AND CORRECT ANSWERS WITH RATIONALES | VERIFIED
ANSWERS | JUST RELEASED | UPDATED VERSION
During a physical assessment, the nurse notes cutaneous fibromas and
Lisch nodules (yellow elevations) on a client's irises. What genetic
condition might this client have?
1
Phenylketonuria
2
Neurofibromatosis
3
Huntington disease
4
Myotonic dystrophy ---------CORRECT ANSWER-----------------2
Cutaneous fibromas and Lisch nodules (yellow elevations on the iris)
are signs of neurofibromatosis. Growth failure, frequent vomiting,
irritability, hyperactivity, and erratic behavior are signs of
phenylketonuria. Huntington disease is a progressive
neurodegenerative disease. Muscle weakness, wasting, myotonia,
and cardiac conduction abnormalities are signs of myotonic
dystrophy.
,A client with chronic obstructive pulmonary disease is admitted to the
hospital with a tentative diagnosis of pleuritis. When caring for this
client, what should the nurse do?
1
Administer opioids frequently
2
Assess for signs of pneumonia
3
Give medication to suppress coughing
4
Limit fluid intake to prevent pulmonary edema ---------CORRECT
ANSWER-----------------2
Clients with pleuritic disease are prone to developing pneumonia
because of impaired lung expansion, air exchange, and drainage.
Opioids are contraindicated because opioids depress respirations.
Coughing should not be suppressed; it enhances lung expansion, air
exchange, and lung drainage. Oral fluids should be encouraged;
pulmonary edema does not develop unless the client has severe
cardiovascular disease.
A nurse is caring for a client who has had multiple myocardial
infarctions and has now developed cardiogenic shock. Which clinical
manifestation supports this diagnosis?
1
,Cold, clammy skin
2
Slow, bounding pulse
3
Increased blood pressure
4
Hyperactive bowel sounds ---------CORRECT ANSWER-----------------1
The action of the sympathetic nervous system causes
vasoconstriction, and as cellular and peripheral hypoperfusion
progresses, the skin becomes cold, clammy, cyanotic, or mottled. The
heart rate increases in an attempt to meet the body's oxygen
demands and circulate blood to vital organs; it has a low volume
(weak, thready) because of peripheral vasoconstriction. The blood
pressure decreases because of continued hypoperfusion and
multiorgan failure. Bowel sounds are hypoactive or absent, not
hyperactive.
After multiple upper respiratory infections, a school-aged child
undergoes a tonsillectomy and adenoidectomy. Two weeks after
surgery the nurse assesses the child's condition. On what should the
nurse focus? Select all that apply.
1
Taste
2
, Smell
3
Hearing
4
Breathing
5
Facial symmetry ---------CORRECT ANSWER-----------------1234
Edematous adenoids interfere with nasal breathing, which affects the
sense of taste. Enlarged adenoids usually cause mouth breathing,
which affects the sense of smell. Because hearing usually is affected
by repeated oropharyngeal infections, this is an important
postoperative assessment. Breathing is an important postoperative
assessment because one goal of a tonsillectomy and adenoidectomy is
to convert mouth breathing to nasal breathing. Facial symmetry is not
affected by these procedures.
Test-Taking Tip: Pace yourself while taking a quiz or exam. Read the
entire question and all answer choices before answering the question.
Do not assume that you know what the question is asking without
reading it entirely.
After assessing a 5-year-old child, the nurse suspects the child has
mumps. Which symptoms present in the child may support the nurse's
suspicion? Select all that apply.