GCC 325 - 350

Which sign or symptom typically occurs early in the development of multiple sclerosis (MS)?

• Diplopia
• Grief
• Paralysis
• Dementia

Answer explanation

Option 1: Diplopia

Option 2: Grief

Option 3: Paralysis

Option 4: Dementia

Correct Option: Option 1 – Diplopia

Explanation: Early indications of MS include slurred speech and diplopia. Grief (Option B) isn't a clinical manifestation. Paralysis (Option C) is a late symptom of MS. Although depression and a short attention span may occur, dementia (Option D) is rarely associated with MS.

When preparing the room for admission of a multigravid client at 36 weeks’ gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain?

• Oxytocin infusion solution.
• Disposable tongue blades.
• Portable ultrasound machine.
• Padding for the side rails.

Answer explanation

Option 1: Oxytocin infusion solution.

Option 2: Disposable tongue blades.

Option 3: Portable ultrasound machine.

Option 4: Padding for the side rails.

Correct Option: Option 4 – Padding for the side rails.

Explanation: The client with severe preeclampsia may develop eclampsia, which is characterized by seizures. The client needs a darkened, quiet room and side rails with thick padding. This helps decrease the potential for injury should a seizure occur. Airways, a suction machine, and oxygen also should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be obtained at a later time. Tongue blades are not necessary. However, the emergency cart should be placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client and her fetus is the priority.

The nurse knows which burn involves the entire thickness of the skin?

• First degree.
• Second degree.
• Third degree.
• Fifth degree.

Answer explanation

Option 1: First degree.

Option 2: Second degree.

Option 3: Third degree.

Option 4: Fifth degree.

Correct Option: Option 3 – Third degree.

Explanation: Full-thickness (third-degree) burns involve the entire thickness of the skin, and may involve subcutaneous fat, connective tissue, muscle, and even bone. Superficial (first-degree) burns have minimal epithelial damage and cause no skin loss. Partial-thickness (superficial second-degree) burns involve the upper layers of the epidermis, but spare epidermal appendages such as hair follicles, nails, sweat and sebaceous glands, and sensory nerve cells. Deep dermal partial-thickness (deep second-degree) burns typically have patchy areas of injury varying from superficial partial thickness to full thickness; wounds may progress to full thickness. There is no fifth-degree burn classification.

A client with a severe corneal ulcer has an order for Gentamycin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?

• Allow 5 minutes between the two medications.
• The medications may be used together.
• The medications should be separated by a cycloplegic drug.
• The medications should not be used in the same client.

Answer explanation

Option 1: Allow 5 minutes between the two medications.

Option 2: The medications may be used together.

Option 3: The medications should be separated by a cycloplegic drug.

Option 4: The medications should not be used in the same client.

Correct Option: Option 1 – Allow 5 minutes between the two medications.

Explanation: When using eyedrops, allow 5 minutes between medications. Answer B is incorrect because the two medications should not be used simultaneously. Answer C is incorrect because there is no need for the client to also use a cycloplegic. Answer D is incorrect because these drugs can be used by the same client.

Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. The nurse realizes that the medication is having a therapeutic effect when which of the following is noted?

• There is an absence of peristalsis.
• The number of diarrhea stools decreases.
• Cramping in the abdomen has increased.
• Abdominal girth size increases.

Answer explanation

Option 1: There is an absence of peristalsis.

Option 2: The number of diarrhea stools decreases.

Option 3: Cramping in the abdomen has increased.

Option 4: Abdominal girth size increases.

Correct Option: Option 2 – The number of diarrhea stools decreases.

Explanation: Lomotil's desired effect is to decrease GI motility and the number of diarrhea stools. Answers A and D do not occur with the use of Lomotil. The drug should decrease cramping instead of increasing it, as in answer C.

A client presents to the emergency department (ED) via ambulance with SOB for the past 3 days. After spending 4 hours in the ED, the client is admitted to the intensive care unit (ICU) with pulmonary edema requiring intubation and ventilation. The ED nurse reports to the ICU nurse that a Foley catheter was placed and that the client has had a total of 25 mL of urine output. The labs from the ED reveal (1) BG of 300, (2) BUN of 100, and (3) creatinine of 5.0. The client has a medical history of CAD, CHF, diabetes, COPD, and asthma. What is the most likely cause of the client’s low urine output?

• Acute and chronic renal failure due to diabetes and a decreased blood flow to the kidneys due to heart failure.
• Renal failure due to decreased coronary output secondary to heart failure.
• Decreased blood flow to the kidneys due to congestive heart failure (CHF) secondary to noncompliance with home fluid restriction.
• Severe dehydration.

Answer explanation

Option 1: Acute and chronic renal failure due to diabetes and a decreased blood flow to the kidneys due to heart failure.

Option 2: Renal failure due to decreased coronary output secondary to heart failure.

Option 3: Decreased blood flow to the kidneys due to congestive heart failure (CHF) secondary to noncompliance with home fluid restriction.

Option 4: Severe dehydration.

Correct Option: Option 1 – Acute and chronic renal failure due to diabetes and a decreased blood flow to the kidneys due to heart failure.

Explanation: Acute and chronic renal failure due to diabetes and a decreased blood flow to the kidneys due to heart failure. Renal failure can be caused by both decreased blood flow to the kidneys, as is common in heart failure and damage to the glomeruli, as is common in uncontrolled diabetes. The blood glucose taken in the ED suggests that the client's diabetes is not well controlled. The BUN and creatinine are elevated showing renal failure. The patient is in pulmonary edema, suggesting a fluid overload, not a deficit.

A nurse is performing the Trendelenburg test for the client with multiple sclerosis. The nurse is aware that this test is used to measure:

• Muscle weakness
• Fluid retention
• Ability to concentrate
• Dexterity

Answer explanation

Option 1: Muscle weakness

Option 2: Fluid retention

Option 3: Ability to concentrate

Option 4: Dexterity

Correct Option: Option 1 – Muscle weakness

Explanation: A Trendelenburg test is done to determine muscle weakness. The Trendelenburg sign is positive if the client cannot stand on one leg without having pelvic weakness. The test is not done to determine fluid volume, as stated in answer B, or to determine the client’s ability to concentrate, as stated in answer C. Answer D is incorrect because the Trendelenburg test does not check for dexterity.

A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn:

• Prone
• Supine
• On either side
• With the head elevated

Answer explanation

Option 1: Prone

Option 2: Supine

Option 3: On either side

Option 4: With the head elevated

Correct Option: Option 3 – On either side

Explanation: Placing the newborn in a side-lying position helps the urine to drain from the exposed bladder. Answer A is incorrect because it would position the child on the exposed bladder. Answers B and D are incorrect choices because they would allow the urine to pool.

When performing Leopold’s maneuvers, which of the following would the nurse ask the client to do to ensure optimal comfort and accuracy?

• Breathe deeply for 1 minute.
• Empty her bladder.
• Drink a full glass of water.
• Lie on her left side.

Answer explanation

Option 1: Breathe deeply for 1 minute.

Option 2: Empty her bladder.

Option 3: Drink a full glass of water.

Option 4: Lie on her left side.

Correct Option: Option 2 – Empty her bladder.

Explanation: Leopold’s maneuvers involve abdominal palpation. The client should empty her bladder before the nurse palpates the abdomen. Doing so increases the client’s comfort and makes palpation more accurate. Although breathing deeply may help to relax the client, it has no effect on the accuracy of the results of Leopold’s maneuvers. The client does not need to drink a full glass of water before the examination. The client should be lying in a supine position with the head slightly elevated for greater comfort and with the knees drawn up slightly.

The nurse is caring for a patient admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless the patient:

• is mentally ill.
• refuses to give informed consent.
• is in an emergency situation.
• asks the nurse to give substituted consent.

Answer explanation

Option 1: is mentally ill.

Option 2: refuses to give informed consent.

Option 3: is in an emergency situation.

Option 4: asks the nurse to give substituted consent.

Correct Option: Option 3 – is in an emergency situation.

Explanation: The law doesn’t require informed consent in an emergency situation when the patient can’t give consent and no next of kin is available. Option A is incorrect because even though a patient who is declared mentally incompetent can’t give informed consent, mental illness doesn’t by itself indicate that the patient is incompetent to give such consent. Option B is incorrect because a mentally competent patient may refuse or revoke consent at any time. Option D is incorrect because although the nurse may act as a patient advocate, the nurse can never give substituted consent.