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

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.