ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING

ANSWERS AND RATIONALE – MEDICAL SURGICAL
NURSING

1. C. Glucocorticoids (steroids) are used for their
anti-inflammatory action, which decreases the
development of edema.

2. A. The blood must be stopped at once, and then
normal saline should be infused to keep the line
patent and maintain blood volume.
3. B. These tests confirm the presence of HIV
antibodies that occur in response to the
presence of the human immunodeficiency virus
(HIV).

4. D. One cup of cottage cheese contains
approximately 225 calories, 27g of protein, 9g of
fat, 30mg cholesterol, and 6g of carbohydrate.
Proteins of high biologic value (HBV) contain
optimal levels of amino acids essential for life.

5. A. Elevation of uremic waste products causes
irritation of the nerves, resulting in flapping
hand tremors.

6. B. This indicates that the bladder is distended
with urine, therefore palpable.

7. C. Elevation increases lymphatic drainage,
reducing edema and pain.

8. B. Detection of myoglobin is a diagnostic tool to
determine whether myocardial damage has
occurred.

9. D. When mitral stenosis is present, the left
atrium has difficulty emptying its contents into
the left ventricle because there is no valve to
prevent back ward flow into the pulmonary vein,
the pulmonary circulation is under pressure.

10. A. Managing hypertension is the priority for the
client with hypertension. Clients with
hypertension frequently do not experience pain,
deficient volume, or impaired skin integrity. It is
the asymptomatic nature of hypertension that
makes it so difficult to treat.

11. C. Because of its widespread vasodilating effects,
nitroglycerin often produces side effects such as
headache, hypotension and dizziness.

12. A. An increased in LDL cholesterol concentration
has been documented at risk factor for the
development of atherosclerosis. LDL cholesterol
is not broken down into the liver but is
deposited into the wall of the blood vessels.

13. D. There is a potential alteration in renal
perfusion manifested by decreased urine output.
The altered renal perfusion may be related to
renal artery embolism, prolonged hypotension,
or prolonged aortic cross-clamping during the
surgery.

14. A. Good source of vitamin B12 are dairy
products and meats.

15. C. Aplastic anemia decreases the bone marrow
production of RBC’s, white blood cells, and
platelets. The client is at risk for bruising and
bleeding tendencies.

16. B. An elective procedure is scheduled in advance
so that all preparations can be completed ahead
of time. The vital signs are the final check that
must be completed before the client leaves the
room so that continuity of care and assessment
is provided for.

17. A. The peak incidence of Acute Lymphocytic
Leukemia (ALL) is 4 years of age. It is uncommon
after 15 years of age.

18. D. Acute Lymphocytic Leukemia (ALL) does not
cause gastric distention. It does invade the
central nervous system, and clients experience
headaches and vomiting from meningeal
irritation.

19. B. Disseminated Intravascular Coagulation (DIC)
has not been found to respond to oral
anticoagulants such as Coumadin.

20. A. Urine output provides the most sensitive
indication of the client’s response to therapy for
hypovolemic shock. Urine output should be
consistently greater than 30 to 35 mL/hr.

21. C. Early warning signs of laryngeal cancer can
vary depending on tumor location. Hoarseness
lasting 2 weeks should be evaluated because it is
one of the most common warning signs.

22. C. Steroids decrease the body’s immune
response thus decreasing the production of
antibodies that attack the acetylcholine
receptors at the neuromuscular junction

23. C. The osmotic diuretic mannitol is
contraindicated in the presence of inadequate
renal function or heart failure because it
increases the intravascular volume that must be
filtered and excreted by the kidney.

24. A. These devices are more accurate because
they are easily to used and have improved
adherence in insulin regimens by young people
because the medication can be administered
discreetly.

25. C. Damage to blood vessels may decrease the
circulatory perfusion of the toes, this would
indicate the lack of blood supply to the
extremity.

26. D. Elevation will help control the edema that
usually occurs.

27. B. Uric acid has a low solubility, it tends to
precipitate and form deposits at various sites
where blood flow is least active, including
cartilaginous tissue such as the ears.

28. B. The palms should bear the client’s weight to
avoid damage to the nerves in the axilla.

29. A. Active exercises, alternating extension,
flexion, abduction, and adduction, mobilize
exudates in the joints relieves stiffness and pain.

30. C. Alteration in sensation and circulation
indicates damage to the spinal cord, if these
occurs notify physician immediately.

31. A. In the diuretic phase fluid retained during the
oliguric phase is excreted and may reach 3 to 5
liters daily, hypovolemia may occur and fluids
should be replaced.

32. C. The constituents of CSF are similar to those of
blood plasma. An examination for glucose
content is done to determine whether a body
fluid is a mucus or a CSF. A CSF normally contains
glucose.

33. B. Trauma is one of the primary causes of brain
damage and seizure activity in adults. Other
common causes of seizure activity in adults
include neoplasms, withdrawal from drugs and
alcohol, and vascular disease.

34. A. It is crucial to monitor the pupil size and
papillary response to indicate changes around
the cranial nerves.

35. C. The nurse most positive approach is to
encourage the client with multiple sclerosis to
stay active, use stress reduction techniques and
avoid fatigue because it is important to support
the immune system while remaining active.

36. D. Restlessness is an early indicator of hypoxia.
The nurse should suspect hypoxia in unconscious
client who suddenly becomes restless.

37. B. In spinal shock, the bladder becomes
completely atonic and will continue to fill unless
the client is catheterized.

38. A. Progression stage is the change of tumor from
the preneoplastic state or low degree of
malignancy to a fast growing tumor that cannot
be reversed.

39. D. Intensity is the major indicative of severity of
pain and it is important for the evaluation of the
treatment.

40. B. The use of fragrant soap is very drying to skin
hence causing the pruritus.

41. C. Atropine sulfate is contraindicated with
glaucoma patients because it increases
intraocular pressure.

42. A. A 67 year old client is greater risk because the
older adult client is more likely to have a lesseffective
immune system.

43. B. The last area to return sensation is in the
perineal area, and the nurse in charge should
monitor the client for distended bladder.

44. D. Glucocorticoids play no significant role in
disease treatment.

45. D. Tracheostomy tube has several potential
complications including bleeding, infection and
laryngeal nerve damage.

46. C. In burn, the capillaries and small vessels
dilate, and cell damage cause the release of a
histamine-like substance. The substance causes
the capillary walls to become more permeable
and significant quantities of fluid are lost.

47. A. Aging process involves increased capillary
fragility and permeability. Older adults have a
decreased amount of subcutaneous fat and
cause an increased incidence of bruise like
lesions caused by collection of extravascular
blood in loosely structured dermis.

48. D. Intermittent pain is the classic sign of renal
carcinoma. It is primarily due to capillary erosion
by the cancerous growth.

49. B. Tubercle bacillus is a drug resistant organism
and takes a long time to be eradicated. Usually a
combination of three drugs is used for minimum
of 6 months and at least six months beyond
culture conversion.

50. A. Patent airway is the most priority; therefore
removal of secretions is necessary