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Questions 158

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Question 1 of 5

The nurse is caring for a client with a history of fibromyalgia. The nurse should expect the client to have:

Correct Answer: A

Rationale: Fibromyalgia causes widespread musculoskeletal pain, often accompanied by fatigue and tender points.

Question 2 of 5

A client has begun to exhibit signs of alcohol withdrawal. Her blood pressure has risen from 120/60 to 190/100, pulse is increased from 88 to 110 bpm, and she is irritable and agitated and has gross motor tremors of the hands. The nurse notifies the doctor. The nurse can anticipate that the doctor will order which of the following?

Correct Answer: B

Rationale: This answer is incorrect. Benzodiazepines are drugs of choice for alcohol withdrawal. This answer is correct. The drug has a sedative effect, is safe, and has an anticonvulsant effect. This answer is incorrect. Amitriptyline is an antidepressant. This answer is incorrect. Chlorpromazine is most effective in psychotic disorders.

Question 3 of 5

The best indicator of peripheral edema is determined by:

Correct Answer: D

Rationale: Checking for pitting (indentation after pressing the skin) is the most direct and reliable indicator of peripheral edema. While weight extremity measurement and intake/output are relevant pitting specifically confirms edema.

Question 4 of 5

A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot of blood and required multiple blood transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss has occurred?

Correct Answer: A

Rationale: Whole blood is the transfusion component of choice when large volumes of blood need to be replaced. Whole blood contains all blood components that are lost during active bleeding.

Question 5 of 5

On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:

Correct Answer: C

Rationale: Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. Breast-feeding every 1½-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottle-feeding mother. Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.

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