GCC 551 - 575

Which information should be given to the client taking phenytoin (Dilantin)?

• Taking the medication with meals will increase its effectiveness.
• The medication can cause sleep disturbances.
• More frequent dental appointments will be needed for special gum care.
• The medication decreases the effects of oral contraceptives.
• -

Answer explanation

Option 1: Taking the medication with meals will increase its effectiveness.

Option 2: The medication can cause sleep disturbances.

Option 3: More frequent dental appointments will be needed for special gum care.

Option 4: The medication decreases the effects of oral contraceptives.

Option 5: -

Correct Option: Option 3 – More frequent dental appointments will be needed for special gum care.

Explanation: Gingival hyperplasia is a side effect of phenytoin. The client will need more frequent dental visits. Answers A, B, and D do not apply to the medication; therefore, they are incorrect.

The nurse is caring for an infant with atopic dermatitis. An important part of the infant's care will be:

• Keeping the infant warm
• Trimming the fingernails
• Using soap for bathing
• Applying peroxide to dry areas
• -

Answer explanation

Option 1: Keeping the infant warm

Option 2: Trimming the fingernails

Option 3: Using soap for bathing

Option 4: Applying peroxide to dry areas

Option 5: -

Correct Option: Option 2 – Trimming the fingernails

Explanation: The infant's fingernails should be kept short to prevent scratching the skin. Keeping the infant warm will increase itching; therefore, answer A is incorrect. Soap should not be used because it dries the skin; therefore, answer C is incorrect. Peroxide is damaging to the tissues; therefore, answer D is incorrect.

Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) can be differentiated from diabetic ketoacidosis (DK) by which physiologic finding?

• Increased serum osmolarity.
• Hypokalemia.
• Hyperglycemia.
• Absence of ketosis.
• -

Answer explanation

Option 1: Increased serum osmolarity.

Option 2: Hypokalemia.

Option 3: Hyperglycemia.

Option 4: Absence of ketosis.

Option 5: -

Correct Option: Option 4 – Absence of ketosis.

Explanation: HHNS is hyperglycemia in the absence of ketosis. Enough insulin is released but not enough to prevent hyperglycemia. Just as the name of the syndrome implies, no ketosis is present in HHNS. Clients with HHNS and DK both show increased serum osmolarity, hypokalemia, and hyperglycemia.

A postsurgical client requires a blood transfusion. Which disorder is common in critically ill and postsurgical clients requiring blood transfusions?

• Hypercalcemia.
• Hyperkalemia.
• Hypocalcemia.
• Hypokalemia.
• -

Answer explanation

Option 1: Hypercalcemia.

Option 2: Hyperkalemia.

Option 3: Hypocalcemia.

Option 4: Hypokalemia.

Option 5: -

Correct Option: Option 3 – Hypocalcemia.

Explanation: Hypocalcemia is common in critically ill and postsurgical clients because of blood transfusions (the citrate used as an anticoagulant in bank blood binds to the calcium), magnesium imbalances, shock, or alkalosis. Hypercalcemia, hyperkalemia, and hypokalemia are not found secondary to blood transfusions.

The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:

• Hallucinogenic drugs create both stimulant and depressant effects.
• Hallucinogenic drugs induce a state of altered perception.
• Hallucinogenic drugs produce severe respiratory depression.
• Hallucinogenic drugs induce rapid physical dependence.
• -

Answer explanation

Option 1: Hallucinogenic drugs create both stimulant and depressant effects.

Option 2: Hallucinogenic drugs induce a state of altered perception.

Option 3: Hallucinogenic drugs produce severe respiratory depression.

Option 4: Hallucinogenic drugs induce rapid physical dependence.

Option 5: -

Correct Option: Option 2 – Hallucinogenic drugs induce a state of altered perception.

Explanation: Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Answer A is incorrect because hallucinogenic drugs don't create both stimulant and depressant effects. Answer C is incorrect because these drugs do not produce severe respiratory depression. Answer D is incorrect because these drugs produce psychological dependence rather than physical dependence.

A monthly testicular self-exam is recommended for males to permit early detection and treatment of testicular cancer. Testicular cancer is more prevalent:

• As male clients age with the highest incidence in the elderly.
• In male clients who have a second type of cancer.
• Among young, adult male clients between 20 and 35 years of age.
• In male clients with mental retardation.
• -

Answer explanation

Option 1: As male clients age with the highest incidence in the elderly.

Option 2: In male clients who have a second type of cancer.

Option 3: Among young, adult male clients between 20 and 35 years of age.

Option 4: In male clients with mental retardation.

Option 5: -

Correct Option: Option 3 – Among young, adult male clients between 20 and 35 years of age.

Explanation: Testicular cancer is rare, but in young adult males the incidence is the most common type of cancer. Risk factors include positive family history, gonadal dysgenesis or Klinefelter's syndrome, cancer in one testicle, and white race. While some testicular cancers are discovered by routine physical examination, the majority are detected by the patient. Therefore, routine self-examinations are recommended. Older clients are at less risk for testicular cancer. Clients with testicular cancer are at a higher risk for a second type of cancer, but another type of cancer does not predispose the client to testicular cancer. Male clients with mental deficits not attributable to chromosome abnormalities are not at an increased risk for testicular cancer.

The mother of a 6-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age:

• 12 months
• 18 months
• 24 months
• 30 months
• -

Answer explanation

Option 1: 12 months

Option 2: 18 months

Option 3: 24 months

Option 4: 30 months

Option 5: -

Correct Option: Option 4 – 30 months

Explanation: All 20 primary, or deciduous, teeth should be present by age 30 months. Answers A, B, and C are incorrect because the ages are wrong.

The heart rhythm of a patient in cardiac arrest undergoing cardiopulmonary resuscitation (CPR) deteriorates to ventricular fibrillation. Which action should the nurse take first?

• Administer 1 mg of epinephrine I.V.
• Defibrillate with a monophasic defibrillator at 360 joules.
• Continue CPR.
• Administer 40 units of vasopressin I.V.
• -

Answer explanation

Option 1: Administer 1 mg of epinephrine I.V.

Option 2: Defibrillate with a monophasic defibrillator at 360 joules.

Option 3: Continue CPR.

Option 4: Administer 40 units of vasopressin I.V.

Option 5: -

Correct Option: Option 2 – Defibrillate with a monophasic defibrillator at 360 joules.

Explanation: To attempt to convert the rhythm, the nurse should first defibrillate the patient with a monophasic defibrillator at 360 joules. If this fails, then the nurse should continue CPR (Option C) for 2 minutes and attempt to defibrillate again. Epinephrine (Option A) and vasopressin (Option D) may be given, but not until after the first two defibrillation attempts.

The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic?

• The client's blood pressure is 130/86.
• The client is unable to concentrate.
• The client's pupils are dilated.
• The client grimaces during care.
• -

Answer explanation

Option 1: The client's blood pressure is 130/86.

Option 2: The client is unable to concentrate.

Option 3: The client's pupils are dilated.

Option 4: The client grimaces during care.

Option 5: -

Correct Option: Option 4 – The client grimaces during care.

Explanation: Facial grimace is an indication of pain. The blood pressure in answer A is within normal limits. The client's inability to concentrate, along with dilated pupils, as stated in answers B and C, may be related to the anesthesia that he received during surgery.

The physician has ordered Cortisporin ear drops for a 2-year-old. To administer the ear drops, the nurse should:

• Pull the ear down and back
• Pull the ear straight out
• Pull the ear up and back
• Leave the ear undisturbed
• -

Answer explanation

Option 1: Pull the ear down and back

Option 2: Pull the ear straight out

Option 3: Pull the ear up and back

Option 4: Leave the ear undisturbed

Option 5: -

Correct Option: Option 1 – Pull the ear down and back

Explanation: When administering ear drops to a child under 3 years of age, the nurse should pull the ear down and back to straighten the ear canal. Answers B and D are incorrect positions for administering ear drops. Answer C is used for administering ear drops to an adult client.