Practice Test III- Medical Surgical Nursing

These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).

A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system.

Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.

Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.

Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.

It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.

Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs.

These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly.

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.

Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion.

Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness.

The use of fragrant soap is very drying to skin hence causing the pruritus.

Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in
loosely structured dermis.

Elevation increases lymphatic drainage, reducing edema and pain.

Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.

An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.

One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.

Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.

The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney.

Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage.

Patent airway is the most priority; therefore removal of secretions is necessary.

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.

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.

The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.

Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately.

There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.

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.

In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.

Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction

Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous growth.

Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears.

The palms should bear the client’s weight to avoid damage to the nerves in the axilla.

Atropine sulfate, commonly known as Atropine, is a medication that works by blocking certain nerve impulses. It has various effects on the body, including dilating the pupils, increasing heart rate, and reducing secretions in the respiratory and digestive tracts.

The contraindication in a client with glaucoma stems from Atropine's ability to dilate the pupils. In glaucoma, there is increased pressure within the eye due to fluid buildup. Dilating the pupils further in this condition can exacerbate the problem by narrowing the angle between the iris and the cornea, leading to a sudden increase in eye pressure, potentially causing acute angle-closure glaucoma, which is a medical emergency.

Restlessness is an early indicator of hypoxia, even in an unconscious client. It reflects the brain's response to insufficient oxygen, which can cause agitation and anxiety before other physical symptoms manifest. While cyanosis, increased respirations, and hypertension can occur as hypoxia progresses, restlessness is typically one of the first signs, making it an important early indicator for healthcare providers to monitor.

Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.

This indicates that the bladder is distended with urine, therefore palpable.

In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.

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.

Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.

Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.

Elevation will help control the edema that usually occurs.

Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.

The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.

When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent back ward flow into the pulmonary vein, the pulmonary circulation is under pressure.

Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain.

An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and
assessment is provided for.

Good source of vitamin B12 are dairy products and meats.

Glucocorticoids play no significant role in disease treatment.

The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder.