A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?
- A. Hyperactivity of the medium-sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest.
- B. Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.
- C. Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production.
- D. Chloride is not being transported properly, producing excess absorption of water and sodium, and thick viscous mucus.
Correct Answer: B
Rationale: Larger-than-normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways. Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COPD).
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A client goes to the mental health center for difficulty concentrating, insomnia, and nightmares. The client reports being raped as a child. The nurse should assess the client for further signs of:
- A. General anxiety disorder
- B. Schizophrenia
- C. Post-traumatic stress disorder
- D. Bipolar disorder
Correct Answer: C
Rationale: Childhood sexual abuse is strongly associated with post-traumatic stress disorder (PTSD), characterized by nightmares, insomnia, and concentration difficulties.
A nurse is performing a screening on a patient that has been casted recently on the left lower extremity. Which of the following statements should the nurse be most concerned about?
- A. The patient reports, 'I didn't keep my extremity elevated like the doctor asked me to.'
- B. The patient reports, 'I have been having pain in my left calf.'
- C. The patient reports, 'My left leg has really been itching.'
- D. The patient reports, 'The arthritis in my wrists is flaring up, when I put weight on my crutches.'
Correct Answer: B
Rationale: Pain may be indicating neurovascular complication.
Appropriate nursing strategies to assist a client in maintaining a sense of self include:
- A. using the client's first name when addressing the client
- B. treating the client with dignity
- C. explaining procedures only if the client is attentive
- D. discouraging the use of personal items
Correct Answer: B
Rationale: Treating the client with dignity respects their individuality and fosters a sense of self, unlike the other options, which may undermine autonomy or engagement.
The kind of man who beats a woman is:
- A. from a minority culture in a low-income group.
- B. from a majority culture in a middle-income group.
- C. one who was never allowed to compete as a child.
- D. from any walk of life, race, income group, or profession.
Correct Answer: D
Rationale: Batterers cannot be predicted by demographic features related to age, ethnicity, race, religious denomination, education, socioeconomic status, or class. Ninety-five percent of domestic abuse cases involve male perpetrators and female victims.
Which statement about chemotherapy is true?
- A. It is a local treatment affecting only tumor cells.
- B. It is a systemic treatment affecting both tumor and normal cells.
- C. It has not yet been proved an effective treatment for cancer.
- D. It is often the drug of choice because it causes few, if any, side effects.
Correct Answer: B
Rationale: 5-FU is an antineoplastic, antimetabolic drug that inhibits DNA synthesis and interferes with cell replication. It is given intravenously and acts systemically. It affects all rapidly growing cells, both malignant and normal. It is used as adjuvant therapy for treating cancer of the colon, rectum, stomach, breast, and pancreas. This drug has many side effects, including bone marrow depression, anorexia, stomatitis, nausea, and vomiting.