Question 6061)
The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?
A. Infection
B. Hemorrhage
C. Chronic hypertension
D. Disseminated intravascular coagulation
Answer: B
Explanation: In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding.
Question 6062)
The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic an their frequency, duration and intensity. What is the priority nursing action?
A. Provide pain relief measures.
B. Prepare the client for an amniotomy.
C. Promote ambulation every 30 minutes.
D. Monitor the oxytocin infusion closely.
Answer: A
Explanation: Hypertonic uterine contractions are painful, occur frequently and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions, however, these treatments may be used in clients with hypertonic dysfunction. A client with hypertonic uterine contraction would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.
Question 6063)
Pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks gestation because of which factor?
A. The appearance of the fetal external genitalia
B. The beginning of differentiation in the fetal groin
C. The fetal testes are descended into the scrotal sac
D. The internal differences in males and females become apparent
Answer: A
Explanation: By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Differentiation of the external genitalia occurs at the end of the ninth week. Testes descend into the scrotal sac at the end of the thirty-eight week. Internal differences in the male and female occur at the end of the seventh week.
Question 6064)
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?
A. "Did you ever had surgery?"
B. "Do you plan to have any other children?"
C. "Do either of you have diabetes mellitus?"
D. "Do either of you have problems with high blood pressure?"
Answer: B
Explanation: Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future.
Question 6065)
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation is NOT observed in cataract?
A. Decrease color perception
B. Blurred vision
C. Dizziness
D. Opaque
Answer: C
Explanation: Cataract Vision starts as slightly blurred vision an decreased color perception (pt may think contacts or glasses dirty); then blurred and double vision occur and may have difficulty with ADLs; can progress to blindness w/o surgery; no pain or eye redness is associated with age-related cataracts The eye becomes progressively opaque (not transparent) -> resulting in blurred vision - Progressive opacity of the crystalline lens - It is loss of transparency of the lens -> causes decreased transmission of light to retina - Usually not treated until there is visual loss that interferes with ADLs - Occurs in patients > 50 years old Signs & Symptoms of Cataract - Painless - Progressive -- in early stages vision is minimally distorted -- there is gradual decrease in visual acuity - Hazy vision - b/c of light scattering - cloudy vision - b/c of light scattering - Blurry, blurred vision - b/cof light scattering - Decrease in color perception - Decrease in night vision -- pts who drive at night may notice cataracts more - Pt ll see glare from lights - specially from other cars' headlights when driving at night - Photophobia = sensitivity to light, light can cause headache - Decrease in depth perception - On eye exam you will see pt's pupils change colors -- Pupils goes from Cloudy -> Yellow -> Grey -> Milky White --Once pupils are milky white - it is mature cataract - Opthalmoscope - will show the opacity -- may not be able to see retina - due to the opacity - Once the cataracts are mature & interferes with ADLs - it is treated with eye surgery
Question 6066)
What is the priority problem in the client diagnosed with congestive heart failure?
A. Fluid volume overload
B. Decreased cardiac output
C. Activity intolerance
D. Knowledge deficit
Answer: A
Explanation: Fluid volume overload.
Question 6067)
Which laboratory data confirm the diagnosis of congestive heart failure?
A. Chest X-ray (CXR)
B. Liver function tests
C. Blood Urea Nitrogen (BUN)
D. Beta-type natriuteric peptide (BNP)
Answer: A
Explanation: A chest X-ray may show features of heart failure such as an increased cardiothoracic ratio, lung interstitial oedema or bilateral pleural effusions. 17 A systematic review including five studies that estimated the accuracy of an abnormal chest X-ray in detecting a diagnosis of heart failure found considerable variation between studies. 24 Sensitivity was 68% and specificity 83%.
Question 6068)
The newer drug given to interfere with the production of angiotensin II in heart failure is:
A. Isordil
B. Enoximone
C. Esmolol
D. Captopril
Answer: C
Explanation: Esmolol hydrochloride injection is indicated for the short-term treatment of tachycardia and hypertension that occur during induction and intubation, during surgery, on emergency from anesthesia and in the postoperative period, when in the physician's judgment such specific intervention is considered indicated.
Question 6069)
What are the signs of shock
A. Sweating and forgetfulness
B. Cold clammy skin, unconsciousness and rapid pulse rate
C. Rapid pulse rate and unconsciousness
D. Lethargy and slow pulse rate
Answer: B
Explanation: Eyes appear to stare. Cold clammy skin, Rapid pulse -> Anxiety or agitation. -> Seizures. ->Confusion or unresponsiveness. -> Low or no urine output.
Question 6070)
The client is diagnosed with neurogenic shock which sign/symptoms would the nurse assess in this client:
A. Cool moist skin
B. Bradycardia
C. Wheezing
D. Decreased bowel sounds
Answer: B
Explanation: The client will have bradycardia instead of tachycardia, which is seen in other forms of shock.
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