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A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?
- A. Moist skin.
- B. Blood in the urine.
- C. Spider angiomas.
- D. Tarry stools.
Correct Answer: C
Rationale: The correct answer is C: Spider angiomas. In cirrhosis, the liver is damaged leading to increased pressure in the portal vein. This results in dilated blood vessels on the skin surface known as spider angiomas. This finding is expected due to the liver's inability to process blood effectively. Choice A (Moist skin) is incorrect as cirrhosis commonly causes dry and itchy skin. Choice B (Blood in the urine) is incorrect because cirrhosis typically does not directly affect the kidneys. Choice D (Tarry stools) is incorrect as it is a symptom of gastrointestinal bleeding, which can occur in cirrhosis but is not a specific finding.
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The nurse reviews a primary health care provider’s prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Fever usually accompanies myocardial infarction.
- B. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
- C. Headache is a common side effect of nitrates.
- D. Acetaminophen potentiates the therapeutic effect of nitrates.
- E. Acetaminophen potentiates the therapeutic effect of nitrates.
Correct Answer: C
Rationale: The correct answer is C. Headache is a common side effect of nitrates. Nitroglycerin, a common topical nitrate, is often prescribed for angina to dilate blood vessels and improve blood flow to the heart. One common side effect of nitrates is headache due to vasodilation, and acetaminophen is often prescribed to help alleviate this headache. Choices A and B are incorrect as they do not directly relate to why acetaminophen is prescribed with nitrates. Choice D is incorrect because acetaminophen does not potentiate the therapeutic effect of nitrates, it only helps with headache relief. Choice E is a duplicate of D.
A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?
- A. Use friction when washing the affected area.
- B. Use a new cosmetic pad with each limited application of makeup.
- C. Use an oil-based soap to wash affected areas daily.
- D. Express the larger comedones periodically.
Correct Answer: B
Rationale: The correct answer is B: Use a new cosmetic pad with each limited application of makeup. This is important to prevent the spread of bacteria and reduce the risk of exacerbating acne. Using a new pad each time helps to avoid introducing more bacteria to the skin. Choice A is incorrect because friction can irritate the skin and worsen acne. Choice C is incorrect as oil-based soap can clog pores and worsen acne. Choice D is incorrect because expressing comedones can lead to scarring and infection. It's crucial to provide accurate and evidence-based information to clients to promote effective management of their condition.
A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skin traction. The nurse may remove the weights from the traction device if which of the following occurs?
- A. The client develops a life-threatening situation.
- B. The client has to be repositioned in the bed.
- C. The client complains of pain.
- D. The client needs to have an x-ray of the femur performed.
Correct Answer: A
Rationale: The correct answer is A: The client develops a life-threatening situation. In this scenario, the nurse can remove the weights from the traction device to address the life-threatening situation promptly. Removing the weights in such a situation takes precedence over other concerns like repositioning, pain complaints, or even the need for an x-ray. Life-threatening situations must always be prioritized in patient care to ensure their safety and well-being. It is crucial for the nurse to act swiftly and appropriately in such emergencies to provide the necessary care and support to the client.
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
- A. The ability to comply with anticoagulant therapy for life.
- B. The likelihood of the client experiencing body image problems.
- C. The physical demands of the client’s lifestyle.
- D. The ability to participate in a cardiac rehabilitation program.
Correct Answer: A
Rationale: The correct answer is A: The ability to comply with anticoagulant therapy for life. This is essential because mechanical valve replacement requires lifelong anticoagulant therapy to prevent clot formation. Noncompliance can lead to serious complications such as thromboembolism or valve failure. Assessing the client's understanding, willingness, and ability to adhere to this therapy is crucial for successful outcomes.
Other options are incorrect because:
B: Body image problems are important but not essential before surgery.
C: Physical demands of lifestyle are relevant but not crucial for valve replacement.
D: Participation in cardiac rehab is beneficial post-surgery but not essential before.
Overall, the ability to comply with anticoagulant therapy is the most critical factor to assess preoperatively.
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?
- A. Does drinking coffee or ingesting chocolate seem related to the episodes?
- B. Does being exposed to heat seem to cause the episodes?
- C. Do the signs and symptoms occur while you are asleep?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: A
Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.
Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them. Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep. Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.