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The nurse understands that which of the ff. is a side effect most likely to be reported by patients receiving enalapril maleate (Vasotec)?
- A. Acne
- B. Diarrhea
- C. Cough
- D. Heartburn
Correct Answer: C
Rationale: The most common side effect reported by patients receiving enalapril maleate (Vasotec) is a persistent dry cough. This cough is due to the medication's effect on bradykinin levels in the body, leading to irritation of the respiratory tract and causing the cough. While other side effects such as diarrhea and heartburn may occur, cough is the most frequently reported side effect associated with enalapril maleate. Acne is not a commonly reported side effect of this medication.
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A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. What should the nurse recommend the infant be given?
- A. Skim milk
- B. Whole cow's milk
- C. Commercial iron-fortified formula
- D. Commercial formula without iron
Correct Answer: C
Rationale: When a mother decides to discontinue breastfeeding, it is important for the infant to receive an appropriate alternative that provides essential nutrients, including iron. Commercial iron-fortified formula ensures that the infant is receiving adequate iron, which is crucial for healthy growth and development. Skim milk is not recommended for infants under age 1 due to its high protein and mineral content, which can strain the baby's immature kidneys. Whole cow's milk is also not suitable before age 1 because it lacks essential nutrients such as iron and vitamin E, and can lead to iron deficiency anemia. Commercial formula without iron would not provide enough iron for the infant's needs, making commercial iron-fortified formula the most appropriate choice for the 5-month-old infant.
Which of the ff factors predisposes a client to the development of TB?
- A. Exposure to toxic gases
- B. Congenital abnormalities
- C. Obstruction by tumor
- D. Malnutrition
Correct Answer: D
Rationale: Malnutrition predisposes a client to the development of Tuberculosis (TB) because a lack of proper nutrition weakens the immune system, making the individual more susceptible to infections such as TB. Adequate nutrition is essential for maintaining a healthy immune system that can effectively fight off pathogens. Malnourished individuals are less able to mount a strong immune response, thus increasing their vulnerability to contracting TB and experiencing more severe symptoms and complications from the disease.
The nurse is teaching nursing students about childhood skin lesions. Which is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?
- A. Cyst
- B. Papule
- C. Pustule
- D. Vesicle
Correct Answer: D
Rationale: A vesicle is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid. Serous fluid is a clear, watery fluid that can accumulate within the vesicle. Vesicles are commonly seen in conditions such as herpes simplex virus infections (cold sores) and contact dermatitis. It is important for nursing students to understand the characteristics of different skin lesions to accurately assess and provide appropriate care for patients.
Choose the condition that exhibits blood values with a low pH and a high PCO :
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metaboliâ‚‚c alkalosis
Correct Answer: A
Rationale: Respiratory acidosis is a condition characterized by elevated levels of carbon dioxide (high PCOâ‚‚) and decreased blood pH (low pH) due to inadequate ventilation leading to the accumulation of carbon dioxide in the body. The excess carbon dioxide reacts with water in the blood to form carbonic acid, resulting in a decrease in pH. This is in contrast to metabolic acidosis, which is characterized by an accumulation of acids other than carbon dioxide, leading to a low blood pH. Respiratory alkalosis would present with a low PCOâ‚‚ and high pH, while metabolic alkalosis features a high pH and elevated bicarbonate levels due to non-respiratory causes.
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?
- A. Night sweats, weight loss, and diarrhea
- B. Nausea, vomiting, and anorexia
- C. Dyspnea, tachycardia, and pallor
- D. Itching, rash, and jaundice  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET H
Correct Answer: C
Rationale: Iron-deficiency anemia is a common type of anemia characterized by a lack of iron in the body, which leads to decreased production of red blood cells containing hemoglobin. The assessment findings characteristic of iron-deficiency anemia include dyspnea (shortness of breath) due to decreased oxygen-carrying capacity of the blood, tachycardia (rapid heart rate) as the body tries to compensate for decreased oxygen delivery, and pallor (pale skin and mucous membranes) due to reduced red blood cell production. These symptoms result from insufficient iron levels affecting the body's ability to produce an adequate number of healthy red blood cells. Night sweats, weight loss, and diarrhea are not typically associated with iron-deficiency anemia. Nausea, vomiting, anorexia, itching, rash, and jaundice are also not primary manifestations of iron-deficiency an