GCC 451 - 475

After conducting a presentation to a group of adolescent parents on the topic of adolescent pregnancy, the nurse determines that one of the parents needs further instruction when the parent says that adolescents are at greater risk for which of the following?

• Denial of the pregnancy.
• Low-birth-weight infant.
• Cephalopelvic disproportion.
• Congenital anomalies.
• -

Answer explanation

Option 1: Denial of the pregnancy.

Option 2: Low-birth-weight infant.

Option 3: Cephalopelvic disproportion.

Option 4: Congenital anomalies.

Option 5: -

Correct Option: Option 4 – Congenital anomalies.

Explanation: Additional teaching is needed when the parent says that adolescents are at greater risk for congenital anomalies. Although adolescents are at greater risk for denial of the pregnancy, lack of prenatal care, low-birth-weight infant, cephalopelvic disproportion, anemia, and nutritional deficits and have a higher maternal mortality rate, studies reveal that congenital anomalies are not more common in adolescent pregnancies.

A patient is taking isoniazid to treat TB. Which instruction should the nurse give him about this drug?

• Drinking alcohol daily can cause drug-induced hepatitis.
• Taking isoniazid with aluminum hydroxide minimizes GI upset.
• Isoniazid is best absorbed when taken on an empty stomach.
• Prolonged use of isoniazid causes dark, concentrated urine.
• -

Answer explanation

Option 1: Drinking alcohol daily can cause drug-induced hepatitis.

Option 2: Taking isoniazid with aluminum hydroxide minimizes GI upset.

Option 3: Isoniazid is best absorbed when taken on an empty stomach.

Option 4: Prolonged use of isoniazid causes dark, concentrated urine.

Option 5: -

Correct Option: Option 1 – Drinking alcohol daily can cause drug-induced hepatitis.

Explanation: Drinking alcohol daily during isoniazid therapy can induce drug-related hepatitis. Option B is incorrect because the patient should avoid concomitant use of aluminum-containing antacids with isoniazid because they impair isoniazid absorption. Option C is incorrect because the patient should take isoniazid with meals for maximal absorption and to decrease GI upset. Option D gives false information.

Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis?

• She was born at 42 weeks gestation.
• She had meningitis when she was 6 months old.
• She had physiologic jaundice after delivery.
• She has frequent sore throats.
• -

Answer explanation

Option 1: She was born at 42 weeks gestation.

Option 2: She had meningitis when she was 6 months old.

Option 3: She had physiologic jaundice after delivery.

Option 4: She has frequent sore throats.

Option 5: -

Correct Option: Option 2 – She had meningitis when she was 6 months old.

Explanation: The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C and D are not related to the question.

At 32 weeks’ gestation, a 15-year-old primigravid client who is 5 feet, 2 inches tall has gained a total of 20 lb, with a 1-lb gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which of the following factors increases her risk for preeclampsia?

• Total weight gain.
• Short stature.
• Adolescent age group.
• Proteinuria.
• -

Answer explanation

Option 1: Total weight gain.

Option 2: Short stature.

Option 3: Adolescent age group.

Option 4: Proteinuria.

Option 5: -

Correct Option: Option 3 – Adolescent age group.

Explanation: Clients with increased risk for preeclampsia include primigravid clients younger than 20 years or older than 40 years, clients with five or more pregnancies, women of color, women with multifetal pregnancies, women with diabetes or heart disease, and women with hydramnios. A total weight gain of 20 lb at 32 weeks’ gestation with a 1-lb weight gain in the last 2 weeks is within normal limits. Short stature is not associated with the development of preeclampsia. A trace amount of protein in the urine is common during pregnancy. However, protein amounts of 1+ or more may be a symptom of pregnancy-induced hypertension.

The nurse collects a urine specimen from a client’s indwelling urinary catheter. Which method is the correct procedure for obtaining a urine specimen from an indwelling urinary catheter?

• Place a new drainage bag on the catheter and collect the specimen from the bag.
• Disconnect the catheter tubing from the drainage bag and drain urine from the tubing into a specimen cup.
• Remove the catheter and insert a straight catheter to collect the specimen.
• Clean the sampling port on the catheter with an alcohol pad and insert a sterile needle with syringe into the port.
• -

Answer explanation

Option 1: Place a new drainage bag on the catheter and collect the specimen from the bag.

Option 2: Disconnect the catheter tubing from the drainage bag and drain urine from the tubing into a specimen cup.

Option 3: Remove the catheter and insert a straight catheter to collect the specimen.

Option 4: Clean the sampling port on the catheter with an alcohol pad and insert a sterile needle with syringe into the port.

Option 5: -

Correct Option: Option 4 – Clean the sampling port on the catheter with an alcohol pad and insert a sterile needle with syringe into the port.

Explanation: When obtaining a urine sample from an indwelling urinary catheter, the sampling port must be cleaned with alcohol so that bacteria are not introduced into the catheter. A urine sample must be fresh, and urine in the drainage bag may have been sitting for several hours, allowing for bacterial growth. To prevent contamination, the drainage system should never be disconnected.

A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:

• Hypothyroidism
• Diabetic ulcers
• Ulcerative colitis
• Pneumonia
• -

Answer explanation

Option 1: Hypothyroidism

Option 2: Diabetic ulcers

Option 3: Ulcerative colitis

Option 4: Pneumonia

Option 5: -

Correct Option: Option 1 – Hypothyroidism

Explanation: The best roommate for the post-surgical client is the client with hypothyroidism. This client is sleepy and has no infectious process. Answers B, C, and D are incorrect because the client with a diabetic ulcer, ulcerative colitis, or pneumonia can transmit infection to the post-surgical client.

Which laboratory values will a nurse interpret as confirming a patient’s diagnosis of pancreatitis?

• Elevated amylase, elevated lipase, elevated serum glucose, and decreased serum calcium levels
• Elevated amylase, elevated lipase, decreased serum glucose, and decreased serum calcium levels
• Decreased amylase, decreased lipase, elevated serum glucose, and increased serum calcium levels
• Decreased amylase, decreased lipase, decreased serum glucose, and increased serum calcium levels
• -

Answer explanation

Option 1: Elevated amylase, elevated lipase, elevated serum glucose, and decreased serum calcium levels

Option 2: Elevated amylase, elevated lipase, decreased serum glucose, and decreased serum calcium levels

Option 3: Decreased amylase, decreased lipase, elevated serum glucose, and increased serum calcium levels

Option 4: Decreased amylase, decreased lipase, decreased serum glucose, and increased serum calcium levels

Option 5: -

Correct Option: Option 1 – Elevated amylase, elevated lipase, elevated serum glucose, and decreased serum calcium levels

Explanation: Inflammation of the pancreas causes it to excrete pancreatic enzymes. The inflammation also causes a blockage of the ducts from the pancreas to the GI tract; therefore, the pancreatic enzymes are released into the blood, resulting in an elevation of amylase and lipase levels. Carbohydrate metabolism is impaired secondary to damage to pancreatic beta cells. This impairment causes the patient to become hyperglycemic. As in many other disease processes, the serum calcium level decreases because of the saponification of calcium by fatty acids in the area of the inflamed pancreas.

A client complains of progressively worsening shortness of breath since cutting the grass 3 days ago. The client has a history of asthma. The nurse knows this client is having a severe exacerbation and should immediately receive:

• High doses of inhaled short-acting beta2-agonist.
• Intravenous fluids.
• Oxygen.
• Systemic corticosteroids.
• -

Answer explanation

Option 1: High doses of inhaled short-acting beta2-agonist.

Option 2: Intravenous fluids.

Option 3: Oxygen.

Option 4: Systemic corticosteroids.

Option 5: -

Correct Option: Option 3 – Oxygen.

Explanation: Owing to the life-threatening nature of severe exacerbations of asthma, treatment should be started immediately once the exacerbation is recognized. All clients with a severe exacerbation should immediately receive oxygen. High doses of inhaled short-acting beta2-agonist and systemic corticosteroids are secondary interventions. Asphyxia is a common cause of death.

The nurse explains the complications of pregnancy that occur with diabetes to a primigravid client at 10 weeks’ gestation who has a 5-year history of insulin-dependent diabetes. Which of the following, if stated by the client as a complication, indicates the need for additional teaching?

• Candida albicans infection.
• Twin-to-twin transfer.
• Polyhydramnios.
• Preeclampsia.
• -

Answer explanation

Option 1: Candida albicans infection.

Option 2: Twin-to-twin transfer.

Option 3: Polyhydramnios.

Option 4: Preeclampsia.

Option 5: -

Correct Option: Option 2 – Twin-to-twin transfer.

Explanation: Clients who are pregnant and have diabetes are not at greater risk for multifetal pregnancy and subsequent twin-to-twin transfer unless they have undergone fertility treatments. The pregnant diabetic client is at higher risk for complications such as infection, polyhydramnios, ketoacidosis, and preeclampsia, compared with the pregnant nondiabetic client.

A client arrives after a house fire. What clinical manifestation is most indicative of possible carbon monoxide poisoning?

• Pulse oximetry reading of 80%
• Expiratory stridor and nasal flaring
• Cherry-red color to the mucous membranes
• Presence of carbonaceous particles in the sputum
• -

Answer explanation

Option 1: Pulse oximetry reading of 80%

Option 2: Expiratory stridor and nasal flaring

Option 3: Cherry-red color to the mucous membranes

Option 4: Presence of carbonaceous particles in the sputum

Option 5: -

Correct Option: Option 3 – Cherry-red color to the mucous membranes

Explanation: The hallmark symptom of carbon monoxide poisoning is the cherry-red color. The answers in A, B, and D are not specific to carbon monoxide poisoning.