1. A nurse is collecting data from a client who has emphysema. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respi
...
1. A nurse is collecting data from a client who has emphysema. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to
inadequate oxygen exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their
elasticity, and the diaphragm becomes permanently flattened by overdistention of the
lungs. The muscles of the rib cage also become rigid, and the ribs flare outward. This
produces the barrel chest typical of emphysema clients.
Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of
elasticity, which decreases oxygenation. Clubbing results from these chronic low bloodoxygen levels.
Shallow respirations is correct. Clients who have emphysema lose lung elasticity;
consequently, respirations become increasingly shallow and more rapid.
Bradycardia is incorrect. The heart rate will increase as the heart tries to
compensate for less oxygen being delivered to the tissues.
2. A nurse is caring for a client who has Cushing's syndrome. Which of the following
clinical manifestations should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
INCORRECT
4) Tremors
INCORRECT
5) Obese extremities
Answer Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased
production of cortisol or by excessive use of corticosteroids. Buffalo hump, a collection
of fat between the shoulders, is a common manifestation of Cushing's syndrome.Purple
striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts
are a common manifestation of Cushing's syndrome. This is due to the collection of
body fat in these areas.Moon face is correct. Moon face is a common manifestation of
Cushing's syndrome. Clients who have this manifestation present with a round, red, full
face.Tremors is incorrect. Tremors are not a common finding of Cushing's
syndrome.Obese extremities is incorrect. Clients who have Cushing's syndrome
have truncal obesity, a protuberant abdomen, with thin extremities, which is due to an
alteration in protein metabolism.
3. A nurse is assisting with the care of a client immediately following a lumbar puncture.
Which of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
INCORRECT
3) Insert a urinary catheter.
INCORRECT
4) Elevate the client’s head of bed.
INCORRECT
5) Apply a cervical collar to the client.
Answer Rationale:
Encourage fluid intake is correct. The nurse should encourage fluids, unless
contraindicated, to replace the cerebrospinal fluid that was removed during the
procedure and reduce the risk for a headache.
Monitor the puncture site for a hematoma is correct. The nurse should monitor
and report a hematoma at the insertion site because this can indicate bleeding.
Insert a urinary catheter is incorrect. There is no indication for a urinary catheter
insertion.
Elevate the client’s head of bed is incorrect. The client should remain flat in bed
for 1 hr or more to reduce the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no indication for a
cervical collar for this client.
4. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery
and is to take hydroxyzine preoperatively. Which of the following effects of the
medication should the nurse include in the teaching? (Select all that apply.)
1) Decreasing anxiety
2) Controlling emesis
INCORRECT
3) Relaxing skeletal muscles
INCORRECT
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
Answer Rationale:
Decreasing anxiety is correct. The nurse should include that hydroxyzine is an
effective antianxiety agent and is used to decrease anxiety in surgical clients as well as
in persons with moderate anxiety.
Controlling emesis is correct. The nurse should include that hydroxyzine is an
effective antiemetic and is used to control nausea and vomiting in pre- and
postoperative clients.
Relaxing skeletal muscles is incorrect. The nurse should recognize
benzodiazepines, such as diazepam (Valium), are used to produce skeletal muscle
relaxation.
Preventing surgical site infections is incorrect. The nurse should instruct the client
that antibiotics administered prior to surgery are used to diminish the risk of surgical
site infections; hydroxyzine, an
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