but does not take priority.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client?

1-Control of pain- CORRECT 2-Immobilization of joints 3-Motivation and teaching 4-Bladder training and control After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client's basic needs. Joints must be exercised, not immobilized, to prevent stiffness, contractures, and muscle atrophy. Motivation and learning will not occur unless basic needs, such as freedom from pain, are met. Although bladder training should be included in care, it is not the priority when the client is in pain.

What are the mediators of injury in IgE-mediated hypersensitivity reactions? Select all that apply.

1-Cytokines 2-Mast cells-CORRECT 3-Histamines-CORRECT 4-Neutrophils 5- Leukotrienes-CORRECT Mast cells, histamines, and leukotrienes are the mediators of injury in IgE-mediated hypersensitivity reactions. Cytokines are the mediators of injury in the delayed type of hypersensitivity reaction. Neutrophils are the mediators of injury in the immune-complex type of hypersensitivity reaction.

A group of clients is admitted with neurologic injury after hiking at high altitude. The nurse is assessing using the "AVPU" mnemonic. Which type of emergency assessment is the nurse performing?

1-Disability-CORRECT 2-Exposure 3-Breathing 4-Circulation Disability assessment is a part of the primary survey that is done to assess the level of consciousness that may occur due to a neurologic injury. In the mnemonic "AVPU," A indicates alert, V indicates response to voice, P stands for response to pain, and U indicates unresponsive. Exposure assessment is one of the priorities of a primary survey, which involves removing clothing for a complete assessment and preventing hypothermia using heat devices. Breathing assessment involves checking breath sounds and respiratory effort. Circulation assessment is performed in a primary survey to monitor blood pressure and pulse.

A client with gastroesophageal reflux disease reports having difficulty sleeping at night. What should the nurse instruct the client to do?

1-Drink a glass of milk before retiring.-CORRECT 2-Elevate the head of the bed on blocks. 3-Eliminate carbohydrates from the diet. 4-Take antacids, such as sodium bicarbonate. Elevating the head of the bed on blocks raises the upper torso and minimizes reflux of gastric contents. Increasing the content of the stomach before lying down will aggravate the symptoms associated with gastroesophageal reflux. Eliminating carbohydrates from the diet will have no effect on the reflux of gastric contents. The effect of antacids is not long-lasting enough to promote a full night's sleep; sodium bicarbonate is not recommended as an antacid.

A client has a history of gastroesophageal reflux disease (GERD). Why should the nurse also monitor the client for clinical manifestations of heart disease?

1-Esophageal pain may imitate the symptoms of a heart attack.- CORRECT 2-GERD may predispose to heart disease. 3-Strenuous exercise may exacerbate reflux problems. 4-Similar changes in laboratory studies may occur in both cardiac and reflux problems. Symptoms associated with myocardial infarction may be interpreted by a client as esophageal reflux and therefore ignored. GERD does not predispose to heart disease. Exercise does not seem to exacerbate esophageal reflux problems unless the stomach is full when exercising. Exercising to maintain a healthy weight helps reduce esophageal reflux. Laboratory workups help differentiate these two diagnoses. Tests, such as cardiac enzymes, can help to reveal a myocardial infarction, thereby facilitating differentiation between these problems.

A nurse is caring for a client with pruritic lesions from an IgE-mediated hypersensitivity reaction. Which mediator of injury is involved?

1-Histamine- CORRECT 2-Cytokine 3-Neutrophil 4-Macrophage Histamine is one of the mediators of injury involving IgE-mediated injury that may cause pruritus. Cytokines are the mediators of injury in delayed hypersensitivity reaction. Neutrophils are involved in immune complex-mediated hypersensitivity reactions. Macrophages in tissues are involved in cytotoxic reactions.

A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease?

1-Inclusion of transmural involvement of the small bowel wall 2-Higher occurrence of fistulas and abscesses from changes in the bowel wall 3-Pathology beginning proximally with intermittent plaques found along the colon 4-Involvement starting distally with rectal bleeding that spreads continuously up the colon-CORRECT Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.

A nurse inspects a two-day-old intravenous (IV) site and identifies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first?

1-Irrigate the IV tubing 2-Discontinue the infusion- CORRECT 3-Slow the rate of the infusion 4-Obtain a prescription for an analgesic The clinical findings indicate the presence of inflammation. The IV catheter should be removed to prevent the development of thrombophlebitis. Irrigating the IV tubing and slowing the rate of the infusion do not address the underlying problem and may further irritate the vein and precipitate a thrombophlebitis. Although an analgesic may relieve the discomfort, it is not an intervention that will resolve the problem.

A client with colitis has had a hemicolectomy. Three days after surgery the nurse identifies that the client has abdominal distention and absent bowel sounds, and has vomited 300 mL of dark green viscous fluid. The nurse contacts the primary healthcare provider and recommends which intervention?

1-Nasogastric tube for decompression-CORRECT 2-Antiemetic for nausea/vomiting 3-Intravenous (IV) lactated Ringer for fluid replacement 4-Stat electrolytes to assess for probable electrolyte imbalance Decompression removes collected secretions behind the nonfunctioning bowel segment (paralytic ileus), thus reducing pressure on the suture line and allowing healing. Vomiting will subside as the bowel is decompressed. Although IV lactated Ringer for fluid replacement is important, the primary concern is decompression of the bowel; the amount of fluid removed will direct fluid and electrolyte replacement therapy.

Which benign condition of the client's skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells?

1-Nevi-CORRECT 2-Psoriasis 3-Acne vulgaris 4-Plantar warts Nevi (moles) are hyperpigmented areas that vary in form and size. Nevi are a common benign condition of the skin that is associated with the grouping of normal cells derived from melanocyte-like precursor cells. Psoriasis is an autoimmune chronic dermatitis that involves excessively rapid turnover of epidermal cells. Acne vulgaris is an inflammatory disorder of sebaceous glands. Plantar warts are formed due to a viral infection. Plantar warts appear on the bottom surface of the feet and grow inward because of pressure.

A nurse assesses a client's intravenous site. What clinical finding, unique to infiltration, leads the nurse to conclude that the intravenous (IV) site has infiltrated, rather than become inflamed?

1-Pain 2-Coolness-CORRECT 3-Localized swelling 4-Cessation in flow of solution When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approximately 75° F [23.9° C]), whereas body temperature is approximately 98.6° F (37° C); therefore, the client's skin will feel cool to the touch at the site of an IV infiltration. The site of an inflammation will feel warm to the touch because of vasodilation and hyperemia. Pain may occur with both an inflammation and an infiltration. The pain of an inflammation is related to the pressure of edema on nerve endings. The pain of an infiltration is related to the IV solution in the interstitial compartment pressing on nerve endings. An increase in interstitial fluid occurs with both an inflammation and an infiltration. With an inflammation there is increased vascular permeability at the site; fluid, proteins, and leukocytes then move from the intravascular compartment into the interstitial compartment. With an infiltration the IV solution enters the interstitial compartment rather than the intravascular compartment. A cessation in flow of solution occurs with both an inflammation and an infiltration. An inflammation in the vein at the insertion site may close the lumen of the vessel, interfering with the flow of solution. An infiltration will cause excess fluid in the interstitial compartment to the extent that it will not accommodate more solution, interfering with the flow of the solution.

Before a client with syphilis can be treated, what should be determined?

1-Portal of entry 2-Size of chancre 3-Existence of allergies-CORRECT 4-Names of sexual contacts Although the treatment of choice is penicillin, clients who are allergic must be given other antimicrobial agents to avoid an anaphylactic reaction. The portal of entry does not influence treatment. The chancre is present only in the primary stage; it does not alter treatment. Although sexual contacts should be identified and notified, treatment should not be delayed.

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve?

1-Reduce gastric acidity 2-Reduce colonic irritation-CORRECT 3-Reduce intestinal absorption 4-Reduce bowel infection rate A low-residue diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, intestinal absorption. This diet is to allow the bowel to rest, not to reduce infection rates.

A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably is experiencing?

1-Salicylate toxicity- CORRECT 2-Anaphylactic reaction 3-Withdrawal symptoms 4-Acetaminophen overdose Excessive aspirin ingestion can influence the vestibulocochlear nerve (cranial nerve VIII), causing tinnitus and dizziness. The client is experiencing symptoms of toxicity, not an anaphylactic response. Withdrawal symptoms occur when a medication is no longer being administered. The chemical name of aspirin is acetylsalicylic acid, not acetaminophen.

What is the nurse's primary consideration when caring for a client with rheumatoid arthritis?

1-Surgery-CORRECT 2-Comfort 3-Education 4-Motivation Because pain is an all-encompassing and often demoralizing experience, the client should be kept as pain-free as possible. Surgery is used to correct deformities and facilitate movement, which is not the priority. Concentration and motivation are difficult when a client is in severe pain.

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

1-Thready, weak pulse 2-Narrowing pulse pressure 3-Regular, shallow breathing 4-Lowered level of consciousness Altered consciousness is the first sign of increased intracranial pressure. An increase in intracranial pressure causes impaired cerebral blood flow affecting the cells of the cerebral cortex, which results in a decreased level of consciousness. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in a slow pulse. A widening pulse pressure occurs because of an increase in the systolic pressure. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in irregular respirations that progress to deep, rapid breathing alternating with periods of apnea (Cheyne-Stokes respirations).

Which hypersensitivity reaction may occur in a newborn with hemolytic disease?

1-Type I- CORRECT 2-Type II 3-Type III 4-Type IV Hemolytic disease in a pregnant woman may result in erythroblastosis fetalis, a type II hypersensitivity reaction. Type I reactions involve immunoglobulin E (IgE)-mediated reactions such as anaphylaxis and wheal-and-flare reactions. Type III reactions are immune complex reactions such as rheumatoid arthritis or systemic lupus erythematosus. Type IV reactions are delayed hypersensitivity reactions such as contact dermatitis.