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A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud's disease. The nurse should assess the trigger of these signs/symptoms by asking which question?
- A. Does being exposed to heat seem to cause the episodes?
- B. Do the signs and symptoms occur while you are asleep?
- C. Does drinking coffee or ingesting chocolate seem related to the episodes?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: C
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity are unrelated to these episodes.
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The nurse is caring for a client in active labor. Which intervention should the nurse implement to prevent fetal heart rate decelerations?
- A. Discourage the client from walking.
- B. Increase the rate of the oxytocin infusion.
- C. Monitor the fetal heart rate every 30 minutes.
- D. Encourage upright or side-lying maternal positions.
Correct Answer: D
Rationale: Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. There are many nursing actions to prevent fetal heart rate decelerations without necessitating surgical intervention.
Which piece of equipment will the nurse routinely use to assess the fetal heart rate of a woman at 16 weeks' gestation?
- A. Fetal heart monitor
- B. An adult stethoscope
- C. Bell of a stethoscope
- D. Ultrasound fetoscope
Correct Answer: D
Rationale: Toward the end of the first trimester, the fetal heart tones can be heard with an ultrasound fetoscope. Options 2 and 3 are not designed to adequately assess the fetal heart rate. A fetal heart monitor is used during labor or in other situations when the fetal heart rate needs continuous monitoring.
A clinical nurse specialist is asked to present a clinical conference to the student group about brain tumors in children younger than 3 years. The nurse should include which information in the presentation?
- A. Radiation is the treatment of choice.
- B. The most significant symptoms are headache and vomiting.
- C. Head shaving is not required before removal of the brain tumor.
- D. Surgery is not normally performed because of the increased risk of functional deficits.
Correct Answer: B
Rationale: The classic symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the tumor. Before surgery, the child's head will be shaved, although every effort is made to shave only as much hair as is necessary. Radiation therapy is avoided in children younger than 3 years because of the toxic side effects on the developing brain, particularly in very young children.
The nurse provides discharge instructions to a client beginning oral hypoglycemic therapy. Which statements if made by the client indicate a need for further teaching? Select all that apply.
- A. If I am ill, I should skip my daily dose.
- B. If I overeat, I will double my dosage of medication.
- C. Oral agents are effective in managing type 2 diabetes.
- D. If I become pregnant, I will discontinue my medication.
- E. Oral hypoglycemic medications will cause my urine to turn orange.
- F. My medications are used to manage my diabetes along with diet and exercise.
Correct Answer: A,B,D,E
Rationale: Clients are instructed that oral agents are used in addition to diet and exercise as therapy for diabetes mellitus. During illness or periods of intense stress, the client should be instructed to monitor her or his blood glucose level frequently and should contact the primary health care provider if the blood glucose is elevated because insulin may be needed to prevent symptoms of acute hyperglycemia. The medication should not be skipped or the dosage should not be doubled. Taking extra medication should be avoided unless specifically prescribed by the primary health care provider. Medication should never be discontinued unless instructed to do so by the primary health care provider. However, the diabetic who becomes pregnant will need to contact her primary health care provider because the oral diabetic medication may have to be changed to insulin therapy because some oral hypoglycemics can be harmful to the fetus. These medications do not change the color of the urine.
The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention should the nurse include in the plan of care to minimize the client's long-term risk for injury?
- A. Change the client's positions slowly.
- B. Assess the client for decreased sensation to touch.
- C. Assess the client for decreased sensation to vibration.
- D. Teach the client about loss of motor function and decreased pain sensation.
Correct Answer: D
Rationale: Anterior cord syndrome is caused by damage to the anterior portion of the gray and white matter. Clinical findings related to anterior cord syndrome include loss of motor function, temperature sensation, and pain sensation below the level of injury. The syndrome does not affect sensations of fine touch, position, and vibration.