BSN Hesi 266 Medical surg

The correct answer is  A. Hydration of the affected dry skin area.

Explanation:

Urea cream is commonly used to treat dry, scaly skin conditions such as eczema. Urea is a humectant, meaning it helps draw moisture into the skin, improving hydration and alleviating dryness. The primary expected therapeutic response to the application of 10% urea cream is the hydration of the affected dry skin area. Urea also works as a keratolytic, breaking down the outer layer of the skin to allow better penetration of moisture and other treatments.

Why the other options are wrong:

B. Healing with a return to normal skin appearance

While urea cream can improve the appearance of the skin by promoting hydration and reducing dryness, it does not guarantee full healing or a return to the "normal" skin appearance, especially in chronic conditions like eczema. The skin may improve, but healing to a completely normal state is not always expected or realistic with just topical therapy.

C. Decreased weeping of ulcerations in affected areas

Weeping of ulcerations is not a typical feature of eczema; rather, it is more common in conditions like infections or severe dermatitis. Urea cream is not typically used to manage ulcerations or weeping lesions. The expected therapeutic response would be more focused on improving skin hydration and reducing the dryness, scaling, and itchiness associated with eczema.

D. Reduced pain in eczematous areas

Urea cream does not have a significant analgesic effect. While it may help alleviate discomfort by reducing dryness and inflammation, pain relief is not the primary therapeutic response. Other treatments, such as corticosteroids or antihistamines, would be more effective for addressing pain and inflammation associated with eczema.

Summary:

The expected therapeutic response to the use of 10% urea cream in a client with eczema is the hydration of the affected dry skin areas. Urea helps draw moisture into the skin and improves hydration, alleviating dryness. Full healing, reduction of weeping, or pain relief are not the primary therapeutic effects of this cream.

The correct answer is: A. Diabetes mellitus.

Explanation:

Hypertension is a significant risk factor for a cerebrovascular accident (CVA), or stroke. When combined with diabetes mellitus, the risk for a CVA increases substantially. Diabetes contributes to the development of atherosclerosis (hardening and narrowing of the arteries) and accelerates the damage to blood vessels, making them more prone to rupture or blockage, which are common causes of stroke. Additionally, individuals with diabetes often experience impaired blood flow and poor circulation, which can further increase the likelihood of a stroke. Therefore, diabetes mellitus is the greatest risk factor for developing a CVA when combined with hypertension.

Why the other options are wrong:

B. Hypothyroidism. While hypothyroidism can affect cardiovascular health, it does not directly increase the risk of a CVA as much as diabetes does. Hypothyroidism can lead to a slower heart rate and increased cholesterol, which may contribute to cardiovascular disease, but the risk is not as significant as that associated with diabetes and hypertension.

C. Parkinson's disease. Parkinson's disease primarily affects motor function and does not significantly increase the risk of a CVA. While the disease can impact the cardiovascular system, it is not directly linked to the development of strokes in the same way that diabetes and hypertension are.

D. Recurring pneumonia. Recurring pneumonia may contribute to other complications, such as respiratory issues and infections, but it does not have a direct connection to the development of a CVA. While severe infections can impact overall health, pneumonia is not a primary risk factor for stroke compared to diabetes.

Summary:

The greatest risk factor for developing a cerebrovascular accident (CVA) in a client with hypertension is diabetes mellitus. The combination of hypertension and diabetes significantly increases the likelihood of stroke due to the effects of both conditions on blood vessels and circulation. The other medical conditions listed (hypothyroidism, Parkinson's disease, and recurring pneumonia) do not pose as significant a risk for stroke.

Correct Answer: B: Completes education and becomes self-supporting.

Explanation:

While completing education and becoming financially independent are significant life achievements, they do not universally define success in young adulthood. Many individuals take alternative paths, such as entrepreneurship, vocational training, or extended education. Additionally, success in young adulthood is more closely associated with the ability to establish meaningful relationships, develop a stable sense of identity, and adapt to adult roles. According to Erik Erikson’s psychosocial development theory, young adulthood is defined by the stage of intimacy versus isolation, where individuals seek to form close relationships and establish independence. Financial stability is important, but personal identity and relationships hold greater significance in measuring success in this life stage.

Why the Other Options Are Incorrect:

Option A: Demonstrates a conceptualization of death and dying.

Understanding death and mortality is more relevant in middle and late adulthood rather than young adulthood.

Option C: Creates a new definition of self and roles with others.

This is the best indicator of successful young adulthood, as it reflects the ability to develop meaningful relationships and adjust to new social roles.

Option D: Develops a strong need for parental support and approval.

Young adulthood is about independence. A strong reliance on parental approval may indicate difficulty transitioning into adulthood rather than success.

Summary:

While completing education and becoming self-supporting are important milestones, they do not solely define success in young adulthood. Personal growth, identity formation, and meaningful relationships are stronger indicators of developmental success in this life stage.

Correct Answer: C. Potassium.

Explanation:

Primary hyperaldosteronism (also known as Conn's syndrome) is characterized by excess production of aldosterone from the adrenal glands. Aldosterone promotes sodium retention and potassium excretion by the kidneys. This leads to increased sodium levels and decreased potassium levels in the blood.

Why the Other Options Are Incorrect:

A. Sodium.

Aldosterone promotes sodium retention by the kidneys, which typically leads to increased sodium levels in the blood, not decreased. This can result in hypertension due to increased sodium retention and fluid volume.

B. Antidiuretic hormone.

Antidiuretic hormone (ADH) regulates water balance in the body and is not directly affected by aldosterone levels in primary hyperaldosteronism. ADH secretion may be influenced by other factors like blood volume and osmolality but is not directly linked to hyperaldosteronism.

D. Glucose.

Hyperaldosteronism does not directly affect glucose metabolism. Elevated glucose levels can occur in other conditions (such as diabetes or stress), but this is not the primary concern in primary hyperaldosteronism.

Summary:

In primary hyperaldosteronism, aldosterone excess leads to increased sodium retention and increased potassium excretion, resulting in a decreased serum potassium level (hypokalemia). Therefore, the nurse would expect low potassium levels on laboratory tests for this condition.

The correct answer is A. Wearing gloves when handling cold items against painful spasms.

Explanation:

Raynaud's disease is characterized by vasospasms of small blood vessels in response to cold or stress, which leads to episodes of pain, color changes (usually white or blue), and numbness, especially in the fingers and toes. The pain is often triggered by cold temperatures. Wearing gloves when handling cold objects or being exposed to cold environments helps protect the hands from triggering vasospasms, thereby preventing pain and discomfort.

Why the other options are incorrect:

B. Return appointments will be needed for IV pain medication: While pain management is important in Raynaud's disease, IV pain medications are generally not a first-line treatment. This condition is usually managed with lifestyle modifications, medications for vasodilation (e.g., calcium channel blockers), and avoiding triggers (cold, stress).

C. Painful areas should be rubbed gently until the pain subsides: Rubbing painful areas may not be effective and could possibly exacerbate the problem, especially if there is already vasospasm. Warming the hands with gloves or by using warm water may be more helpful to relieve the symptoms of Raynaud's disease.

D. Enrolling in a pain clinic can provide pain relief alternatives: While a pain clinic can offer alternatives for managing chronic pain, Raynaud's disease is typically managed with preventative measures, medications, and lifestyle changes. It is not usually necessary to seek specialized pain management unless the symptoms are severe or persistent.

Summary:

The best advice is for the client to wear gloves to protect their hands from the cold, which is a common trigger for painful episodes of Raynaud's disease. Managing cold exposure is one of the key components in preventing painful spasms.

The correct answer is C. Increase the flow of the bladder irrigation.

Explanation:

Following a transurethral resection of the prostate (TURP), continuous bladder irrigation (CBI) is commonly used to keep the bladder clear of blood clots and debris that can form after surgery. An increase in blood clots in the drainage tubing may indicate that clots are forming in the bladder and blocking the flow of urine. Increasing the flow of the bladder irrigation helps flush out these clots, reducing the risk of blockage and ensuring the proper flow of urine and irrigation fluid.

Why the other options are wrong:

A. Provide additional oral fluid intake.

While adequate hydration is important for the client’s overall well-being, increasing oral fluid intake alone will not resolve the issue of blood clots forming in the drainage tubing. The primary issue in this case is related to the irrigation flow, not oral hydration.

B. Measure the client's intake and output.

While it is important to monitor intake and output for clients undergoing TURP with CBI, this action is not the most immediate or effective intervention to address the presence of blood clots in the drainage tubing. The primary concern here is preventing further clot formation or obstruction, which can be achieved by adjusting the irrigation flow.

D. Administer a PRN dose of an antispasmodic agent.

Antispasmodic agents may be prescribed to reduce bladder spasms following TURP, but the presence of blood clots is more related to the irrigation flow and not bladder spasms. The most appropriate initial action is to increase the irrigation flow to help clear the clots, not administer medication for spasms unless prescribed specifically for that purpose.

Summary:

When a client with continuous bladder irrigation after TURP shows an increased number of blood clots in the drainage tubing, the best initial nursing action is to increase the flow of the bladder irrigation. This helps flush out the clots and prevent any potential obstruction or complications.

The correct answer is: D. Confusion and tachycardia.

Explanation:

In elderly clients, bacterial pneumonia may present with atypical symptoms. While fever and leukocytosis are common in younger adults, older adults may exhibit more subtle or non-specific symptoms due to changes in their immune response. Common symptoms in elderly clients with bacterial pneumonia may include:

Confusion: Pneumonia in older adults can cause delirium or confusion, as the body may not mount the typical immune response. Confusion is often one of the first signs of infection in older individuals.

Tachycardia: Tachycardia (an increased heart rate) is often seen in pneumonia as the body tries to compensate for hypoxia and fever.

Why the other options are less appropriate:

A. Leukocytosis and febrile: While these are common symptoms of bacterial pneumonia in younger adults, elderly clients may not have a noticeable fever (they may have a low-grade or absent fever) and may not show significant leukocytosis, making this less likely.

B. Polycythemia and crackles: Polycythemia (an increase in red blood cells) is not typically associated with pneumonia. Crackles may be heard on auscultation of the lungs, but polycythemia is more related to chronic hypoxia conditions, not bacterial pneumonia.

C. Pharyngitis and sputum production: Pharyngitis (sore throat) is usually more common with viral infections like the common cold or influenza, rather than bacterial pneumonia. Sputum production can occur with pneumonia but is not as specific to elderly clients as confusion and tachycardia.

Summary:

In elderly clients with bacterial pneumonia, confusion and tachycardia are common signs, especially as the infection may present with atypical symptoms. The nurse should be alert to these signs as they may indicate the presence of pneumonia in an older adult.

Correct answer: C. Describe the use of an elimination diet to find trigger foods

Explanation:

Crohn's disease is a type of inflammatory bowel disease (IBD) that affects the gastrointestinal (GI) tract, causing symptoms like diarrhea, abdominal pain, and malnutrition. Dietary management is important in managing flare-ups and maintaining remission. However, there is no one-size-fits-all diet for Crohn's disease because the triggers can vary from person to person. The elimination diet is often used to identify specific trigger foods that may worsen symptoms or lead to flare-ups. This involves removing suspected foods from the diet for a period of time and gradually reintroducing them to see which ones provoke symptoms. This method helps the client identify which foods may need to be limited or avoided in their specific case.

Why the other options are wrong:

A. Explain that the need to restrict fluids is the primary limitation:

This is incorrect because there is no need to restrict fluids in Crohn's disease unless the client is experiencing complications like dehydration or electrolyte imbalances. In fact, maintaining adequate hydration is important, especially if diarrhea is frequent.

B. Instruct the client to avoid foods with gluten, such as wheat bread:

This recommendation is not universally necessary for clients with Crohn's disease. Gluten may be a trigger for some individuals, particularly those with celiac disease or gluten sensitivity, but not all Crohn's patients need to avoid gluten. Gluten is not a general dietary restriction for Crohn's disease unless the individual has specific sensitivity to it.

D. Advise the client to limit foods that are high in calcium and iron:

This is incorrect because Crohn's disease can lead to nutrient deficiencies, particularly in calcium, iron, and vitamin D due to malabsorption. Clients with Crohn's disease may need to increase their intake of calcium and iron-rich foods, not limit them, especially if they are at risk for osteoporosis or anemia due to malabsorption or blood loss.

Summary:

The best response is to describe the use of an elimination diet to identify trigger foods, as this approach helps tailor the diet to the specific needs of the individual with Crohn's disease. Restricting fluids, avoiding gluten (unless necessary), or limiting calcium and iron-rich foods are not appropriate general dietary recommendations for Crohn's disease management.

Correct answer: D. Move the client to a private room, keep the door closed, and initiate droplet precautions.

Explanation:

The client is exhibiting symptoms of COVID-19 (fever, cough, and shortness of breath), which suggests a possible infection. The most important priority is to prevent the potential spread of the virus to others, which is accomplished by isolating the client and initiating droplet precautions. Droplet precautions include moving the client to a private room, keeping the door closed, and using appropriate personal protective equipment (PPE) to protect healthcare workers, other patients, and visitors. This action is essential to reduce the risk of transmission, as COVID-19 spreads primarily through respiratory droplets.

Why the other options are wrong:

A. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient:

While it is important for family members to monitor their health, this is secondary to the immediate need to isolate the client to prevent the spread of the virus. The primary concern right now is protecting others from potential exposure within the healthcare setting.

B. Assist the client to recall everyone possibly exposed since onset of symptoms:

Contact tracing is important for notifying and advising those who may have been exposed, but the priority action at this moment is to ensure that the client does not transmit the virus to others in the healthcare environment. Isolation is a more immediate concern.

C. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results:

While antiviral treatment may be part of the care for a positive COVID-19 result, starting an intravenous infusion is not the most urgent action. The first priority is to isolate the patient and ensure appropriate infection control measures are in place to prevent transmission.

Summary:

The most important action in this situation is to isolate the client and implement droplet precautions, which will prevent the spread of COVID-19 to others in the healthcare facility. This is crucial to protect staff, patients, and visitors while also providing the client with necessary care.