RN VATI Adult Medical Surgical Assessment.
A nurse is caring for a client who has atopic dermatitis and a prescription for
triamcinolone ointment. The nurse should assess the client to monitor for which of
the following adverse effects?
(ANS-
Thinning of the skin.
Only apply the ointment to dry patches of the skin to avoid atrophy.
Topical Glucocorticoids Side effects
(ANS-
Tiamcinolone
- Hypopigmentation
- Excessive hair growth (hypertrichosis)
- Thinning of the skin
A nurse is assessing a client who has left-sided heart failure. Which of the
following findings should the nurse identify as a manifestation of left-sided heart
failure?
(ANS- Frothy sputum
,Pink-tinged frothy sputum can be an early indication of pulmonary edema and can
be life-threatening. Therefore, the nurse should notify the provider immediately.
Left Sided Heart Failure
(ANS-
- Frothy sputum
- Dyspnea
- Wheezing
Treatment:
Fluid restriction & diuretics to decrease preload & pulmonary congestion
Right heart sided failure
(ANS-
- Dependent edma
- Jugular distention
- Weight gain
A nurse is caring for a client who is experiencing anxiety as well as numbness and
tingling of the lips and fingers.
,The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85
mm Hg. Which of the following acid-base imbalances should the nurse identify
that the client is experiencing?
(ANS- Respiratory alkalosis
- The pH is alkaline (increased)
- PCO2 is decreased representing alveolar hyperventilation & resultant respiratory
alkalosis
A nurse is assessing a client who has Cushing's syndrome. Which of the following
findings should the nurse expect?
(ANS- Osteoporosis
Bone become thinner as a result of mineral loss & nitrogen depletion.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse
should identify which of the following lesion characteristics on the client's skin?
(ANS- A pearly, waxy nodule.
, - Basal cell carcinoma has a nodular lesion with well defined borders & pearly or
waxy appearance resulting from overexposure to the sun. especially on the face,
head, and neck.
-A client who has melanoma has a lesion with irregular borders and variegated
colors of red, white, and blue, most often on the upper back or lower legs.
-A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion
with a ulcerated center, resulting from sun exposure, chronic irritation, burns, or
irradiation to the skin.
Melanoma
(ANS-
Irregular border and varigated colored lesions of red, white, blue.
- Most often on the upper back or lower legs
Squamous cell carcinoma
(ANS- Firm, nodular, and crusty lesion with an ulcerated center from sun
exposure, chronic irritation, burns, or irradiation to the skin.
weeping vescile
(ANS- Herpes Zoster
A nurse is caring for a client who has atopic dermatitis and a prescription for
triamcinolone ointment. The nurse should assess the client to monitor for which of
the following adverse effects?
(ANS-
Thinning of the skin.
Only apply the ointment to dry patches of the skin to avoid atrophy.
Topical Glucocorticoids Side effects
(ANS-
Tiamcinolone
- Hypopigmentation
- Excessive hair growth (hypertrichosis)
- Thinning of the skin
A nurse is assessing a client who has left-sided heart failure. Which of the
following findings should the nurse identify as a manifestation of left-sided heart
failure?
(ANS- Frothy sputum
,Pink-tinged frothy sputum can be an early indication of pulmonary edema and can
be life-threatening. Therefore, the nurse should notify the provider immediately.
Left Sided Heart Failure
(ANS-
- Frothy sputum
- Dyspnea
- Wheezing
Treatment:
Fluid restriction & diuretics to decrease preload & pulmonary congestion
Right heart sided failure
(ANS-
- Dependent edma
- Jugular distention
- Weight gain
A nurse is caring for a client who is experiencing anxiety as well as numbness and
tingling of the lips and fingers.
,The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85
mm Hg. Which of the following acid-base imbalances should the nurse identify
that the client is experiencing?
(ANS- Respiratory alkalosis
- The pH is alkaline (increased)
- PCO2 is decreased representing alveolar hyperventilation & resultant respiratory
alkalosis
A nurse is assessing a client who has Cushing's syndrome. Which of the following
findings should the nurse expect?
(ANS- Osteoporosis
Bone become thinner as a result of mineral loss & nitrogen depletion.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse
should identify which of the following lesion characteristics on the client's skin?
(ANS- A pearly, waxy nodule.
, - Basal cell carcinoma has a nodular lesion with well defined borders & pearly or
waxy appearance resulting from overexposure to the sun. especially on the face,
head, and neck.
-A client who has melanoma has a lesion with irregular borders and variegated
colors of red, white, and blue, most often on the upper back or lower legs.
-A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion
with a ulcerated center, resulting from sun exposure, chronic irritation, burns, or
irradiation to the skin.
Melanoma
(ANS-
Irregular border and varigated colored lesions of red, white, blue.
- Most often on the upper back or lower legs
Squamous cell carcinoma
(ANS- Firm, nodular, and crusty lesion with an ulcerated center from sun
exposure, chronic irritation, burns, or irradiation to the skin.
weeping vescile
(ANS- Herpes Zoster
