Answers and Rationale – TEST IV Care of Clients with Physiologic and Psychosocial Alterations part 1

Answers and Rationale – TEST IV Care of Clients with Physiologic and Psychosocial Alterations part 1   

1. Answer: (C) Hypertension

Rationale: Hypertension, along with fever,

and tenderness over the grafted kidney,

reflects acute rejection.

2. Answer: (A) Pain

Rationale: Sharp, severe pain (renal colic)

radiating toward the genitalia and thigh is

caused by uretheral distention and

smooth muscle spasm; relief form pain is

the priority.

3. Answer: (D) Decrease the size and

vascularity of the thyroid gland.

Rationale: Lugol’s solution provides

iodine, which aids in decreasing the

vascularity of the thyroid gland, which

limits the risk of hemorrhage when

surgery is performed.

4. Answer: (A) Liver Disease

Rationale: The client with liver disease has

a decreased ability to metabolize

carbohydrates because of a decreased

ability to form glycogen (glycogenesis) and

to form glucose from glycogen.

5. Answer: (C) Leukopenia

Rationale: Leukopenia, a reduction in

WBCs, is a systemic effect of

chemotherapy as a result of

myelosuppression.               

6. Answer: (C) Avoid foods that in the past

caused flatus.

Rationale: Foods that bothered a person

preoperatively will continue to do so after

a colostomy.

7. Answer: (B) Keep the irrigating container

less than 18 inches above the stoma.”

Rationale: This height permits the solution

to flow slowly with little force so that

excessive peristalsis is not immediately

precipitated.             

8. Answer: (A) Administer Kayexalate

Rationale: Kayexalate,a potassium

exchange resin, permits sodium to be

exchanged for potassium in the intestine,

reducing the serum potassium level.

9. Answer:(B) 28 gtt/min

Rationale: This is the correct flow rate;

multiply the amount to be infused (2000

ml) by the drop factor (10) and divide the

result by the amount of time in minutes

(12 hours x 60 minutes)

10. Answer: (D) Upper trunk

Rationale: The percentage designated for

each burned part of the body using the

rule of nines: Head and neck 9%; Right

upper extremity 9%; Left upper extremity

9%; Anterior trunk 18%; Posterior trunk

18%; Right lower extremity 18%; Left

lower extremity 18%; Perineum 1%.

11. Answer: (C) Bleeding from ears

Rationale: The nurse needs to perform a

thorough assessment that could indicate

alterations in cerebral function, increased

intracranial pressures, fractures and

bleeding. Bleeding from the ears occurs

only with basal skull fractures that can

easily contribute to increased intracranial

pressure and brain herniation.

12. Answer: (D) may engage in contact sports

Rationale: The client should be advised by

the nurse to avoid contact sports. This will

prevent trauma to the area of the

pacemaker generator.

13. Answer: (A) Oxygen at 1-2L/min is given to

maintain the hypoxic stimulus for

breathing.

Rationale: COPD causes a chronic CO2

retention that renders the medulla

insensitive to the CO2 stimulation for

breathing. The hypoxic state of the client

then becomes the stimulus for breathing.

Giving the client oxygen in low

concentrations will maintain the client’s

hypoxic drive.

14. Answer: (B) Facilitate ventilation of the

left lung.

Rationale: Since only a partial

pneumonectomy is done, there is a need

to promote expansion of this remaining

Left lung by positioning the client on the

opposite unoperated side.

15. Answer: (A) Food and fluids will be

withheld for at least 2 hours.

Rationale: Prior to bronchoscopy, the

doctors sprays the back of the throat with

anesthetic to minimize the gag reflex and

thus facilitate the insertion of the

bronchoscope. Giving the client food and

drink after the procedure without

checking on the return of the gag reflex

can cause the client to aspirate. The gag

reflex usually returns after two hours.

16. Answer: (C) hyperkalemia.

Rationale: Hyperkalemia is a common

complication of acute renal failure. It's

life-threatening if immediate action isn't

taken to reverse it. The administration of

glucose and regular insulin, with sodium

bicarbonate if necessary, can temporarily

prevent cardiac arrest by moving

potassium into the cells and temporarily

reducing serum potassium levels.

Hypernatremia, hypokalemia, and

hypercalcemia don't usually occur with

acute renal failure and aren't treated with

glucose, insulin, or sodium bicarbonate.

17. Answer: (A) This condition puts her at a

higher risk for cervical cancer; therefore,

she should have a Papanicolaou (Pap)

smear annually.

Rationale: Women with condylomata

acuminata are at risk for cancer of the

cervix and vulva. Yearly Pap smears are

very important for early detection.

Because condylomata acuminata is a

virus, there is no permanent cure.

Because condylomata acuminata can

occur on the vulva, a condom won't

protect sexual partners. HPV can be

transmitted to other parts of the body,

such as the mouth, oropharynx, and

larynx.

18. Answer: (A) The left kidney usually is

slightly higher than the right one.

Rationale: The left kidney usually is

slightly higher than the right one. An

adrenal gland lies atop each kidney. The

average kidney measures approximately

11 cm (4-3/8") long, 5 to 5.8 cm (2" to

2¼") wide, and 2.5 cm (1") thick. The

kidneys are located retroperitoneally, in

the posterior aspect of the abdomen, on

either side of the vertebral column. They

lie between the 12th thoracic and 3rd

lumbar vertebrae.

19. Answer: (C) Blood urea nitrogen (BUN)

100 mg/dl and serum creatinine 6.5mg/dl.

Rationale: The normal BUN level ranges 8

to 23 mg/dl; the normal serum creatinine

level ranges from 0.7 to 1.5 mg/dl. The

test results in option C are abnormally

elevated, reflecting CRF and the kidneys'

decreased ability to remove nonprotein

nitrogen waste from the blood. CRF

causes decreased pH and increased

hydrogen ions — not vice versa. CRF also

increases serum levels of potassium,

magnesium, and phosphorous, and

decreases serum levels of calcium. A uric

acid analysis of 3.5 mg/dl falls within the

normal range of 2.7 to 7.7 mg/dl; PSP

excretion of 75% also falls with the normal

range of 60% to 75%.

20. Answer: (D) Alteration in the size, shape,

and organization of differentiated cells

Rationale: Dysplasia refers to an alteration

in the size, shape, and organization of

differentiated cells. The presence of

completely undifferentiated tumor cells

that don't resemble cells of the tissues of

their origin is called anaplasia. An increase

in the number of normal cells in a normal

arrangement in a tissue or an organ is

called hyperplasia. Replacement of one

type of fully differentiated cell by another

in tissues where the second type normally

isn't found is called metaplasia.

21. Answer: (D) Kaposi's sarcoma

Rationale: Kaposi's sarcoma is the most

common cancer associated with AIDS.

Squamous cell carcinoma, multiple

myeloma, and leukemia may occur in

anyone and aren't associated specifically

with AIDS.

22. Answer: (C) To prevent cerebrospinal fluid

(CSF) leakage

Rationale: The client receiving a

subarachnoid block requires special

positioning to prevent CSF leakage and

headache and to ensure proper anesthetic

distribution. Proper positioning doesn't

help prevent confusion, seizures, or

cardiac arrhythmias.

23. Answer: (A) Auscultate bowel sounds.

Rationale: If abdominal distention is

accompanied by nausea, the nurse must

first auscultate bowel sounds. If bowel

sounds are absent, the nurse should

suspect gastric or small intestine dilation

and these findings must be reported to

the physician. Palpation should be

avoided postoperatively with abdominal

distention. If peristalsis is absent,

changing positions and inserting a rectal

tube won't relieve the client's discomfort.

24. Answer: (B) Lying on the left side with

knees bent

Rationale: For a colonoscopy, the nurse

initially should position the client on the

left side with knees bent. Placing the

client on the right side with legs straight,

prone with the torso elevated, or bent

over with hands touching the floor

wouldn't allow proper visualization of the

large intestine.

25. Answer: (A) Blood supply to the stoma has

been interrupted

Rationale: An ileostomy stoma forms as

the ileum is brought through the

abdominal wall to the surface skin,

creating an artificial opening for waste

elimination. The stoma should appear

cherry red, indicating adequate arterial

perfusion. A dusky stoma suggests

decreased perfusion, which may result

from interruption of the stoma's blood

supply and may lead to tissue damage or

necrosis. A dusky stoma isn't a normal

finding. Adjusting the ostomy bag

wouldn't affect stoma color, which

depends on blood supply to the area. An

intestinal obstruction also wouldn't

change stoma color.                        

26. Answer: (A) Applying knee splints

Rationale: Applying knee splints prevents

leg contractures by holding the joints in a

position of function. Elevating the foot of

the bed can't prevent contractures

because this action doesn't hold the joints

in a position of function. Hyperextending a

body part for an extended time is

inappropriate because it can cause

contractures. Performing shoulder rangeof-

motion exercises can prevent

contractures in the shoulders, but not in

the legs.

27. Answer: (B) Urine output of 20 ml/hour.

Rationale: A urine output of less than 40

ml/hour in a client with burns indicates a

fluid volume deficit. This client's PaO2

value falls within the normal range (80 to

100 mm Hg). White pulmonary secretions

also are normal. The client's rectal

temperature isn't significantly elevated

and probably results from the fluid

volume deficit.

28. Answer: (A) Turn him frequently.

Rationale: The most important

intervention to prevent pressure ulcers is

frequent position changes, which relieve

pressure on the skin and underlying

tissues. If pressure isn't relieved,

capillaries become occluded, reducing

circulation and oxygenation of the tissues

and resulting in cell death and ulcer

formation. During passive ROM exercises,

the nurse moves each joint through its

range of movement, which improves joint

mobility and circulation to the affected

area but doesn't prevent pressure ulcers.

Adequate hydration is necessary to

maintain healthy skin and ensure tissue

repair. A footboard prevents plantar

flexion and footdrop by maintaining the

foot in a dorsiflexed position.

29. Answer: (C) In long, even, outward, and

downward strokes in the direction of hair

growth

Rationale: When applying a topical agent,

the nurse should begin at the midline and

use long, even, outward, and downward

strokes in the direction of hair growth.

This application pattern reduces the risk

of follicle irritation and skin inflammation.

30. Answer: (A) Beta -adrenergic blockers

Rationale: Beta-adrenergic blockers work

by blocking beta receptors in the

myocardium, reducing the response to

catecholamines and sympathetic nerve

stimulation. They protect the

myocardium, helping to reduce the risk of

another infraction by decreasing

myocardial oxygen demand. Calcium

channel blockers reduce the workload of

the heart by decreasing the heart rate.

Narcotics reduce myocardial oxygen

demand, promote vasodilation, and

decrease anxiety. Nitrates reduce

myocardial oxygen consumption bt

decreasing left ventricular end diastolic

pressure (preload) and systemic vascular

resistance (afterload).

31. Answer: (C) Raised 30 degrees

Rationale: Jugular venous pressure is

measured with a centimeter ruler to

obtain the vertical distance between the

sternal angle and the point of highest

pulsation with the head of the bed

inclined between 15 to 30 degrees.

Increased pressure can’t be seen when

the client is supine or when the head of

the bed is raised 10 degrees because the

point that marks the pressure level is

above the jaw (therefore, not visible). In

high Fowler’s position, the veins would be

barely discernible above the clavicle.

32. Answer: (D) Inotropic agents

Rationale: Inotropic agents are

administered to increase the force of the

heart’s contractions, thereby increasing

ventricular contractility and ultimately

increasing cardiac output. Beta-adrenergic

blockers and calcium channel blockers

decrease the heart rate and ultimately

decreased the workload of the heart.

Diuretics are administered to decrease the

overall vascular volume, also decreasing

the workload of the heart.

33. Answer: (B) Less than 30% of calories from

fat

Rationale: A client with low serum HDL

and high serum LDL levels should get less

than 30% of daily calories from fat. The

other modifications are appropriate for

this client.

34. Answer: (C) The emergency department

nurse calls up the latest electrocardiogram

results to check the client’s progress

Rationale: The emergency department

nurse is no longer directly involved with

the client’s care and thus has no legal

right to information about his present

condition. Anyone directly involved in his

care (such as the telemetry nurse and the

on-call physician) has the right to

information about his condition. Because

the client requested that the nurse update

his wife on his condition, doing so doesn’t

breach confidentiality.             

35. Answer: (B) Check endotracheal tube

placement.

Rationale: ET tube placement should be

confirmed as soon as the client arrives in

the emergency department. Once the

airways is secured, oxygenation and

ventilation should be confirmed using an

end-tidal carbon dioxide monitor and

pulse oximetry. Next, the nurse should

make sure L.V. access is established. If the

client experiences symptomatic

bradycardia, atropine is administered as

ordered 0.5 to 1 mg every 3 to 5 minutes

to a total of 3 mg. Then the nurse should

try to find the cause of the client’s arrest

by obtaining an ABG sample. Amiodarone

is indicated for ventricular tachycardia,

ventricular fibrillation and atrial flutter –

not symptomatic bradycardia.

36. Answer: (C) 95 mm Hg

Rationale: Use the following formula to

calculate MAP

MAP = systolic + 2 (diastolic)

3

MAP=126 mm Hg + 2 (80 mm Hg)

3

MAP=286 mm HG

3

MAP=95 mm Hg

37. Answer: (C) Electrocardiogram, complete

blood count, testing for occult blood,

comprehensive serum metabolic panel.

Rationale: An electrocardiogram evaluates

the complaints of chest pain, laboratory

tests determines anemia, and the stool

test for occult blood determines blood in

the stool. Cardiac monitoring, oxygen, and

creatine kinase and lactate

dehydrogenase levels are appropriate for

a cardiac primary problem. A basic

metabolic panel and alkaline phosphatase

and aspartate aminotransferase levels

assess liver function. Prothrombin time,

partial thromboplastin time, fibrinogen

and fibrin split products are measured to

verify bleeding dyscrasias; an

electroencephalogram evaluates brain

electrical activity.

38. Answer: (D) Heparin-associated

thrombosis and thrombocytopenia (HATT)

Rationale: HATT may occur after CABG

surgery due to heparin use during surgery.

Although DIC and ITP cause platelet

aggregation and bleeding, neither is

common in a client after revascularization

surgery. Pancytopenia is a reduction in all

blood cells.

39. Answer: (B) Corticosteroids

Rationale: Corticosteroid therapy can

decrease antibody production and

phagocytosis of the antibody-coated

platelets, retaining more functioning

platelets. Methotrexate can cause

thrombocytopenia. Vitamin K is used to

treat an excessive anticoagulate state

from warfarin overload, and ASA

decreases platelet aggregation.

40. Answer: (D) Xenogeneic

Rationale: An xenogeneic transplant is

between is between human and another

species. A syngeneic transplant is between

identical twins, allogeneic transplant is

between two humans, and autologous is a

transplant from the same individual.

41. Answer: (B)

Rationale: Tissue thromboplastin is

released when damaged tissue comes in

contact with clotting factors. Calcium is

released to assist the conversion of

factors X to Xa. Conversion of factors XII to

XIIa and VIII to IIIa are part of the intrinsic

pathway.

42. Answer: (C) Essential thrombocytopenia

Rationale: Essential thrombocytopenia is

linked to immunologic disorders, such as

SLE and human immunodeficiency virus.

The disorder known as von Willebrand’s

disease is a type of hemophilia and isn’t

linked to SLE. Moderate to severe anemia

is associated with SLE, not polycythemia.

Dressler’s syndrome is pericarditis that

occurs after a myocardial infarction and

isn’t linked to SLE.

43. Answer: (B) Night sweat

Rationale: In stage 1, symptoms include a

single enlarged lymph node (usually),

unexplained fever, night sweats, malaise,

and generalized pruritis. Although

splenomegaly may be present in some

clients, night sweats are generally more

prevalent. Pericarditis isn’t associated

with Hodgkin’s disease, nor is

hypothermia. Moreover, splenomegaly

and pericarditis aren’t symptoms.

Persistent hypothermia is associated with

Hodgkin’s but isn’t an early sign of the

disease.

44. Answer: (D) Breath sounds

Rationale: Pneumonia, both viral and

fungal, is a common cause of death in

clients with neutropenia, so frequent

assessment of respiratory rate and breath

sounds is required. Although assessing

blood pressure, bowel sounds, and heart

sounds is important, it won’t help detect

pneumonia.

45. Answer: (B) Muscle spasm

Rationale: Back pain or paresthesia in the

lower extremities may indicate impending

spinal cord compression from a spinal

tumor. This should be recognized and

treated promptly as progression of the

tumor may result in paraplegia. The other

options, which reflect parts of the nervous

system, aren’t usually affected by MM.        

46. Answer: (C) 10 years

Rationale: Epidermiologic studies show

the average time from initial contact with

HIV to the development of AIDS is 10

years.

47. Answer: (A) Low platelet count

Rationale: In DIC, platelets and clotting

factors are consumed, resulting in

microthrombi and excessive bleeding. As

clots form, fibrinogen levels decrease and

the prothrombin time increases. Fibrin

degeneration products increase as

fibrinolysis takes places.             

48. Answer: (D) Hodgkin’s disease

Rationale: Hodgkin’s disease typically

causes fever night sweats, weight loss,

and lymph mode enlargement. Influenza

doesn’t last for months. Clients with sickle

cell anemia manifest signs and symptoms

of chronic anemia with pallor of the

mucous membrane, fatigue, and

decreased tolerance for exercise; they

don’t show fever, night sweats, weight

loss or lymph node enlargement.

Leukemia doesn’t cause lymph node

enlargement.                     

49. Answer: (C) A Rh-negative

Rationale: Human blood can sometimes

contain an inherited D antigen. Persons

with the D antigen have Rh-positive blood

type; those lacking the antigen have Rhnegative

blood. It’s important that a

person with Rh- negative blood receives

Rh-negative blood. If Rh-positive blood is

administered to an Rh-negative person,

the recipient develops anti-Rh agglutinins,

and sub sequent transfusions with Rhpositive

blood may cause serious

reactions with clumping and hemolysis of

red blood cells.

50. Answer: (B) “I will call my doctor if Stacy

has persistent vomiting and diarrhea”.

Rationale: Persistent (more than 24 hours)

vomiting, anorexia, and diarrhea are signs

of toxicity and the patient should stop the

medication and notify the health care

provider. The other manifestations are

expected side effects of chemotherapy.