A 65 year old female is experiencing flare-up of pruritus. Which of the client’s action could aggravate the cause of flare-ups?
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Solution
Daily baths with fragrant soap
Option B: The use of fragrant soap is very drying to skin hence causing the pruritus.
Among the following components thorough pain assessment, which is the most significant?
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Solution
Intensity
Option D: Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
Which of the following stage is the carcinogen irreversible?
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Solution
Progression stage
Option A: Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast-growing tumor that cannot be reversed.
A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?
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Solution
Atonic
Option B: In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.
The nurse is aware the early indicator of hypoxia in the unconscious client is:
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Solution
Restlessness
Option D: Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless.
Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate?
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Solution
“Keep active, use stress reduction strategies, and avoid fatigue”.
Option C: The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active.
What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?
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Solution
Pupil size and papillary response
Option A: It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.
A 22-year-old client suffered from his first tonic-clonic seizure. Upon awakening, the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic-clonic seizures in adults more the 20 years?
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Solution
Head trauma
Option B: Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
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Solution
Glucose
Option C: The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose.
Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be assessed for signs of developing:
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Solution
Hypovolemia
Option A: In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced.