Nokea
The nurse is performing an admission assessment on a client admitted with a diagnosis of Raynaud's disease. The nurse assesses for the associated symptoms by performing which actions?
- A. Checking for a rash on the digits
- B. Observing for softening of the nails or nail beds
- C. Palpating for a rapid or irregular peripheral pulse
- D. Palpating for diminished or absent peripheral pulses
Correct Answer: D
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. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. A rash on the digits is not a characteristic of this disorder. The nails grow slowly become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.
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A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, which question should the nurse ask the parent?
- A. Does the child play with an imaginary friend?
- B. Was the child recently treated for pneumonia?
- C. Does the child respond when called by name?
- D. Has the child had any difficulty swallowing food?
Correct Answer: C
Rationale: A child with cleft palate is at risk for developing frequent otitis media, which can result in hearing loss. Unresponsiveness may be an indication that the child is experiencing hearing loss. Option 1 is normal behavior for a preschool child. Many preschoolers with vivid imaginations have imaginary friends. Options 2 and 4 are unrelated to cleft palate after repair.
A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder?
- A. Thyroid cancer
- B. Acute laryngitis
- C. Laryngeal cancer
- D. Bronchogenic cancer
Correct Answer: C
Rationale: Hoarseness is a common early sign of laryngeal cancer, but not of thyroid or bronchogenic cancer. Hoarseness that persists for 8 weeks is not associated with an acute problem, such as laryngitis.
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 is planning to give a tepid tub bath to a child experiencing hyperthermia. Which action should the nurse plan to perform?
- A. Obtain isopropyl alcohol to add to the bath water.
- B. Allow 5 minutes for the child to soak in the bath water.
- C. Have cool water available to add to the warm bath water.
- D. Warm the water to the same body temperature as the child's.
Correct Answer: C
Rationale: Adding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to gradually adjust to the changing water temperature and will not experience chilling. Alcohol is toxic, can cause peripheral vasoconstriction, and is contraindicated for tepid sponge or tub baths. The child should be in a tepid tub bath for 20 to 30 minutes to achieve maximum results. To achieve the best cooling results, the water temperature should be at least 2 degrees lower than the child's body temperature.