Nokea
A clinic nurse is assessing a prenatal client who has been diagnosed with heart disease. The nurse carefully assesses the client's vital signs, weight, and fluid and nutritional status to detect for complications caused by which pregnancy-related concern?
- A. Rh incompatibility
- B. Fetal cardiomegaly
- C. The increase in circulating blood volume
- D. Hypertrophy and increased contractility of the heart
Correct Answer: C
Rationale: Pregnancy taxes the circulating system of every woman because the blood volume increases, which causes the cardiac output to increase. Stroke volume × heart rate = cardiac output (SV × HR = CO). Options 1, 2, and 4 are not directly associated with pregnancy in a client with a cardiac condition.
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Tretinoin gel has been prescribed for a client with acne. What is the nurse's response when the client calls and reports that her skin has become very red and is beginning to peel?
- A. Discontinue the medication immediately.
- B. Come to the clinic immediately for an assessment.
- C. I'll notify your primary health care provider of these results.
- D. This is a normal occurrence with the use of this medication.
Correct Answer: D
Rationale: Tretinoin decreases cohesiveness of the epithelial cells, increasing cell mitosis and turnover. It is potentially irritating, particularly when used correctly. Within 48 hours of use, the skin generally becomes red and begins to peel. Options 1, 2, and 3 are incorrect statements to the client.
The nurse provides information to a preoperative client who will be receiving relaxation therapy. What effects should the nurse teach the client to expect regarding this type of therapy? Select all that apply.
- A. Increased heart rate
- B. Improved well-being
- C. Lowered blood pressure
- D. Increased respiratory rate
- E. Decreased muscle tension
- F. Increased neural impulses to the brain
Correct Answer: B,C,E
Rationale: Relaxation is the state of generalized decreased cognitive, physiological, and/or behavioral arousal. Relaxation elongates the muscle fibers, reduces the neural impulses to the brain, and thus decreases the activity of the brain and other systems. The effects of relaxation therapy include improved well-being; lowered blood pressure, heart rate, and respiratory rate; decreased muscle tension; and reduced symptoms of distress in persons who need to undergo treatments, those experiencing complications from medical treatment or disease, or those grieving the loss of a significant other. This therapy does not cause an increased heart rate, increased respiratory rate, or increased neural impulses to the brain.
A client has developed oral mucositis as a result of radiation to the head and neck. Which measure should the nurse teach the client to incorporate in a daily home care routine to help manage this condition?
- A. A glass of wine per day will introduce useful bacterial to the oral cavity.
- B. High-protein foods such as peanut butter should be incorporated in the diet.
- C. Clean teeth and rinse mouth with a weak saline and water solution before and after each meal.
- D. Oral hygiene, including brushing and flossing, should be performed in the morning and evening.
Correct Answer: C
Rationale: Oral mucositis (irritation, inflammation, and/or ulceration of the mucosa) also known as stomatitis, commonly occurs in clients receiving radiation to the head and neck. Measures need to be taken to soothe the mucosa and provide effective cleansing of the oral cavity. A combination of a weak saline and water solution is an effective cleansing agent. Oral hygiene should be performed more frequently than in the morning and evening. Alcohol would dry and irritate the mucosa and not affect the oral bacteria. Peanut butter has a thick consistency and will stick to the irritated mucosa.
A client diagnosed with myxedema reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse plans care knowing that these clinical manifestations are caused by a lack of production of which hormones? Select all that apply.
- A. Thyroxine (T4)
- B. Prolactin (PRL)
- C. Triiodothyronine (T3)
- D. Growth hormone (GH)
- E. Luteinizing hormone (LH)
- F. Adrenocorticotropic hormone (ACTH)
Correct Answer: A,C
Rationale: Although all of these hormones originate from the anterior pituitary, only T3 and T4 are associated with the client's symptoms. Myxedema results from inadequate thyroid hormone levels (T3 and T4). Low levels of thyroid hormone result in an overall decrease in the basal metabolic rate, affecting virtually every body system and leading to weakness, fatigue, and a decrease in heat production. A decrease in LH results in the loss of secondary sex characteristics. A decrease in ACTH is seen in Addison's disease. PRL stimulates breast milk production by the mammary glands, and GH affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.
The ambulatory care nurse is assessing a client with chronic sinusitis. The nurse determines that which manifestations reported by the client are related to this problem? Select all that apply.
- A. Anosmia
- B. Chronic cough
- C. Blurry vision
- D. Nasal stuffiness
- E. Purulent nasal discharge
- F. Headache that worsens in the evening
Correct Answer: A,B,D,E
Rationale: Chronic sinusitis is characterized by anosmia (loss of smell), a chronic cough resulting from nasal discharge, nasal stuffiness, persistent purulent nasal discharge, and headache that is worse upon arising after sleep. Blurred vision is not associated directly to this condition.