Detailed Answer Ke7
ty ty
3y Medical Surgical,
ty ty ty
A
1.73A73nurse73is73reviewing73the73cause73of73gout73with73a73group73of73nurses.73Which73of73the73following73stateme
nts73should73the73nurse73make?
A. "Uric73acid73levels73drop73and73calcium73forms73precipitate."
Rationale:73With73gout,73clients73 have73hyperuricemia,73rather73than73 a73reduction73 in73uric73 acid.
B. "Tophi73form73in73the73kidneys73and73they73impair73the73excretion73of73uric73acid."
Rationale:73Tophi,73or73deposits73in73tissues73near73a73joint,73develop73in73chronic,73late-
stage73gout.73They73are73not73part73of73the73primary73disease73process.
C. "The73intra-articular73deposition73of73urate73crystals73causes73inflammation."
Rationale:73Gout,73or73gouty73arthritis,73develops73when73urate73crystals73deposit73in73joints73and73tissues
73and73cause73inflammation73and73pain.
D. "Articular73cartilage73thins,73leading73to73splitting73and73fragmentation."
Rationale:73Gout73does73not73thin73and73fragment73cartilage.
2.73A73nurse73is73teaching73a73group73of73clients73about73osteoarthritis.73Which73of73the73following73reco
mmendations73should73thenurse73include73in73the73teaching?
A. Use73 Echinacea73 to73 manage73 joint7 3 pain.
Rationale:73The7 3 nurse7 3 may7 3 include7 3 the7 3 use7 3 of7 3 complementary7 3 and7 3 alternative7 3 therapi
es7 3 in7 3 the7 3 teaching.73However,73Echinacea73is73used73for73the73treatment73of73the73com
mon73cold,73not73osteoarthritis.73Alterna7 3 tivetherapies73that73are73used73for73osteoarthritis73i
nclude73glucosamine,73chondroitin,73and73topical73cap73saicin.
B. Apply73 ice73 to73 the73 joint73 before73 exercising.
Rationale:73The7 3 nurse7 3 should7 3 recommend7 3 that7 3 the7 3 clients7 3 begin7 3 exercising7 3 im
mediately7 3 followi73ng7 3 theapplication73of73heat.73This73reduces73pain73and73improv
es73mobility,73allowing73for73incr7 3 eased73range-of-
motion73during73exercises.73Cold73application73may73be73applied73following73exercis
e73todecrea73se73discomfort73and73inflammation.
C. Maintain7 3 a73 recommended73 body73 weight.
Rationale:7 3 Obesity73is7 3 a73risk73factor73for7 3 the73development73 of7 3 osteoarthritis.7 3 Maintenance7
3 of7 3 an7 3 ideal7 3 weig73ht7 3 isone7 3 way73a73client73can73prevent73added7 3 wear7 3 and7 3 t
ear7 3 on73joints7 3 and7 3 promote73overall73joint73health.
D. Reduce7 3 the7 3 amount73 of7 3 purine73 in73 the73 diet.
Rationale:73The73nurse73should73recognize73that7 3 limiting73purine73in7 3 the7 3 diet,73which73is73often73fou
nd7 3 in7 3 organ73me73ats,is73recommended73for73clients73who73have73gout.
3.73A7 3 nurse7 3 is7 3 caring7 3 for7 3 a7 3 client7 3 who7 3 has7 3 had7 3 a7 3 myocardial7 3 infarction.7 3 Upon7 3 his7 3 first7 3 v
isit7 3 to7 3 cardiac7 3 rehabilitatio73n,7 3 hetells7 3 the7 3 nurse7 3 that7 3 he7 3 doesn't7 3 understand7 3 why73he7 3 need
s7 3 to7 3 be7 3 there7 3 because7 3 there7 3 is7 3 nothing7 3 more7 3 to73do,73as73the
Page7 3
1
,Detailed Answer Ke7
ty ty
3y Medical Surgical,
ty ty ty
A
damage73 is73 done.73Which73 of73 the73 following7 3 is73 the7 3 correcttynursing73 response?
A. "Cardiac73rehabilitation7 3 cannot73undo73the73damage73to7 3 your73heart7 3 but73it73can73help7 3 you73get
73back7 3 to73your73prev73iouslevel73of73activity73safely."
Rationale:73With73this73response,73the73nurse73uses73the73therapeutic73communication73technique7
3of73presentingr73eality73by73indicating73her73perception73of73the73situation73for73the73clie
nt.
B. "It’s7 3 not73 unusual73 to73 feel73 that7 3 way73at73 first,73 but73 once7 3 you73 learn73 the73 routine,7 3 you’ll73 enjoy73it."
Rationale:73With7 3 this7 3 response,7 3 the7 3 nurse7 3 illustrates7 3 the7 3 nontherapeutic7 3 communication7
3 technique7 3 of7 3 giv73ingreassurance,73thus73discouraging73the73client73from73further73comm
unication.
C. "Exercise7 3 is73 good73 for7 3 you73 and73 good73 for7 3 your73 heart."
Rationale:73With7 3 this7 3 response,7 3 the7 3 nurse7 3 illustrates7 3 the7 3 nontherapeutic7 3 communication7 3 tec
hniques7 3 ofdis73agreeing73and73giving73advice.
D. "Your73 doctor73 is73 the73 expert73 here,73 and73 I’m7 3 sure73 he73 would73 only73recommend73 what73 is73 best73 for7
3 you."
Rationale:73With7 3 this7 3 response,7 3 the7 3 nurse7 3 illustrates7 3 the7 3 nontherapeutic7 3 communication7
3 technique7 3 ofdef73ending.
4.73A73 nurse7 3 is7 3 caring7 3 for7 3 a73client7 3 who7 3 has7 3 heart7 3 failure7 3 and7 3 a7 3 potassium7 3 level73 of7 3 2.473mEq/L
.73 The73 nurse73should73 id73entifyywhich73of73the73following73medications7 3 as73the73cause73of73the7 3 client’s73lo
w73potassium7 3 level?
A. Furosemide
Rationale:7 3 Furosemide73 is73 a73 loop73 (high-
ceiling)73diuretic73that73inhibits73the73reabsorption73of73sodium73and73chlorideand73results73i
n73diuresis,73wh73ich73decreases73potassium73through73excretion73in73the73distal73nephrons.
Hypokalemia73 is73 an73 adverse7 3 effect73 of73 furosemide.
B. Nitroglycerin
Rationale:73A73potassium73level73of732.473mEq/L73is73not73an73adverse73effect73of73nitroglycerin.73Nitrog
lycerin73is73a tvy 73 asod73ilator73medication73to73treat73angina.
C. Metoprolol
Rationale:7 3 A73potassium7 3 level73of7 3 2.473mEq/L73 is7 3 not73an73 adverse73effect73of73met
oprolol.73 Metoprolol73is73abeta-
blocker73 that73 slows7 3 the7 3 heart73 rate73 and73 improves73 contractility73of7 3 the73 heart73 muscle.
D. Spironolactone
Rationale:73 Spironolactone73is73 a73potassium-
sparing73diuretic73medication;73 therefore,73 hyperkalemia73is73 anadverse73 effect73 of7 3 this73 medica
tion.
5.73A7 3 nurse7 3 is7 3 caring7 3 for7 3 a7 3 client7 3 who7 3 is7 3 postoperative7 3 following7 3 an7 3 open7 3 reduction7 3 internal7
Page7 3
2
,Detailed Answer Ke7
ty ty
3y Medical Surgical,
ty ty ty
A
3 fixation7 3 (ORIF)7 3 of7 3 a7 3 fem73ur7 3 fracture.73Which73of73the73following7 3 parameters73should73the73nurse7 3 in
clude7 3 in7 3 the73evaluation73of7 3 the73neurovascular7 3 st73atus73ofthe73client's73affected73extremity?73(Select73al
l73that73apply.)
Page7 3
3
, Detailed Answer Ke7
ty ty
3y Medical Surgical,
ty ty ty
A
A. Color
B. Temperature
C. Ecchymosis
D. Skin73 integrity
E. Sensation
Rationale:7 3 Color7 3 is7 3 correct.7 3 Clients7 3 who7 3 have7 3 sustained7 3 trauma7 3 to7 3 an7 3 extremity,7 3 suc
h7 3 as7 3 a7 3 fracture,7 3 are73at73increased73risk73for73neurovascular73compromise.73The73nurs
e73should73check7 3 the73color73of73the73clie7 3 nt's7 3 affected7 3 extremity7 3 as7 3 part7 3 of7 3 this
7 3 assessment.7 3 The7 3 nurse7 3 should7 3 identify7 3 pallor7 3 or7 3 cyanosi73s7 3 of7 3 theextremity7 3
as7 3 an7 3 indication7 3 of7 3 peripheral7 3 neurovascular7 3 dysfunction7 3 and7 3 should7 3 notify7 3 t7
3he7 3 provider.Temperature7 3 is7 3 correct.7 3 Clients7 3 who7 3 have7 3 sustained7 3 trauma7 3 to7 3 a
n7 3 extremity,7 3 such73as7 3 a73fracture,7 3 are73at73increased73risk73for7 3 neurovascular7 3 comp
romise.73The73nurse73should73monitor73the7 3 temperature7 3 of7 3 the7 3 extremity7 3 as7 3 a7 3 par
t7 3 of7 3 this7 3 assessment7 3 and7 3 identify7 3 skin7 3 thattyis7 3 cool7 3 o73r7 3 cold7 3 to7 3 the7 3 touch
7 3 as7 3 having7 3 decreased7 3 perfusion7 3 to7 3 the7 3 tissues7 3 of7 3 the7 3 extremity,7 3 which7 3 is7 3
an73indication7 3 ofperipheral7 3 neurovascular7 3 dysfunction.7 3 The7 3 nurse7 3 should7 3 report7 3
skin7 3 that7 3 is7 3 cool7 3 t73o73the73touch73to73the73provider.Ecchymosis73is73incorrect.73Ecchy
mosis,73or73bruising,73is73an73expected73f7 3 inding7 3 with73leg73injuries7 3 and7 3 is73not73a73c
omponent73of7 3 a73neurovascular7 3 check.Skin73integrity73is73inc73orrect.7 3 While7 3 the7 3 nurs
e7 3 should7 3 assess7 3 the7 3 incision7 3 of7 3 a7 3 client7 3 who7 3 is7 3 postoperative7 3 following73a
n7 3 open7 3 reduction7 3 and7 3 internal7 3 fixation7 3 of7 3 the7 3 femur,7 3 it7 3 is7 3 not7 3 a7 3 componen
t7 3 of7 3 a7 3 neurovascula73r7 3 check.Sensation7 3 is7 3 correct.73Clients7 3 who73have7 3 sustained
7 3 trauma73to73an73extremity,7 3 such73as7 3 a73f73racture,73are73at73increased73risk73for73neur
ovascular73compromise.73The73nurse73should73assess73the73cli7 3 ent's73extremity73for73num
bnessor73tingling.73The73nurse73should73recognize73diminished73pain73or73pares7 3 thesia73as
73an73indication73of73damage73to73the73nerves73or73peripheral73neurovascular73dysfunction73
and7 3 should73report73it73to73the73provider.
6.73A73nurse73is73monitoring73a73client73following73a73thoracentesis.73The73nurse73should73identify73which73of7 3 the
73follo7 3 wingmanifestations73as73a73complication73and73contact73the73provider73immediately?
A. Serosanguineous73 drainage73 from7 3 the73puncture73site
Rationale:73A73small73amounttyof73serosanguineous73drainage73attythe73puncture73site73is73expected73aft
er73athoracent73esis.
B. Discomfort73 at73 the73 puncture7 3 site
Rationale:73 Mild7 3 discomfort7 3 at7 3 the7 3 puncture7 3 site7 3 is7 3 expected7 3 after7 3 a7 3 thoracentesis.
C. Increased73 heart73 rate
Rationale:73Clients73are73at73risk73for73developing73pulmonary73edema73or73cardiovascular73distress73du
e73mediastinalc73ontent7 3 shift7 3 after7 3 the7 3 aspiration7 3 of7 3 a7 3 large7 3 amount7 3 of7 3 fluid7 3 f
rom7 3 the73client's7 3 pleural7 3 space.
Therefore,73the73client73may73experience73an73increase73in73heart73and73respiratory73rate,73al
ong73with73co7 3 ughing73with73blood-
tinged73frothy73sputum,73and73tightness73in73the73chest.73These73findings73requirenotification
73of73the73prov73ider73immediately.
D. Decreased73temperature
Rationale:7 3 Infection73is73possible73after73any73invasive73procedure;73however,73it73takes73tim
Page7 3
4
ty ty
3y Medical Surgical,
ty ty ty
A
1.73A73nurse73is73reviewing73the73cause73of73gout73with73a73group73of73nurses.73Which73of73the73following73stateme
nts73should73the73nurse73make?
A. "Uric73acid73levels73drop73and73calcium73forms73precipitate."
Rationale:73With73gout,73clients73 have73hyperuricemia,73rather73than73 a73reduction73 in73uric73 acid.
B. "Tophi73form73in73the73kidneys73and73they73impair73the73excretion73of73uric73acid."
Rationale:73Tophi,73or73deposits73in73tissues73near73a73joint,73develop73in73chronic,73late-
stage73gout.73They73are73not73part73of73the73primary73disease73process.
C. "The73intra-articular73deposition73of73urate73crystals73causes73inflammation."
Rationale:73Gout,73or73gouty73arthritis,73develops73when73urate73crystals73deposit73in73joints73and73tissues
73and73cause73inflammation73and73pain.
D. "Articular73cartilage73thins,73leading73to73splitting73and73fragmentation."
Rationale:73Gout73does73not73thin73and73fragment73cartilage.
2.73A73nurse73is73teaching73a73group73of73clients73about73osteoarthritis.73Which73of73the73following73reco
mmendations73should73thenurse73include73in73the73teaching?
A. Use73 Echinacea73 to73 manage73 joint7 3 pain.
Rationale:73The7 3 nurse7 3 may7 3 include7 3 the7 3 use7 3 of7 3 complementary7 3 and7 3 alternative7 3 therapi
es7 3 in7 3 the7 3 teaching.73However,73Echinacea73is73used73for73the73treatment73of73the73com
mon73cold,73not73osteoarthritis.73Alterna7 3 tivetherapies73that73are73used73for73osteoarthritis73i
nclude73glucosamine,73chondroitin,73and73topical73cap73saicin.
B. Apply73 ice73 to73 the73 joint73 before73 exercising.
Rationale:73The7 3 nurse7 3 should7 3 recommend7 3 that7 3 the7 3 clients7 3 begin7 3 exercising7 3 im
mediately7 3 followi73ng7 3 theapplication73of73heat.73This73reduces73pain73and73improv
es73mobility,73allowing73for73incr7 3 eased73range-of-
motion73during73exercises.73Cold73application73may73be73applied73following73exercis
e73todecrea73se73discomfort73and73inflammation.
C. Maintain7 3 a73 recommended73 body73 weight.
Rationale:7 3 Obesity73is7 3 a73risk73factor73for7 3 the73development73 of7 3 osteoarthritis.7 3 Maintenance7
3 of7 3 an7 3 ideal7 3 weig73ht7 3 isone7 3 way73a73client73can73prevent73added7 3 wear7 3 and7 3 t
ear7 3 on73joints7 3 and7 3 promote73overall73joint73health.
D. Reduce7 3 the7 3 amount73 of7 3 purine73 in73 the73 diet.
Rationale:73The73nurse73should73recognize73that7 3 limiting73purine73in7 3 the7 3 diet,73which73is73often73fou
nd7 3 in7 3 organ73me73ats,is73recommended73for73clients73who73have73gout.
3.73A7 3 nurse7 3 is7 3 caring7 3 for7 3 a7 3 client7 3 who7 3 has7 3 had7 3 a7 3 myocardial7 3 infarction.7 3 Upon7 3 his7 3 first7 3 v
isit7 3 to7 3 cardiac7 3 rehabilitatio73n,7 3 hetells7 3 the7 3 nurse7 3 that7 3 he7 3 doesn't7 3 understand7 3 why73he7 3 need
s7 3 to7 3 be7 3 there7 3 because7 3 there7 3 is7 3 nothing7 3 more7 3 to73do,73as73the
Page7 3
1
,Detailed Answer Ke7
ty ty
3y Medical Surgical,
ty ty ty
A
damage73 is73 done.73Which73 of73 the73 following7 3 is73 the7 3 correcttynursing73 response?
A. "Cardiac73rehabilitation7 3 cannot73undo73the73damage73to7 3 your73heart7 3 but73it73can73help7 3 you73get
73back7 3 to73your73prev73iouslevel73of73activity73safely."
Rationale:73With73this73response,73the73nurse73uses73the73therapeutic73communication73technique7
3of73presentingr73eality73by73indicating73her73perception73of73the73situation73for73the73clie
nt.
B. "It’s7 3 not73 unusual73 to73 feel73 that7 3 way73at73 first,73 but73 once7 3 you73 learn73 the73 routine,7 3 you’ll73 enjoy73it."
Rationale:73With7 3 this7 3 response,7 3 the7 3 nurse7 3 illustrates7 3 the7 3 nontherapeutic7 3 communication7
3 technique7 3 of7 3 giv73ingreassurance,73thus73discouraging73the73client73from73further73comm
unication.
C. "Exercise7 3 is73 good73 for7 3 you73 and73 good73 for7 3 your73 heart."
Rationale:73With7 3 this7 3 response,7 3 the7 3 nurse7 3 illustrates7 3 the7 3 nontherapeutic7 3 communication7 3 tec
hniques7 3 ofdis73agreeing73and73giving73advice.
D. "Your73 doctor73 is73 the73 expert73 here,73 and73 I’m7 3 sure73 he73 would73 only73recommend73 what73 is73 best73 for7
3 you."
Rationale:73With7 3 this7 3 response,7 3 the7 3 nurse7 3 illustrates7 3 the7 3 nontherapeutic7 3 communication7
3 technique7 3 ofdef73ending.
4.73A73 nurse7 3 is7 3 caring7 3 for7 3 a73client7 3 who7 3 has7 3 heart7 3 failure7 3 and7 3 a7 3 potassium7 3 level73 of7 3 2.473mEq/L
.73 The73 nurse73should73 id73entifyywhich73of73the73following73medications7 3 as73the73cause73of73the7 3 client’s73lo
w73potassium7 3 level?
A. Furosemide
Rationale:7 3 Furosemide73 is73 a73 loop73 (high-
ceiling)73diuretic73that73inhibits73the73reabsorption73of73sodium73and73chlorideand73results73i
n73diuresis,73wh73ich73decreases73potassium73through73excretion73in73the73distal73nephrons.
Hypokalemia73 is73 an73 adverse7 3 effect73 of73 furosemide.
B. Nitroglycerin
Rationale:73A73potassium73level73of732.473mEq/L73is73not73an73adverse73effect73of73nitroglycerin.73Nitrog
lycerin73is73a tvy 73 asod73ilator73medication73to73treat73angina.
C. Metoprolol
Rationale:7 3 A73potassium7 3 level73of7 3 2.473mEq/L73 is7 3 not73an73 adverse73effect73of73met
oprolol.73 Metoprolol73is73abeta-
blocker73 that73 slows7 3 the7 3 heart73 rate73 and73 improves73 contractility73of7 3 the73 heart73 muscle.
D. Spironolactone
Rationale:73 Spironolactone73is73 a73potassium-
sparing73diuretic73medication;73 therefore,73 hyperkalemia73is73 anadverse73 effect73 of7 3 this73 medica
tion.
5.73A7 3 nurse7 3 is7 3 caring7 3 for7 3 a7 3 client7 3 who7 3 is7 3 postoperative7 3 following7 3 an7 3 open7 3 reduction7 3 internal7
Page7 3
2
,Detailed Answer Ke7
ty ty
3y Medical Surgical,
ty ty ty
A
3 fixation7 3 (ORIF)7 3 of7 3 a7 3 fem73ur7 3 fracture.73Which73of73the73following7 3 parameters73should73the73nurse7 3 in
clude7 3 in7 3 the73evaluation73of7 3 the73neurovascular7 3 st73atus73ofthe73client's73affected73extremity?73(Select73al
l73that73apply.)
Page7 3
3
, Detailed Answer Ke7
ty ty
3y Medical Surgical,
ty ty ty
A
A. Color
B. Temperature
C. Ecchymosis
D. Skin73 integrity
E. Sensation
Rationale:7 3 Color7 3 is7 3 correct.7 3 Clients7 3 who7 3 have7 3 sustained7 3 trauma7 3 to7 3 an7 3 extremity,7 3 suc
h7 3 as7 3 a7 3 fracture,7 3 are73at73increased73risk73for73neurovascular73compromise.73The73nurs
e73should73check7 3 the73color73of73the73clie7 3 nt's7 3 affected7 3 extremity7 3 as7 3 part7 3 of7 3 this
7 3 assessment.7 3 The7 3 nurse7 3 should7 3 identify7 3 pallor7 3 or7 3 cyanosi73s7 3 of7 3 theextremity7 3
as7 3 an7 3 indication7 3 of7 3 peripheral7 3 neurovascular7 3 dysfunction7 3 and7 3 should7 3 notify7 3 t7
3he7 3 provider.Temperature7 3 is7 3 correct.7 3 Clients7 3 who7 3 have7 3 sustained7 3 trauma7 3 to7 3 a
n7 3 extremity,7 3 such73as7 3 a73fracture,7 3 are73at73increased73risk73for7 3 neurovascular7 3 comp
romise.73The73nurse73should73monitor73the7 3 temperature7 3 of7 3 the7 3 extremity7 3 as7 3 a7 3 par
t7 3 of7 3 this7 3 assessment7 3 and7 3 identify7 3 skin7 3 thattyis7 3 cool7 3 o73r7 3 cold7 3 to7 3 the7 3 touch
7 3 as7 3 having7 3 decreased7 3 perfusion7 3 to7 3 the7 3 tissues7 3 of7 3 the7 3 extremity,7 3 which7 3 is7 3
an73indication7 3 ofperipheral7 3 neurovascular7 3 dysfunction.7 3 The7 3 nurse7 3 should7 3 report7 3
skin7 3 that7 3 is7 3 cool7 3 t73o73the73touch73to73the73provider.Ecchymosis73is73incorrect.73Ecchy
mosis,73or73bruising,73is73an73expected73f7 3 inding7 3 with73leg73injuries7 3 and7 3 is73not73a73c
omponent73of7 3 a73neurovascular7 3 check.Skin73integrity73is73inc73orrect.7 3 While7 3 the7 3 nurs
e7 3 should7 3 assess7 3 the7 3 incision7 3 of7 3 a7 3 client7 3 who7 3 is7 3 postoperative7 3 following73a
n7 3 open7 3 reduction7 3 and7 3 internal7 3 fixation7 3 of7 3 the7 3 femur,7 3 it7 3 is7 3 not7 3 a7 3 componen
t7 3 of7 3 a7 3 neurovascula73r7 3 check.Sensation7 3 is7 3 correct.73Clients7 3 who73have7 3 sustained
7 3 trauma73to73an73extremity,7 3 such73as7 3 a73f73racture,73are73at73increased73risk73for73neur
ovascular73compromise.73The73nurse73should73assess73the73cli7 3 ent's73extremity73for73num
bnessor73tingling.73The73nurse73should73recognize73diminished73pain73or73pares7 3 thesia73as
73an73indication73of73damage73to73the73nerves73or73peripheral73neurovascular73dysfunction73
and7 3 should73report73it73to73the73provider.
6.73A73nurse73is73monitoring73a73client73following73a73thoracentesis.73The73nurse73should73identify73which73of7 3 the
73follo7 3 wingmanifestations73as73a73complication73and73contact73the73provider73immediately?
A. Serosanguineous73 drainage73 from7 3 the73puncture73site
Rationale:73A73small73amounttyof73serosanguineous73drainage73attythe73puncture73site73is73expected73aft
er73athoracent73esis.
B. Discomfort73 at73 the73 puncture7 3 site
Rationale:73 Mild7 3 discomfort7 3 at7 3 the7 3 puncture7 3 site7 3 is7 3 expected7 3 after7 3 a7 3 thoracentesis.
C. Increased73 heart73 rate
Rationale:73Clients73are73at73risk73for73developing73pulmonary73edema73or73cardiovascular73distress73du
e73mediastinalc73ontent7 3 shift7 3 after7 3 the7 3 aspiration7 3 of7 3 a7 3 large7 3 amount7 3 of7 3 fluid7 3 f
rom7 3 the73client's7 3 pleural7 3 space.
Therefore,73the73client73may73experience73an73increase73in73heart73and73respiratory73rate,73al
ong73with73co7 3 ughing73with73blood-
tinged73frothy73sputum,73and73tightness73in73the73chest.73These73findings73requirenotification
73of73the73prov73ider73immediately.
D. Decreased73temperature
Rationale:7 3 Infection73is73possible73after73any73invasive73procedure;73however,73it73takes73tim
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4
