Looking For Something in this Blog? Search here

Sunday, February 16, 2014

Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations part 2

Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations part 2

51. Answer: (B) Lung cancer
Rationale: Lung cancer is the most deadly type
of cancer in both women and men. Breast
cancer ranks second in women, followed (in
descending order) by colon and rectal cancer,
pancreatic cancer, ovarian cancer, uterine
cancer, lymphoma, leukemia, liver cancer,
brain cancer, stomach cancer, and multiple
myeloma.

52. Answer: (A) miosis, partial eyelid ptosis, and
anhidrosis on the affected side of the face.
Rationale: Horner's syndrome, which occurs
when a lung tumor invades the ribs and
affects the sympathetic nerve ganglia, is
characterized by miosis, partial eyelid ptosis,
and anhidrosis on the affected side of the
face. Chest pain, dyspnea, cough, weight loss,
and fever are associated with pleural tumors.
Arm and shoulder pain and atrophy of the arm
and hand muscles on the affected side suggest
Pancoast's tumor, a lung tumor involving the
first thoracic and eighth cervical nerves within
the brachial plexus. Hoarseness in a client
with lung cancer suggests that the tumor has
extended to the recurrent laryngeal nerve;
dysphagia suggests that the lung tumor is
compressing the esophagus.

53. 53. Answer: (A) prostate-specific antigen,
which is used to screen for prostate cancer.
Rationale: PSA stands for prostate-specific
antigen, which is used to screen for prostate
cancer. The other answers are incorrect.

54. Answer: (D) "Remain supine for the time
specified by the physician." Rationale: The
nurse should instruct the client to remain
supine for the time specified by the physician.
Local anesthetics used in a subarachnoid block
don't alter the gag reflex. No interactions
between local anesthetics and food occur.
Local anesthetics don't cause hematuria.

55. Answer: (C) Sigmoidoscopy
Rationale: Used to visualize the lower GI tract,
sigmoidoscopy and proctoscopy aid in the
detection of two-thirds of all colorectal
cancers. Stool Hematest detects blood, which
is a sign of colorectal cancer; however, the
test doesn't confirm the diagnosis. CEA may
be elevated in colorectal cancer but isn't
considered a confirming test. An abdominal CT
scan is used to stage the presence of
colorectal cancer.

56. Answer: (B) A fixed nodular mass with
dimpling of the overlying skin
Rationale: A fixed nodular mass with dimpling
of the overlying skin is common during late
stages of breast cancer. Many women have
slightly asymmetrical breasts. Bloody nipple
discharge is a sign of intraductal papilloma, a
benign condition. Multiple firm, round, freely
movable masses that change with the
menstrual cycle indicate fibrocystic breasts, a
benign condition.

57. Answer: (A) Liver
Rationale: The liver is one of the five most
common cancer metastasis sites. The others
are the lymph nodes, lung, bone, and brain.
The colon, reproductive tract, and WBCs are
occasional metastasis sites.

58. Answer: (D) The client wears a watch and
wedding band.
Rationale: During an MRI, the client should
wear no metal objects, such as jewelry,
because the strong magnetic field can pull on
them, causing injury to the client and (if they
fly off) to others. The client must lie still
during the MRI but can talk to those
performing the test by way of the microphone
inside the scanner tunnel. The client should
hear thumping sounds, which are caused by
the sound waves thumping on the magnetic
field.

59. Answer: (C) The recommended daily
allowance of calcium may be found in a wide
variety of foods.
Rationale: Premenopausal women require
1,000 mg of calcium per day. Postmenopausal
women require 1,500 mg per day. It's often,
though not always, possible to get the
recommended daily requirement in the foods
we eat. Supplements are available but not
always necessary. Osteoporosis doesn't show
up on ordinary X-rays until 30% of the bone
loss has occurred. Bone densitometry can
detect bone loss of 3% or less. This test is
sometimes recommended routinely for
women over 35 who are at risk. Strenuous
exercise won't cause fractures.

60. Answer: (C) Joint flexion of less than 50%
Rationale: Arthroscopy is contraindicated in
clients with joint flexion of less than 50%
because of technical problems in inserting the
instrument into the joint to see it clearly.
Other contraindications for this procedure
include skin and wound infections. Joint pain
may be an indication, not a contraindication,
for arthroscopy. Joint deformity and joint
stiffness aren't contraindications for this
procedure.

61. Answer: (D) Gouty arthritis
Rationale: Gouty arthritis, a metabolic disease,
is characterized by urate deposits and pain in
the joints, especially those in the feet and
legs. Urate deposits don't occur in septic or
traumatic arthritis. Septic arthritis results from
bacterial invasion of a joint and leads to
inflammation of the synovial lining. Traumatic
arthritis results from blunt trauma to a joint or
ligament. Intermittent arthritis is a rare,
benign condition marked by regular, recurrent
joint effusions, especially in the knees.

62. Answer: (B) 30 ml/hou
Rationale: An infusion prepared with 25,000
units of heparin in 500 ml of saline solution
yields 50 units of heparin per milliliter of
solution. The equation is set up as 50 units
times X (the unknown quantity) equals 1,500
units/hour, X equals 30 ml/hour.

63. Answer: (B) Loss of muscle contraction
decreasing venous return
Rationale: In clients with hemiplegia or
hemiparesis loss of muscle contraction
decreases venous return and may cause
swelling of the affected extremity.
Contractures, or bony calcifications may occur
with a stroke, but don’t appear with swelling.
DVT may develop in clients with a stroke but is
more likely to occur in the lower extremities.
A stroke isn’t linked to protein loss.

64. Answer: (B) It appears on the distal
interphalangeal joint
Rationale: Heberden’s nodes appear on the
distal interphalageal joint on both men and
women. Bouchard’s node appears on the
dorsolateral aspect of the proximal
interphalangeal joint.

65. Answer: (B) Osteoarthritis is a localized
disease rheumatoid arthritis is systemic
Rationale: Osteoarthritis is a localized disease,
rheumatoid arthritis is systemic. Osteoarthritis
isn’t gender-specific, but rheumatoid arthritis
is. Clients have dislocations and subluxations
in both disorders.

66. Answer: (C) The cane should be used on the
unaffected side
Rationale: A cane should be used on the
unaffected side. A client with osteoarthritis
should be encouraged to ambulate with a
cane, walker, or other assistive device as
needed; their use takes weight and stress off
joints.

67. Answer: (A) a. 9 U regular insulin and 21 U
neutral protamine Hagedorn (NPH).
Rationale: A 70/30 insulin preparation is 70%
NPH and 30% regular insulin. Therefore, a
correct substitution requires mixing 21 U of
NPH and 9 U of regular insulin. The other
choices are incorrect dosages for the
prescribed insulin.

68. Answer: (C) colchicines
Rationale: A disease characterized by joint
inflammation (especially in the great toe),
gout is caused by urate crystal deposits in the
joints. The physician prescribes colchicine to
reduce these deposits and thus ease joint
inflammation. Although aspirin is used to
reduce joint inflammation and pain in clients
with osteoarthritis and rheumatoid arthritis, it
isn't indicated for gout because it has no
effect on urate crystal formation. Furosemide,
a diuretic, doesn't relieve gout. Calcium
gluconate is used to reverse a negative
calcium balance and relieve muscle cramps,
not to treat gout.

69. Answer: (A) Adrenal cortex
Rationale: Excessive secretion of aldosterone
in the adrenal cortex is responsible for the
client's hypertension. This hormone acts on
the renal tubule, where it promotes
reabsorption of sodium and excretion of
potassium and hydrogen ions. The pancreas
mainly secretes hormones involved in fuel
metabolism. The adrenal medulla secretes the
catecholamines — epinephrine and
norepinephrine. The parathyroids secrete
parathyroid hormone.

70. Answer: (C) They debride the wound and
promote healing by secondary intention
Rationale: For this client, wet-to-dry dressings
are most appropriate because they clean the
foot ulcer by debriding exudate and necrotic
tissue, thus promoting healing by secondary
intention. Moist, transparent dressings
contain exudate and provide a moist wound
environment. Hydrocolloid dressings prevent
the entrance of microorganisms and minimize
wound discomfort. Dry sterile dressings
protect the wound from mechanical trauma
and promote healing.

71. Answer: (A) Hyperkalemia
Rationale: In adrenal insufficiency, the client
has hyperkalemia due to reduced aldosterone
secretion. BUN increases as the glomerular
filtration rate is reduced. Hyponatremia is
caused by reduced aldosterone secretion.
Reduced cortisol secretion leads to impaired
glyconeogenesis and a reduction of glycogen
in the liver and muscle, causing hypoglycemia.

72. Answer: (C) Restricting fluids
Rationale: To reduce water retention in a
client with the SIADH, the nurse should
restrict fluids. Administering fluids by any
route would further increase the client's
already heightened fluid load.

73. Answer: (D) glycosylated hemoglobin level.
Rationale: Because some of the glucose in the
bloodstream attaches to some of the
hemoglobin and stays attached during the
120-day life span of red blood cells,
glycosylated hemoglobin levels provide
information about blood glucose levels during
the previous 3 months. Fasting blood glucose
and urine glucose levels only give information
about glucose levels at the point in time when
they were obtained. Serum fructosamine
levels provide information about blood
glucose control over the past 2 to 3 weeks.

74. Answer: (C) 4:00 pm
Rationale: NPH is an intermediate-acting
insulin that peaks 8 to 12 hours after
administration. Because the nurse
administered NPH insulin at 7 a.m., the client
is at greatest risk for hypoglycemia from 3
p.m. to 7 p.m.

75. Answer: (A) Glucocorticoids and androgens
Rationale: The adrenal glands have two
divisions, the cortex and medulla. The cortex
produces three types of hormones:
glucocorticoids, mineralocorticoids, and
androgens. The medulla produces
catecholamines— epinephrine and
norepinephrine.

76. Answer: (A) Hypocalcemia
Rationale: Hypocalcemia may follow thyroid
surgery if the parathyroid glands were
removed accidentally. Signs and symptoms of
hypocalcemia may be delayed for up to 7 days
after surgery. Thyroid surgery doesn't directly
cause serum sodium, potassium, or
magnesium abnormalities. Hyponatremia may
occur if the client inadvertently received too
much fluid; however, this can happen to any
surgical client receiving I.V. fluid therapy, not
just one recovering from thyroid surgery.
Hyperkalemia and hypermagnesemia usually
are associated with reduced renal excretion of
potassium and magnesium, not thyroid
surgery.

77. Answer: (D) Carcinoembryonic antigen level
Rationale: In clients who smoke, the level of
carcinoembryonic antigen is elevated.
Therefore, it can't be used as a general
indicator of cancer. However, it is helpful in
monitoring cancer treatment because the
level usually falls to normal within 1 month if
treatment is successful. An elevated acid
phosphatase level may indicate prostate
cancer. An elevated alkaline phosphatase level
may reflect bone metastasis. An elevated
serum calcitonin level usually signals thyroid
cancer.

78. Answer: (B) Dyspnea, tachycardia, and pallor
Rationale: Signs of iron-deficiency anemia
include dyspnea, tachycardia, and pallor as
well as fatigue, listlessness, irritability, and
headache. Night sweats, weight loss, and
diarrhea may signal acquired
immunodeficiency syndrome (AIDS). Nausea,
vomiting, and anorexia may be signs of
hepatitis B. Itching, rash, and jaundice may
result from an allergic or hemolytic reaction.

79. Answer: (D) "I'll need to have a C-section if I
become pregnant and have a baby."
Rationale: The human immunodeficiency virus
(HIV) is transmitted from mother to child via
the transplacental route, but a Cesarean
section delivery isn't necessary when the
mother is HIV-positive. The use of birth
control will prevent the conception of a child
who might have HIV. It's true that a mother
who's HIV positive can give birth to a baby
who's HIV negative.

80. Answer: (C) "Avoid sharing such articles as
toothbrushes and razors."
Rationale: The human immunodeficiency virus
(HIV), which causes AIDS, is most
concentrated in the blood. For this reason, the
client shouldn't share personal articles that
may be blood-contaminated, such as
toothbrushes and razors, with other family
members. HIV isn't transmitted by bathing or
by eating from plates, utensils, or serving
dishes used by a person with AIDS.

81. Answer: (B) Pallor, tachycardia, and a sore
tongue
Rationale: Pallor, tachycardia, and a sore
tongue are all characteristic findings in
pernicious anemia. Other clinical
manifestations include anorexia; weight loss; a
smooth, beefy red tongue; a wide pulse
pressure; palpitations; angina; weakness;
fatigue; and paresthesia of the hands and feet.
Bradycardia, reduced pulse pressure, weight
gain, and double vision aren't characteristic
findings in pernicious anemia.

82. Answer: (B) Administer epinephrine, as
prescribed, and prepare to intubate the client
if necessary.
Rationale: To reverse anaphylactic shock, the
nurse first should administer epinephrine, a
potent bronchodilator as prescribed. The
physician is likely to order additional
medications, such as antihistamines and
corticosteroids; if these medications don't
relieve the respiratory compromise associated
with anaphylaxis, the nurse should prepare to
intubate the client. No antidote for penicillin
exists; however, the nurse should continue to
monitor the client's vital signs. A client who
remains hypotensive may need fluid
resuscitation and fluid intake and output
monitoring; however, administering
epinephrine is the first priority.

83. Answer: (D) bilateral hearing loss.
Rationale: Prolonged use of aspirin and other
salicylates sometimes causes bilateral hearing
loss of 30 to 40 decibels. Usually, this adverse
effect resolves within 2 weeks after the
therapy is discontinued. Aspirin doesn't lead
to weight gain or fine motor tremors. Large or
toxic salicylate doses may cause respiratory
alkalosis, not respiratory acidosis.

84. Answer: (D) Lymphocyte
Rationale: The lymphocyte provides adaptive
immunity — recognition of a foreign antigen
and formation of memory cells against the
antigen. Adaptive immunity is mediated by B
and T lymphocytes and can be acquired
actively or passively. The neutrophil is crucial
to phagocytosis. The basophil plays an
important role in the release of inflammatory
mediators. The monocyte functions in
phagocytosis and monokine production.

85. Answer: (A) moisture replacement.
Rationale: Sjogren's syndrome is an
autoimmune disorder leading to progressive
loss of lubrication of the skin, GI tract, ears,
nose, and vagina. Moisture replacement is the
mainstay of therapy. Though malnutrition and
electrolyte imbalance may occur as a result of
Sjogren's syndrome's effect on the GI tract, it
isn't the predominant problem. Arrhythmias
aren't a problem associated with Sjogren's
syndrome.

86. Answer: (C) stool for Clostridium difficile test.
Rationale: Immunosuppressed clients — for
example, clients receiving chemotherapy, —
are at risk for infection with C. difficile, which
causes "horse barn" smelling diarrhea.
Successful treatment begins with an accurate
diagnosis, which includes a stool test. The
ELISA test is diagnostic for human
immunodeficiency virus (HIV) and isn't
indicated in this case. An electrolyte panel and
hemogram may be useful in the overall
evaluation of a client but aren't diagnostic for
specific causes of diarrhea. A flat plate of the
abdomen may provide useful information
about bowel function but isn't indicated in the
case of "horse barn" smelling diarrhea.

87. Answer: (D) Western blot test with ELISA.
Rationale: HIV infection is detected by
analyzing blood for antibodies to HIV, which
form approximately 2 to 12 weeks after
exposure to HIV and denote infection. The
Western blot test — electrophoresis of
antibody proteins — is more than 98%
accurate in detecting HIV antibodies when
used in conjunction with the ELISA. It isn't
specific when used alone. E-rosette
immunofluorescence is used to detect viruses
in general; it doesn't confirm HIV infection.
Quantification of T-lymphocytes is a useful
monitoring test but isn't diagnostic for HIV.
The ELISA test detects HIV antibody particles
but may yield inaccurate results; a positive
ELISA result must be confirmed by the
Western blot test.

88. Answer: (C) Abnormally low hematocrit (HCT)
and hemoglobin (Hb) levels
Rationale: Low preoperative HCT and Hb
levels indicate the client may require a blood
transfusion before surgery. If the HCT and Hb
levels decrease during surgery because of
blood loss, the potential need for a
transfusion increases. Possible renal failure is
indicated by elevated BUN or creatinine levels.
Urine constituents aren't found in the blood.
Coagulation is determined by the presence of
appropriate clotting factors, not electrolytes.

89. Answer: (A) Platelet count, prothrombin time,
and partial thromboplastin time
Rationale: The diagnosis of DIC is based on the
results of laboratory studies of prothrombin
time, platelet count, thrombin time, partial
thromboplastin time, and fibrinogen level as
well as client history and other assessment
factors. Blood glucose levels, WBC count,
calcium levels, and potassium levels aren't
used to confirm a diagnosis of DIC.

90. Answer: (D) Strawberries
Rationale: Common food allergens include
berries, peanuts, Brazil nuts, cashews,
shellfish, and eggs. Bread, carrots, and
oranges rarely cause allergic reactions.

91. Answer: (B) A client with cast on the right leg
who states, “I have a funny feeling in my right
leg.”
Rationale: It may indicate neurovascular
compromise, requires immediate assessment.

92. Answer: (D) A 62-year-old who had an
abdominal-perineal resection three days ago;
client complaints of chills.
Rationale: The client is at risk for peritonitis;
should be assessed for further symptoms and
infection.

93. Answer: (C) The client spontaneously flexes
his wrist when the blood pressure is obtained.
Rationale: Carpal spasms indicate
hypocalcemia.

94. Answer: (D) Use comfort measures and
pillows to position the client.
Rationale: Using comfort measures and
pillows to position the client is a nonpharmacological
methods of pain relief.

95. Answer: (B) Warm the dialysate solution.
Rationale: Cold dialysate increases discomfort.
The solution should be warmed to body
temperature in warmer or heating pad; don’t
use microwave oven.

96. Answer: (C) The client holds the cane with his
left hand, moves the cane forward followed
by the right leg, and then moves the left leg.
Rationale: The cane acts as a support and aids
in weight bearing for the weaker right leg.

97. Answer: (A) Ask the woman’s family to
provide personal items such as photos or
mementos.
Rationale: Photos and mementos provide
visual stimulation to reduce sensory
deprivation.

98. Answer: (B) The client lifts the walker, moves
it forward 10 inches, and then takes several
small steps forward.
Rationale: A walker needs to be picked up,
placed down on all legs.

99. Answer: (C) Isolation from their families and
familiar surroundings.
Rationale: Gradual loss of sight, hearing, and
taste interferes with normal functioning.

100. Answer: (A) Encourage the client to perform
pursed lip breathing.
Rationale: Purse lip breathing prevents the
collapse of lung unit and helps client control

rate and depth of breathing.

No comments :

Get Website Traffic