GCC 1526 - 1550

As winter approaches, the nurse counsels an elderly client:

• To remain indoors as much as possible.
• That he needs thermal protection when outdoors.
• To consider spending the winter in a milder climate.
• That he will likely become ill if he does not remain in an environment with a constant temperature.
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A client with suspected myasthenias gravis has been administered the drug edrophonium chloride (Tensilon). Which effect would the nurse expect the client to exhibit after administration?

• Decreased motor strength
• Decreased seizure activity
• Increased muscle strength
• Increased cognitive functioning
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When teaching a patient how to prevent the recurrence of acute glomerulonephritis, which instruction should the nurse include?

• Avoid physical activity.
• Strain all urine.
• Seek early treatment for respiratory infections.
• Monitor urine specific gravity daily.
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A patient, age 34, is scheduled for discharge after undergoing a modified retroperitoneal lymph node dissection for testicular cancer. He seems quiet and depressed, and the nurse asks if he has anything on his mind. “Now that I’m ready to go home,” he says, “I keep thinking about the practitioner telling me I’ll be sterile. I’m worried about how my wife will react, even though we didn’t plan to have children.” What would be the nurse’s best response?

• Don’t worry about being sterile if you didn’t plan on having children anyway.
• Sterility is an expected result of the treatment. You can feel comforted by the fact that this disease has a high cure rate.
• Would you like to talk about your concerns?
• I think you should ask the surgeon to talk with you and your wife about your concerns.
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The physician has prescribed Xanax (alprazolam) for a client with acute anxiety. The nurse should teach the client to avoid:

• Sun exposure
• Drinking beer
• Eating cheese
• Taking aspirin
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A 22-year-old nulligravid client tells the nurse that she and her husband have been considering using condoms for family planning. Which of the following instructions should the nurse include about the use of condoms as a method for family planning?

• Using a spermicide with the condom offers added protection against pregnancy.
• Natural skin condoms protect against sexually transmitted diseases.
• The typical failure rate for couples using condoms is about 25%.
• Condom users commonly report penile gland sensitivity.
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The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?

• Continuing to monitor the vital signs
• Contacting the physician
• Asking the client how he feels
• Asking the LPN to continue the post-op care
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A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?

• “Currant jelly” stools
• Projectile vomiting
• “Ribbonlike” stools
• Palpable mass over the flank
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A client has a history of positive HIV with onset of acquired immunodeficiency syndrome (AIDS). The client receives 2 units of whole blood. Which transfusion reaction is this client most likely to have?

• Acute hemolytic reaction
• Graft versus host disease
• Allergic reaction
• Febrile transfusion reaction
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A client has pinpoint, pink-to-purple, nonblanching macular lesions 1 to 3 mm in diameter. Which term best describes the lesions?

• Ecchymosis
• Petechiae
• Purpura
• Hematoma
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