Nokea
The nurse is caring for a client who develops compartment syndrome as a result of a severely fractured arm. When the client asks why this happens, how should the nurse respond?
- A. A bone fragment has injured the nerve supply in the area.
- B. An injured artery causes impaired arterial perfusion through the compartment.
- C. Bleeding and swelling cause increased pressure in an area that cannot expand.
- D. The fascia expands with injury, causing pressure on underlying nerves and muscles.
Correct Answer: C
Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. Therefore, options 1, 2, and 4 are incorrect statements.
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A client who survived a house fire is experiencing respiratory distress, and an inhalation injury is suspected. What should the nurse monitor to determine the presence of carbon monoxide poisoning?
- A. Pulse oximetry
- B. Urine myoglobin
- C. Sputum carbon levels
- D. Serum carboxyhemoglobin levels
Correct Answer: D
Rationale: Serum carboxyhemoglobin levels are the most direct measure of carbon monoxide poisoning, provide the level of poisoning, and thus determine the appropriate treatment measures. The carbon monoxide molecule has a 200 times greater affinity for binding with hemoglobin than an oxygen molecule, causing decreased availability of oxygen to the cells. Clients are treated with 100% oxygen under pressure (hyperbaric oxygen therapy). Options 1, 2, and 3 would not identify carbon monoxide poisoning.
During a health assessment, the client tells the nurse that she was diagnosed with endometriosis. Which explanation presented by the client demonstrates an understanding of the description of the condition?
- A. Endometriosis is known as primary dysmenorrhea.
- B. Endometriosis is what causes me the pain that occurs when I ovulate.
- C. Endometriosis is the condition that has caused me to stop menstruating.
- D. Endometriosis means that I have uterine tissue growing outside my uterus.
Correct Answer: D
Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in structure, function, and response to estrogen and progesterone during the menstrual cycle. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods coinciding with ovulation. Primary dysmenorrhea refers to menstrual pain without identified pathology. Amenorrhea, the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation, can result from a variety of causes.
The nurse provides discharge instructions to a client who is recovering from testicular cancer surgery. Which instruction should the nurse include?
- A. To avoid driving a car for at least 2 weeks
- B. Not to be fitted for a prosthesis for at least 3 months
- C. To avoid sitting for long periods for at least 2 weeks
- D. To report any elevation in temperature to the primary health care provider
Correct Answer: D
Rationale: For the client who has had testicular surgery, the nurse should emphasize the importance of notifying the primary health care provider if chills, fever, drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. One week after testicular surgery, the client may drive. Often, a prosthesis is inserted during surgery. Sitting needs to be avoided with prostate surgery because of the risk of hemorrhage, but this risk is not as high with testicular surgery.
A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?
- A. Myasthenic crisis is present.
- B. Cholinergic crisis is present.
- C. This result is a normal finding.
- D. This result is a positive finding.
Correct Answer: B
Rationale: An edrophonium test may be performed to determine whether increasing weakness in a client with previously diagnosed myasthenic is a result of cholinergic crisis (overmedication) with anticholinesterase medications or myasthenic crisis (undermedication). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.
The nurse caring for a client after right radical mastectomy includes which intervention in the nursing plan of care for this client?
- A. Takes blood pressures in the right arm only
- B. Draws serum laboratory samples from the right arm only
- C. Positions the client supine and flat with the right arm elevated on a pillow
- D. Checks the right posterior axilla area when assessing the surgical dressing
Correct Answer: D
Rationale: If there is drainage or bleeding from the surgical site after mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the dressing first. The nurse checks this area to detect early bleeding. Blood pressure measurement, venipuncture, and intravenous sites should not involve use of the operative arm. The client should be positioned with the head in semi-Fowler's position and the arm on the operative side elevated on pillows to decrease edema.