Answers and Rationale Medical Surgical Nursing Practice Test Part2
1. C. Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.
2. A. The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.
3. B. These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).
4. D. One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.
5. A. Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
6. B. This indicates that the bladder is distended with urine, therefore palpable.
7. C. Elevation increases lymphatic drainage, reducing edema and pain.
8. B. Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
9. D. When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent back ward flow into the pulmonary vein, the pulmonary circulation is under pressure.
10. A. Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat.
11. C. Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness.
12. A. An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.
13. D. There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.
14. A. Good source of vitamin B12 are dairy products and meats.
15. C. Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
16. B. An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for.
17. A. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
18. D. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.
19. B. Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.
20. A. Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.
21. C. Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs.
22. C. Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction
23. C. The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney.
24. A. These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly.
25. C. Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.
26. D. Elevation will help control the edema that usually occurs.
27. B. Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears.
28. B. The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
29. A. Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain.
30. C. Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately.
31. A. In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced.
32. C. The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose.
33. B. Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
34. A. It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.
35. C. The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active.
36. D. Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless.
37. B. In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.
38. A. Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed.
39. D. Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
40. B. The use of fragrant soap is very drying to skin hence causing the pruritus.
41. C. Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure.
42. A. A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system.
43. B. The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder.
44. D. Glucocorticoids play no significant role in disease treatment.
45. D. Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage.
46. C. In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
47. A. Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in loosely structured dermis.
48. D. Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous growth.
49. B. Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion.
50. A. Patent airway is the most priority; therefore removal of secretions is necessary.