GCC 826 - 850

The nurse is assessing a patient with ankylosing spondylitis. Which of the following initial signs or symptoms would the nurse most likely assess in this patient?

• Red, painful, swollen joints
• Fatigue and night sweats
• Low back pain
• Neck pain and stiffness
• -

Answer explanation

Option A: Red, painful, swollen joints

Option B: Fatigue and night sweats

Option C: Low back pain

Option D: Neck pain and stiffness

Option E: -

Correct Option: Option C – Low back pain

Explanation: Typically, intermittent low back pain is the first indication of ankylosing spondylitis... relatively late manifestations.

A secondary latency phase that occurs in some diseases that is commonly followed by another acute phase is referred to as:

• remission.
• convalescence.
• the acute phase.
• the subclinical acute phase.
• -

Answer explanation

Option A: remission.

Option B: convalescence.

Option C: the acute phase.

Option D: the subclinical acute phase.

Option E: -

Correct Option: Option A – remission.

Explanation: A secondary latency phase that occurs in some diseases... the subclinical acute phase... disease weren’t present.

A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?

• Use a magnet to remove the object.
• Rinse the eye thoroughly with saline.
• Cover both eyes with paper cups.
• Patch the affected eye only.
• -

Answer explanation

Option A: Use a magnet to remove the object.

Option B: Rinse the eye thoroughly with saline.

Option C: Cover both eyes with paper cups.

Option D: Patch the affected eye only.

Option E: -

Correct Option: Option C – Cover both eyes with paper cups.

Explanation: Covering both eyes prevents consensual movement... one eye moves, the other also does.

Which of the following conditions can cause right-sided heart failure?

• A ventricular septal defect
• An anterior MI
• An atrial septal defect
• Constrictive pericarditis
• -

Answer explanation

Option A: A ventricular septal defect

Option B: An anterior MI

Option C: An atrial septal defect

Option D: Constrictive pericarditis

Option E: -

Correct Option: Option C – An atrial septal defect

Explanation: An atrial septal defect can lead to right-sided heart failure... Option D).

After administering hydralazine (Apresoline) 5 mg intravenously as ordered... the nurse should assess the client for:

• Tachycardia.
• Bradypnea.
• Polyuria.
• Dysphagia.
• -

Answer explanation

Option A: Tachycardia.

Option B: Bradypnea.

Option C: Polyuria.

Option D: Dysphagia.

Option E: -

Correct Option: Option A – Tachycardia.

Explanation: One of the most common adverse effects of the drug hydralazine... Dysphagia is not a typical adverse effect of hydralazine.

The client using a diaphragm should be instructed to:

• Refrain from keeping the diaphragm in longer than 4 hours
• Keep the diaphragm in a cool location
• Have the diaphragm resized if she gains 5 pounds
• Have the diaphragm resized if she has any surgery
• -

Answer explanation

Option A: Refrain from keeping the diaphragm in longer than 4 hours

Option B: Keep the diaphragm in a cool location

Option C: Have the diaphragm resized if she gains 5 pounds

Option D: Have the diaphragm resized if she has any surgery

Option E: -

Correct Option: Option B – Keep the diaphragm in a cool location

Explanation: The client using a diaphragm should keep the diaphragm in a cool location. She should refrain from leaving the diaphragm in longer than 8 hours, not 4... resized if she gains or loses 10 pounds...

Which of the following recommendations would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks’ gestation who is experiencing occasional heartburn?

• Eat smaller and more frequent meals during the day.
• Take a pinch of baking soda with water before meals.
• Decrease fluid intake to four glasses daily.
• Drink several cups of regular tea throughout the day.
• -

Answer explanation

Option A: Eat smaller and more frequent meals during the day.

Option B: Take a pinch of baking soda with water before meals.

Option C: Decrease fluid intake to four glasses daily.

Option D: Drink several cups of regular tea throughout the day.

Option E: -

Correct Option: Option A – Eat smaller and more frequent meals during the day.

Explanation: Eating smaller and more frequent meals may help prevent heartburn... Caffeinated products... may further contribute to heartburn.

A nurse caring for a client with Alzheimer’s disease administers tacrine hydrochloride (Cognex)... The nurse knows this medication works by binding to:

• Acetylcholine.
• Cholinesterase.
• Norepinephrine.
• Epinephrine.
• -

Answer explanation

Option A: Acetylcholine.

Option B: Cholinesterase.

Option C: Norepinephrine.

Option D: Epinephrine.

Option E: -

Correct Option: Option B – Cholinesterase.

Explanation: Tacrine hydrochloride (Cognex) is a cholinergic medication that works by binding to cholinesterase... does not bind with norepinephrine or epinephrine.

A client admitted with a drug-resistant bacterial infection has been placed on contact precautions... What performance improvement action should the nurse take?

• No action is necessary... physician’s responsibility to use appropriate contact precautions.
• The nurse should say, “Doctor, are you aware that this client is on contact precautions?...”
• Tactfully and in a professional manner, inform the physician... emphasize the personal protective equipment...
• No action is necessary. The physician might be offended...
• -

Answer explanation

Option A: No action is necessary... physician’s responsibility to use appropriate contact precautions.

Option B: The nurse should say, “Doctor, are you aware that this client is on contact precautions?...”

Option C: Tactfully and in a professional manner, inform the physician... emphasize the personal protective equipment...

Option D: No action is necessary. The physician might be offended...

Option E: -

Correct Option: Option C – Tactfully and in a professional manner, inform the physician... emphasize the personal protective equipment...

Explanation: Client safety is the responsibility of all health care personnel... communicate the necessity of contact precautions... reinforce the importance...

A student nurse asks the clinical instructor where there is an accurate place to obtain information regarding immunizations. The instructor recommends:

• Looking up each vaccine in a current drug handbook.
• The Centers for Disease Control and Prevention website.
• Seeking information from the pharmaceutical manufacturer of each vaccine.
• Asking a physician colleague.
• -

Answer explanation

Option A: Looking up each vaccine in a current drug handbook.

Option B: The Centers for Disease Control and Prevention website.

Option C: Seeking information from the pharmaceutical manufacturer of each vaccine.

Option D: Asking a physician colleague.

Option E: -

Correct Option: Option B – The Centers for Disease Control and Prevention website.

Explanation: The Centers for Disease Control and Prevention (CDC) website contains a wealth of information... A physician may be an incomplete source of information.