1. A nurse reviews the record of a client receiving external radiation therapy and notes documentation of a skin finding noted as moist desquamation. The nurse expects to note which of the following on assessment of the client?
- Reddened skin
- A rash
- Weeping of the skin
- Dermatitis
Answer: 3
Rationale: Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. Reddened skin, a rash, and dermatitis may occur with external radiation but is not described as a moist desquamation.
2. A nurse is performing an assessment on a pregnant client with a history of cardiac disease and is assessing for venous congestion. The nurse checks which body area, knowing that venous congestion is most commonly noted in this area?
- Vulva
- Fingers of the hands
- Around the eyes
- Around the abdomen
Answer: 1
Rationale: Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs. Vulva, or serum. It would be difficult to asses for edema in the abdominal area of a client who is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion
3. A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. The nurse would assess for which sign or symptom that correlates with this fluid imbalance?
- Increased blood pressure
- Decreased pulse
- Decreased central venous pressure
- Bibasilar crackles
Answer: 3
Rationale: A client with dehydration has a low CVP. The normal CVP is between 4 to 11 mm H2O. Other assessment findings with fluid volume deficit are increased pulse and respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine output, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The assessment signs in options 1, 2, and 4 occur with fluid volume.
4. A nurse is preparing a plan of care for a child with Reye’s syndrome. The nurse identifies nursing interventions and plans to monitor the child for:
- Signs of increased intracranial pressure (ICP)
- The presence of protein in the urine
- Signs of a bacterial infection
- Signs of hyperglycemia
Answer: 1
Rationale: Intracranial pressure, encephalopathy, and hepatic dysfunction are major symptoms of Reye’s syndrome. Protein is not present in the urine. Reye’s syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.
5. A clinic nurse reads the chart of a client who was seen by the physician and notes that the physician has documented that the client has Lyme disease stage III. On assessment of the client, which clinical manifestation would the nurse expect to note?
- A generalized skin rash
- A cardiac dysrhythmia
- Enlarged and inflamed joints
- Palpitations
Answer: 3
Rationale: Stage III develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage II. A rash occurs in stage I.
6. A female client with narcolepsy has been prescribed dextroamphetamine (Dexedrine). The client complains to the nurse that she cannot sleep well anymore at night and does not want to take the medication any longer. The nurse then asks the client if the medication is taken at which appropriate time?
- At least 6 hours before bedtime
- Two hours before bedtime
- Before a bedtime snack
- Just before going to sleep
Answer: 1
Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep. Therefore, options 2, 3, and 4 are incorrect.
7. A nurse is assessing the level of consciousness in a child with a head injury and documents that the child is obtunded. Based on this documentation, which observation did the nurse note?
- The child is unable to recognize place or person
- The child is unable to think clearly and rapidly
- The child requires considerable stimulation for arousal
- The child sleeps unless aroused and once aroused has limited interaction with the environment.
Answer: 4
Rationale: If the child is obtunded, the child sleeps unless aroused and once aroused has limited interaction with the environment. Option 1 describes disorientation. Option 2 describes confusion. Option 3 describes stupor.
8. A nurse is assessing a client with Addison’s disease for signs of hyperkalemia. The nurse expects to note which of the following if hyperkalemia is present?
- Polyuria
- Dry mucous membranes
- Cardiac dysrhythmias
- Prolonged bleeding time
Answer: 3
Rationale: The inadequate production of aldosterone in Addison’s disease causes inadequate excretion of potassium and results in hyperkalemia. The clinical manifestations of hyperkalemia are the result of altered nerve transmission. The most harmful consequence of hyperkalemia is its effect on cardiac function. Options 1, 2, and 4 are not manifestations associated with Addison’s disease or hyperkalemia
9. A client goes into respiratory distress, and an arterial blood gas (ABG) is drawn from the radial artery. The nurse performs the Allen test before the ABGs to determine the adequacy of the:
- Femoral circulation
- Brachial circulation
- Carotid circulation
- Ulnar circulation
Answer: 4
Rationale: Before radial puncture for obtaining an arterial specimen for ABGs, an Allen test in performed to determine adequate ulnar circulation. Failure to assess collateral circulation could result in severe ischemic injury to the hand, if damage to the radial artery occurs with arterial puncture. The Allen test does not determine adequacy of femoral, brachial, or carotid circulation.
10. A pregnant client with diabetes mellitus arrives at the health care clinic for a follow up visit. In this client, the nurse most importantly monitors:
- Urine for glucose and ketones
- Blood pressure, pulse, and respirations
- Urine for specific gravity
- For the presence of edema
Answer: 1
Rationale: The nurse assesses the pregnant client with diabetes mellitus for glucose and ketones in the urine at each prenatal visit because the physiological changes of pregnancy can drastically alter insulin requirements. Assessment of blood pressure, pulse, respirations, urine for specific gravity, and the presence of edema are more related to the client with pregnancy-induced hypertension. |
