LPN exams medical-surgical practice questions set 28

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The correct answer is C: The signs and symptoms the infant is experiencing. This is the most important information because it helps determine the severity and type of reaction the infant is having. By knowing the specific signs and symptoms, the nurse can assess whether it is a mild or severe reaction and provide appropriate guidance or intervention. Choice A (The time the immunization was received) may be important for tracking purposes but does not provide immediate information on the infant's condition. Choice B (Whether the father has given the infant any acetaminophen) is relevant but not as crucial as knowing the actual symptoms. Choice D (The sites used to administer the immunizations) is less important compared to knowing the symptoms, as the reaction can occur regardless of the administration sites.

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In managing chronic pain, it is essential to employ a multi-faceted approach. Administering pain medication around the clock helps maintain consistent pain relief. Teaching relaxation techniques such as deep breathing or guided imagery can help reduce muscle tension and promote relaxation, which can alleviate pain. Encouraging physical activity, tailored to the client's abilities, can help improve overall physical functioning and reduce pain perception. Therefore, combining all these interventions (pain medication, relaxation techniques, and physical activity) provides a comprehensive approach to pain management, addressing different aspects of the client's experience with chronic pain. This holistic approach is more effective than using a single intervention alone, making 'All of the above' the correct choice.

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The correct answer is B: The need to use barrier contraceptives while taking the drug. This is important because immune modulators can potentially harm a developing fetus, so it is crucial to use barrier contraceptives to prevent pregnancy during treatment. Incorrect answers: A: The need to continue oral contraceptives - This is incorrect because oral contraceptives may not provide sufficient protection against pregnancy while on immune modulators. C: The need to avoid sexual intercourse while taking the drug - This is incorrect as it is an extreme measure and not necessary if barrier contraceptives are used. D: The importance of taking an aspirin daily to decrease the adverse effects of the drug - This is incorrect as aspirin is not typically indicated for reducing adverse effects of immune modulators.

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The correct answer is C: Autoimmune diseases such as SLE. C1q is essential for the classical pathway of the complement system, which plays a crucial role in clearing immune complexes. A deficiency in C1q can lead to impaired immune complex clearance, resulting in the development of autoimmune diseases like Systemic Lupus Erythematosus (SLE). Choice A (Enhanced inflammation) is incorrect because a deficiency in C1q would actually lead to decreased inflammation due to impaired complement activation. Choice B (Reduced phagocytosis) is incorrect because phagocytosis is primarily mediated by the alternative pathway of the complement system, not the classical pathway involving C1q. Choice D (Increased cancer risk) is incorrect as C1q deficiency is not directly associated with an increased risk of cancer.

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The correct answer is B because premedicating the patient with pain and anxiety medications before the dressing change can help decrease their discomfort and anxiety, making the process more tolerable. This intervention promotes patient comfort and cooperation, ensuring a successful and safe dressing change. Allowing the patient to determine the time of dressing change (A) may not address the underlying issue of anxiety and may lead to delays in care. Telling the patient it is okay to cry during the dressing change (C) does not actively address the patient's discomfort and may not be sufficient in managing their distress. Explaining the importance of dressing changes (D) may be helpful in some situations but may not directly address the patient's immediate need for pain and anxiety relief during the procedure.

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The correct answer is D: Risk for injury. The client's symptoms of disorientation, wandering, decreased appetite, and difficulty sleeping indicate an increased risk for falls, accidents, or getting lost. Ensuring the client's safety and preventing any potential harm is the priority. A: Disturbed thought processes may contribute to the client's disorientation but do not pose an immediate threat to their safety. B: Altered sleep pattern is concerning but is secondary to the risk of injury in this scenario. C: Imbalanced nutrition: less than is important, but the immediate priority is addressing the client's safety due to the risk of injury. In summary, the priority nursing problem for this client is the risk for injury due to their disorientation and wandering behavior, which could lead to accidents or harm.

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The correct answer is A: Check the blood glucose level. This is the first action the nurse should take because the client is presenting with symptoms of hypoglycemia, which can be life-threatening for a pregnant woman with Type 1 diabetes. By checking the blood glucose level, the nurse can determine if the client's symptoms are due to low blood sugar levels and take appropriate action. Drawing blood for a Hemoglobin A1C (choice B) is not the first priority in this acute situation. Assessing urine for ketone levels (choice C) is important in managing diabetes but is not the priority when the client is showing signs of hypoglycemia. Providing the client with a protein snack (choice D) may help raise blood sugar levels, but checking the blood glucose level is essential to determine the appropriate intervention.

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Skin tear risk spikes with age and fragility, making 'a 72-year-old female taking a steroid for rheumatoid arthritis' most vulnerable. Steroids thin skin e.g., 20% dermal loss in 6 months per Baranoski and Ayello (2004), and her age adds rete ridge flattening e.g., 70% tear rate. , '22-year-old post-hernia,' has resilient skin e.g., 1 mm thick, tears <5% despite surgery. , '37-year-old with fracture,' risks bruising e.g., not tears skin still elastic. , '64-year-old post-cataract,' is older e.g., 30% risk but mobile, no steroids. The 72-year-old's immobility e.g., RA stiffness plus prednisone (e.g., 10 mg daily) doubles tear odds, a nurse's red flag for padding. Unlike younger, thicker skin or less medicated elders, her profile per *Wound Care Essentials* peaks risk, making the correct, highest-risk patient.

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The correct answer is D: The examination is best performed after the menstrual period because breasts are least likely to be tender or swollen at this time, making it easier to detect any abnormalities. Performing the examination right after the period also ensures a consistent time each month. A: It does matter what day the examination is performed as timing can impact the accuracy of the examination. B: Performing the examination on the first day of the menstrual period may not be ideal as breasts can be more tender and swollen during this time, potentially affecting the accuracy of the examination. C: Performing the examination in the days just prior to the menstrual period may also not be ideal as breasts tend to be more tender and swollen during this time, making it harder to detect abnormalities.

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In a client with AIDS and impaired gas exchange from a respiratory infection, pain when swallowing can indicate esophageal involvement, such as esophagitis or an esophageal infection like candidiasis. These conditions can significantly impact the client's ability to take in nutrition and medications, leading to complications like dehydration and malnutrition. Therefore, immediate intervention is required to address the underlying cause and prevent further complications. Elevated temperature (choice A) may indicate infection but does not directly address the impaired gas exchange. Generalized weakness (choice B) and diminished lung sounds (choice C) are concerning but do not directly relate to the immediate need for intervention in the context of esophageal involvement in a client with impaired gas exchange.