Answers and Rationale – TEST III 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. 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.
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