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Questions 158

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Question 1 of 5

A client is diagnosed with emphysema and cor pulmonale. Which findings are characteristic of cor pulmonale?

Correct Answer: D

Rationale: Cor pulmonale, right heart failure from lung disease, causes lower extremity edema and distended neck veins due to increased venous pressure. Hypoxia and fatigue are general emphysema symptoms.

Question 2 of 5

When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash?

Correct Answer: D

Rationale: The appearance of small, round or oval reddish brown macules scattered over the entire body is characteristic of rubeola. The appearance of scattered clusters of macules, papules, and vesicles throughout the body is characteristic of chickenpox. Palmar redness is seen in clients with cirrhosis of the liver. The characteristic butterfly rash over the cheek and nose and into the scalp is seen with systemic lupus erythematosus.

Question 3 of 5

On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:

Correct Answer: A

Rationale: Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the 'living ligature.' A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.

Question 4 of 5

A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:

Correct Answer: B

Rationale: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.

Question 5 of 5

A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?

Correct Answer: A

Rationale: The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. This type of therapy should be implemented when other methods have been exhausted. The manic client should not be in control of his treatment plan. This type of client may forget to eat. The manic client is unable to sit down to eat full meals.

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