Question

A nurse is teaching a client about the manifestations of menopause. Which of the following findings should the nurse include?

Answer 1

Correct Answers:

Decreased bone density

Rationale :

🔶 Hormonal change: Menopause leads to a decline in estrogen levels, which plays a key role in maintaining bone strength and calcium balance.

🔶 Effect on bones: Low estrogen accelerates bone resorption, resulting in decreased bone mineral density and a higher risk of osteoporosis.

🔶 Other related symptoms: Clients may also experience vaginal dryness, hot flashes, night sweats, and mood changes due to reduced estrogen.

🔶 Nursing education: The nurse should emphasize adequate calcium and vitamin D intake, weight-bearing exercises, and possible hormone replacement therapy to prevent bone loss.

🔶 Clinical importance: Early education helps minimize fracture risk and maintain overall musculoskeletal health during and after menopause.

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Answer 2

Correct Answers:

Serum bicarbonate 9 mEq/L (21 to 28 mEq/L)

Rationale :

💠 Metabolic acidosis indicator: In diabetic ketoacidosis (DKA), serum bicarbonate levels drop below 15 mEq/L due to buffering of excess ketoacids produced from fat breakdown.

💠 Pathophysiology: Insulin deficiency leads to fat metabolism for energy, forming ketone bodies (acidic compounds) that lower blood pH and deplete bicarbonate reserves.

💠 ABG findings: Typical DKA results include low pH (<7.35), low bicarbonate (<18 mEq/L), and low PaCO₂ from compensatory hyperventilation (Kussmaul respirations).

💠 Clinical signs: Clients exhibit polyuria, polydipsia, fruity breath odor, dehydration, and Kussmaul breathing.

💠 Treatment goal: Correct acidosis and dehydration with IV fluids, insulin, and electrolyte replacement (especially potassium).

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Answer 3

Correct Answers:

Tachycardia

Rationale :

🔷 Early compensatory sign: Tachycardia is an early indication of hypovolemic shock as the body attempts to maintain cardiac output despite decreased circulating blood volume.

🔷 Mechanism: Blood loss (e.g., post-colonoscopy bleeding) triggers sympathetic nervous system activation, causing the heart rate to increase to sustain tissue perfusion.

🔷 Progression: If uncorrected, continued fluid loss leads to hypotension, weak pulses, cool clammy skin, and decreased urine output.

🔷 Nursing priority: Rapidly assess vital signs, bleeding sites, and fluid status, then notify the provider and prepare to administer IV fluids or blood products.

🔷 Clinical importance: Recognizing tachycardia early allows prompt intervention before shock progresses to organ hypoperfusion or failure.

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Answer 4

Correct Answers:

Tachycardia

Rationale :

🔷 Early compensatory sign: Tachycardia is an early indication of hypovolemic shock as the body attempts to maintain cardiac output despite decreased circulating blood volume.

🔷 Mechanism: Blood loss (e.g., post-colonoscopy bleeding) triggers sympathetic nervous system activation, causing the heart rate to increase to sustain tissue perfusion.

🔷 Progression: If uncorrected, continued fluid loss leads to hypotension, weak pulses, cool clammy skin, and decreased urine output.

🔷 Nursing priority: Rapidly assess vital signs, bleeding sites, and fluid status, then notify the provider and prepare to administer IV fluids or blood products.

🔷 Clinical importance: Recognizing tachycardia early allows prompt intervention before shock progresses to organ hypoperfusion or failure.

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Answer 5

Correct Answers:

Place a mask on the client during the procedure.

Rationale :

💎 Infection prevention: Placing a mask on the client minimizes the risk of peritonitis, which can occur if microorganisms enter the peritoneal cavity during dressing changes.

💎 Aseptic technique: Peritoneal dialysis requires strict sterile technique, including the nurse and client wearing masks to prevent respiratory droplet contamination.

💎 Pathophysiology: The peritoneal catheter provides a direct pathway to the peritoneal cavity, so even minimal contamination can lead to severe infection.

💎 Nursing care: The nurse should also perform hand hygiene, use sterile gloves, and ensure that the site is cleaned gently using a circular motion from the exit site outward.

💎 Goal: Proper infection control protects the client from peritonitis and sepsis, major complications of peritoneal dialysis.

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Answer 6

Correct Answers:

Play serene soothing music.

Rationale :

🔹 Calming environment: Playing soft, soothing music helps reduce anxiety, agitation, and confusion in older adults with dementia, especially in unfamiliar hospital settings.

🔹 Delirium prevention: A calm environment minimizes sensory overstimulation and supports orientation and comfort during postoperative recovery.

🔹 Non-pharmacologic intervention: Music therapy is a safe and effective method to manage restlessness and behavioral symptoms without medication or restraints.

🔹 Enhances healing: Reducing stress and agitation promotes better pain control, improved sleep, and overall emotional well-being.

🔹 Nursing focus: Maintain a quiet, well-lit (not bright) environment, ensure familiar objects nearby, and promote consistent routines to aid orientation.

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Answer 7

Correct Answers:

Ibuprofen

Rationale :

💠 Drug interaction risk: Both naproxen and ibuprofen are nonsteroidal anti-inflammatory drugs (NSAIDs) that inhibit prostaglandin synthesis, increasing the risk of gastrointestinal irritation and bleeding.

💠 Mechanism: NSAIDs impair the protective mucosal lining of the stomach and inhibit platelet aggregation, which predisposes to GI ulcers and bleeding when used together.

💠 Nursing consideration: The nurse should instruct the client to avoid concurrent use of other NSAIDs or aspirin while taking naproxen.

💠 Alternative options: If additional pain control is needed, the provider may recommend acetaminophen as it has no antiplatelet or GI side effects.

💠 Client education: Report black or tarry stools, abdominal pain, or vomiting blood immediately, as these indicate GI bleeding.

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Answer 8

Correct Answers:

Apply a warming blanket.
Have suction equipment at the bedside

Rationale :

🟣 Have suction equipment at the bedside

🟣 Airway protection: During a seizure, clients often have excess salivation, secretions, or possible emesis. Having suction ready allows the nurse to quickly clear the airway to prevent aspiration.

🟣 Loss of gag reflex: Seizure activity can temporarily suppress the protective airway reflexes, making suctioning essential to prevent choking.

🟣 Immediate response tool: Keeping suction equipment within reach at the bedside ensures that the nurse can respond immediately if respiratory distress occurs during or after a seizure.

🟣 Nursing goal: Maintain airway patency and oxygenation at all times. This is the highest priority in seizure management.

🟣 Post-seizure care: After the seizure, suctioning helps remove mucus or vomitus, reducing the risk of aspiration pneumonia.

🟣 Apply a warming blanket

🟣 Temperature regulation: Clients with meningitis may experience fever alternating with chills, leading to temperature fluctuations and discomfort.

🟣 Postictal care: Following a seizure, muscle activity and diaphoresis can cause heat loss and shivering, so a warming blanket helps restore normal body temperature.

🟣 Prevention of hypothermia: Maintaining warmth supports circulation and metabolic stability, especially in clients weakened by infection.

🟣 Comfort measure: The warming blanket also provides physical comfort during recovery and minimizes stress on the cardiovascular system.

🟣 Nursing monitoring: The nurse must regularly monitor temperature to avoid overheating, adjusting the warming device as needed.

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Answer 9

Correct Answers:

Small blisters on the skin

Rationale :

🔶 Sign of overexposure: The appearance of small blisters, redness, or tenderness on the skin indicates excessive ultraviolet (UV) exposure during phototherapy.

🔶 Mechanism: Phototherapy uses UVB or PUVA light to slow skin cell growth in psoriasis. Overexposure, however, can cause burn-like lesions or blister formation, similar to sunburn.

🔶 Nursing action: If blisters develop, the nurse should stop the treatment immediately, assess the severity, and notify the healthcare provider for dose adjustment or treatment delay.

🔶 Preventive measures: The nurse should ensure protective eyewear, cover unaffected areas, and use emollients after therapy to prevent skin dryness and irritation.

🔶 Client education: Teach the client to report any new redness, pain, or blistering promptly to prevent permanent skin damage.

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Answer 10

Correct Answers:

Heart-rate 120/min

Rationale :

💠 Key sign of pulmonary embolism (PE): A sudden increase in heart rate (tachycardia) is one of the earliest and most common indicators of a pulmonary embolism in a client with deep vein thrombosis (DVT).

💠 Pathophysiology: When a thrombus dislodges and travels to the lungs, it blocks pulmonary circulation, decreasing oxygenation and causing the heart to compensate by beating faster to maintain oxygen delivery.

💠 Associated findings: Clients may also present with dyspnea, chest pain, restlessness, cough, or hemoptysis, along with tachypnea and low oxygen saturation.

💠 Nursing priority: Immediately elevate the head of the bed, apply oxygen, assess vital signs, and notify the healthcare provider. Rapid recognition prevents respiratory and cardiac collapse.

💠 Clinical importance: Early detection of tachycardia in a post-DVT client is critical for preventing fatal pulmonary complications.

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RN Adult Medical Surgical 2023 October

No.

1 :
A nurse is teaching a client about the manifestations of menopause. Which of the following findings should the nurse include?

2 :
A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

3 :
A nurse is monitoring a client who is recovering from a colonoscopy. Which of the following findings should the nurse identify as an indication of hypovolemic shock?

4 :
A nurse is monitoring a client who is recovering from a colonoscopy. Which of the following findings should the nurse identify as an indication of hypovolemic shock?

5 :
A nurse is changing the dressing for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

6 :
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

7 :
A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding?

8 :
A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

9 :
A nurse is caring for a client who is receiving phototherapy for psoriasis. Which of the following findings should the nurse identify as an indication of overexposure?

10 :
A nurse is caring for a client who has a deep vein thrombosis. Which of the following findings should indicate to the nurse that the client could be experiencing a pulmonary embolism?

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RN Adult Medical Surgical 2023 October

No.

1 : A nurse is teaching a client about the manifestations of menopause. Which of the following findings should the nurse include?

2 : A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

3 : A nurse is monitoring a client who is recovering from a colonoscopy. Which of the following findings should the nurse identify as an indication of hypovolemic shock?

4 : A nurse is monitoring a client who is recovering from a colonoscopy. Which of the following findings should the nurse identify as an indication of hypovolemic shock?

5 : A nurse is changing the dressing for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

6 : A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

7 : A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding?

8 : A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

9 : A nurse is caring for a client who is receiving phototherapy for psoriasis. Which of the following findings should the nurse identify as an indication of overexposure?

10 : A nurse is caring for a client who has a deep vein thrombosis. Which of the following findings should indicate to the nurse that the client could be experiencing a pulmonary embolism?

1 :
A nurse is teaching a client about the manifestations of menopause. Which of the following findings should the nurse include?

2 :
A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

3 :
A nurse is monitoring a client who is recovering from a colonoscopy. Which of the following findings should the nurse identify as an indication of hypovolemic shock?

4 :
A nurse is monitoring a client who is recovering from a colonoscopy. Which of the following findings should the nurse identify as an indication of hypovolemic shock?

5 :
A nurse is changing the dressing for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

6 :
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

7 :
A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding?

8 :
A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

9 :
A nurse is caring for a client who is receiving phototherapy for psoriasis. Which of the following findings should the nurse identify as an indication of overexposure?

10 :
A nurse is caring for a client who has a deep vein thrombosis. Which of the following findings should indicate to the nurse that the client could be experiencing a pulmonary embolism?