Nokea
A client with a history of alcoholism is admitted with a diagnosis of cirrhosis. The nurse can expect the client to exhibit:
- A. Lower extremity edema
- B. Dilated pupils
- C. Warm, dry skin
- D. Bradycardia
Correct Answer: A
Rationale: Cirrhosis impairs liver function, leading to portal hypertension and hypoalbuminemia, causing lower extremity edema. Dilated pupils, warm skin, and bradycardia are not typical.
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Nimodipine (Nimotop) is ordered for the client with a ruptured cerebral aneurysm. What does the nurse recognize as a desired effect of this drug?
- A. Prevent the influx of calcium into cells.
- B. Restore a normal blood pressure reading.
- C. Prevent the inflammatory process.
- D. Dissolve the clot that has formed.
Correct Answer: A
Rationale: Nimodipine, a calcium channel blocker, prevents calcium influx into cells, reducing vasospasm post-aneurysm rupture. It doesn’t normalize BP (B), prevent inflammation (C), or dissolve clots (D).
Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. Which of the following nursing observations indicates that the drug is having a therapeutic effect?
- A. There is an absence of peristalsis.
- B. The number of diarrhea stools decreases.
- C. Cramping in the abdomen has increased.
- D. Abdominal girth size increases.
Correct Answer: B
Rationale: Lomotil, an antidiarrheal, slows intestinal motility, reducing diarrhea frequency in ulcerative colitis. Decreased diarrhea stools (B) indicates therapeutic effect. Absent peristalsis (A), increased cramping (C), or girth (D) suggest complications or ineffectiveness.
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?
- A. I've been having a dull pain at the upper left shoulder.'
- B. My legs have been numb for three months.'
- C. I've only been urinating three times a day lately.'
- D. I don't remember anything in particular, I just haven't felt well.'
Correct Answer: D
Rationale: (A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
The physician has ordered aerosol treatments, chest percussion, and postural drainage for a client with cystic fibrosis. The nurse recognizes that the combination of therapies is to:
- A. Decrease respiratory effort and mucous production
- B. Increase efficiency of the diaphragm and gas exchange
- C. Dilate the bronchioles and help remove secretions
- D. Stimulate coughing and oxygen consumption
Correct Answer: C
Rationale: These therapies aim to dilate airways (aerosols), mobilize mucus (percussion), and clear secretions (postural drainage) to improve breathing in cystic fibrosis.
A client with a history of a burn injury is receiving Collagenase (Santyl). The nurse should:
- A. Apply the ointment to healthy skin
- B. Cover the wound with a dry dressing
- C. Clean the wound before application
- D. Expose the wound to air after application
Correct Answer: C
Rationale: Collagenase is applied to debride burn wounds, requiring a clean wound bed for effectiveness. It’s applied only to the wound, covered with a moist dressing, and not exposed to air.