NUR 445 SF-9A1 Comprehensive Final Exam Arizona College School of Nursing.
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Free NUR 445 SF-9A1 Comprehensive Final Exam Arizona College School of Nursing. Questions
1. The nurse is caring for a client with full and partial thickness burns who is intubated, sedated, and receiving mechanical ventilation. The healthcare provider has ordered nutritional support. Which intervention is most appropriate?
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Apply silver sulfadiazine to burn wounds
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Administer IV fentanyl for pain management
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Initiate enteral tube feedings at a low continuous rate
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Apply ice packs to burn wounds
Explanation
Explanation:
Correct Answer: (C) Initiate enteral tube feedings at a low continuous rate
Burn patients have dramatically increased metabolic demands due to the hypermetabolic response triggered by major burns. Early enteral nutrition initiated within 6 hours of injury is the gold standard for nutritional support in intubated burn patients. Tube feedings at a low continuous rate support wound healing, preserve gut mucosal integrity, reduce bacterial translocation, and improve overall survival outcomes. Since the client is intubated and cannot eat orally, enteral feeding is the appropriate route.
Why Other Options are Incorrect:
A. Apply silver sulfadiazine to burn wounds — Silver sulfadiazine is a topical antimicrobial used for burn wound care, not nutritional support. While it is part of burn management, it does not address the provider's order for nutritional support.
B. Administer IV fentanyl for pain management — Fentanyl addresses pain, not nutrition. While pain management is critical in burn care, it does not fulfill the nutritional support order.
D. Apply ice packs to burn wounds — Ice packs are contraindicated in burn care as they cause vasoconstriction, worsen tissue damage, and increase the risk of hypothermia. This is never an appropriate burn management intervention.
Correct Answer: (C) Initiate enteral tube feedings at a low continuous rate
Burn patients have dramatically increased metabolic demands due to the hypermetabolic response triggered by major burns. Early enteral nutrition initiated within 6 hours of injury is the gold standard for nutritional support in intubated burn patients. Tube feedings at a low continuous rate support wound healing, preserve gut mucosal integrity, reduce bacterial translocation, and improve overall survival outcomes. Since the client is intubated and cannot eat orally, enteral feeding is the appropriate route.
Why Other Options are Incorrect:
A. Apply silver sulfadiazine to burn wounds — Silver sulfadiazine is a topical antimicrobial used for burn wound care, not nutritional support. While it is part of burn management, it does not address the provider's order for nutritional support.
B. Administer IV fentanyl for pain management — Fentanyl addresses pain, not nutrition. While pain management is critical in burn care, it does not fulfill the nutritional support order.
D. Apply ice packs to burn wounds — Ice packs are contraindicated in burn care as they cause vasoconstriction, worsen tissue damage, and increase the risk of hypothermia. This is never an appropriate burn management intervention.
2. What is the first step in managing heat exhaustion?
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Providing oral electrolyte replacement
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Administering intravenous normal saline
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Moving to a shaded or air-conditioned environment
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Applying cold packs to the groin and axillae
Explanation
Explanation:
Correct Answer: (C) Moving to a shaded or air-conditioned environment
The first and most immediate step in managing heat exhaustion is removing the client from the hot environment and moving them to a cool, shaded, or air-conditioned location. This stops ongoing heat exposure and allows the body to begin cooling. All subsequent interventions — including rehydration and cooling measures — are built upon this foundational first step.
Why Other Options are Incorrect:
A. Providing oral electrolyte replacement — Oral rehydration is an important subsequent step in heat exhaustion management, but it comes after the client has been removed from the heat source and is alert enough to safely swallow.
B. Administering intravenous normal saline — IV fluid replacement is indicated for severe cases or when the client cannot tolerate oral fluids. It is not the first step and requires clinical assessment following removal from the environment.
D. Applying cold packs to the groin and axillae — Cold pack application is a cooling technique used after the client has been moved to a cool environment. It is a secondary intervention, not the first priority action.
Correct Answer: (C) Moving to a shaded or air-conditioned environment
The first and most immediate step in managing heat exhaustion is removing the client from the hot environment and moving them to a cool, shaded, or air-conditioned location. This stops ongoing heat exposure and allows the body to begin cooling. All subsequent interventions — including rehydration and cooling measures — are built upon this foundational first step.
Why Other Options are Incorrect:
A. Providing oral electrolyte replacement — Oral rehydration is an important subsequent step in heat exhaustion management, but it comes after the client has been removed from the heat source and is alert enough to safely swallow.
B. Administering intravenous normal saline — IV fluid replacement is indicated for severe cases or when the client cannot tolerate oral fluids. It is not the first step and requires clinical assessment following removal from the environment.
D. Applying cold packs to the groin and axillae — Cold pack application is a cooling technique used after the client has been moved to a cool environment. It is a secondary intervention, not the first priority action.
3. The nurse notes a variety of symptoms in a client admitted with possible sepsis. Which symptom is most likely to indicate the development of disseminated intravascular coagulation (DIC)?
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Temperature remains at 38.6°C (101.5°F) despite the administration of acetaminophen
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Blood pressure goes from 108/60 mmHg to 94/52 mmHg over a 2-hour period
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The client develops 4+ pitting edema in both legs after the administration of a fluid bolus
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The client develops a petechial rash over the trunk and legs bilaterally
Explanation
Explanation:
Correct Answer: (D) The client develops a petechial rash over the trunk and legs bilaterally
DIC is a life-threatening coagulation disorder characterized by simultaneous widespread clotting and bleeding throughout the body. As clotting factors are consumed, uncontrolled bleeding occurs in the microvascular system, presenting as petechiae (small pinpoint hemorrhages under the skin) and purpura distributed across the trunk and extremities. This is a hallmark clinical sign of DIC and distinguishes it from other sepsis complications.
Why Other Options are Incorrect:
A. Persistent fever despite acetaminophen — Fever is a nonspecific sign of ongoing infection or inflammation in sepsis and does not specifically indicate DIC. It reflects the inflammatory process rather than coagulopathy.
B. Declining blood pressure over 2 hours — Progressive hypotension is consistent with septic shock and hemodynamic deterioration but is not specific to DIC. It may occur independently of coagulation abnormalities.
C. 4+ pitting edema after fluid bolus — Dependent edema following fluid resuscitation reflects fluid shifts and capillary leak syndrome common in sepsis. While this is concerning, it is not a specific indicator of DIC.
Correct Answer: (D) The client develops a petechial rash over the trunk and legs bilaterally
DIC is a life-threatening coagulation disorder characterized by simultaneous widespread clotting and bleeding throughout the body. As clotting factors are consumed, uncontrolled bleeding occurs in the microvascular system, presenting as petechiae (small pinpoint hemorrhages under the skin) and purpura distributed across the trunk and extremities. This is a hallmark clinical sign of DIC and distinguishes it from other sepsis complications.
Why Other Options are Incorrect:
A. Persistent fever despite acetaminophen — Fever is a nonspecific sign of ongoing infection or inflammation in sepsis and does not specifically indicate DIC. It reflects the inflammatory process rather than coagulopathy.
B. Declining blood pressure over 2 hours — Progressive hypotension is consistent with septic shock and hemodynamic deterioration but is not specific to DIC. It may occur independently of coagulation abnormalities.
C. 4+ pitting edema after fluid bolus — Dependent edema following fluid resuscitation reflects fluid shifts and capillary leak syndrome common in sepsis. While this is concerning, it is not a specific indicator of DIC.
4. A client in the ICU was admitted for acute decompensated heart failure. The client is reporting severe shortness of breath and is tachypneic, tachycardic, and very anxious. What medication should the registered nurse expect to be prescribed first?
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Dobutamine
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Furosemide
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Diazepam
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Adenosine
Explanation
Explanation
Correct Answer: B. Furosemide
In acute decompensated heart failure, the priority is to relieve fluid overload causing the shortness of breath. Furosemide is a loop diuretic that rapidly reduces preload by promoting diuresis, alleviating pulmonary congestion and improving breathing. It is the first-line treatment in this scenario.
Why the other options are incorrect:
A. Dobutamine is a positive inotrope used when there is severely reduced cardiac output or cardiogenic shock, not as a first-line agent for acute decompensated heart failure with fluid overload.
C. Diazepam is a benzodiazepine used for anxiety and seizures. While the client is anxious, addressing the underlying cause of respiratory distress takes priority over sedation.
D. Adenosine is used to treat supraventricular tachycardia (SVT), not heart failure. The tachycardia in this case is secondary to the heart failure and will resolve with proper treatment.
Correct Answer: B. Furosemide
In acute decompensated heart failure, the priority is to relieve fluid overload causing the shortness of breath. Furosemide is a loop diuretic that rapidly reduces preload by promoting diuresis, alleviating pulmonary congestion and improving breathing. It is the first-line treatment in this scenario.
Why the other options are incorrect:
A. Dobutamine is a positive inotrope used when there is severely reduced cardiac output or cardiogenic shock, not as a first-line agent for acute decompensated heart failure with fluid overload.
C. Diazepam is a benzodiazepine used for anxiety and seizures. While the client is anxious, addressing the underlying cause of respiratory distress takes priority over sedation.
D. Adenosine is used to treat supraventricular tachycardia (SVT), not heart failure. The tachycardia in this case is secondary to the heart failure and will resolve with proper treatment.
5. Which action should the nurse take in the management of a bite wound?
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Apply a cool compress to the bite site
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Incise and drain the wound immediately
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Encourage vigorous exercise of the affected area
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Administer antibiotics prophylactically
Explanation
Explanation
Correct Answer: (D) Administer antibiotics prophylactically
Bite wounds, whether from humans or animals, carry a high risk of polymicrobial infection due to the bacteria present in saliva. Prophylactic antibiotics are a standard component of bite wound management to prevent the development of serious soft tissue infections, cellulitis, and in severe cases, sepsis. Amoxicillin-clavulanate is commonly prescribed as the first-line prophylactic antibiotic for bite injuries.
Why Other Options are Incorrect:
A. Apply a cool compress to the bite site — While cool compresses may reduce swelling, they do not address the infection risk associated with bite wounds and are not the priority management action.
B. Incise and drain the wound immediately — Incision and drainage is reserved for established abscesses. Fresh bite wounds should be irrigated and cleaned, not incised, as this can introduce further contamination.
C. Encourage vigorous exercise of the affected area — Vigorous exercise of a bite wound site would increase blood flow and inflammation, potentially spreading infection and delaying healing. Rest and wound care are recommended instead.
Correct Answer: (D) Administer antibiotics prophylactically
Bite wounds, whether from humans or animals, carry a high risk of polymicrobial infection due to the bacteria present in saliva. Prophylactic antibiotics are a standard component of bite wound management to prevent the development of serious soft tissue infections, cellulitis, and in severe cases, sepsis. Amoxicillin-clavulanate is commonly prescribed as the first-line prophylactic antibiotic for bite injuries.
Why Other Options are Incorrect:
A. Apply a cool compress to the bite site — While cool compresses may reduce swelling, they do not address the infection risk associated with bite wounds and are not the priority management action.
B. Incise and drain the wound immediately — Incision and drainage is reserved for established abscesses. Fresh bite wounds should be irrigated and cleaned, not incised, as this can introduce further contamination.
C. Encourage vigorous exercise of the affected area — Vigorous exercise of a bite wound site would increase blood flow and inflammation, potentially spreading infection and delaying healing. Rest and wound care are recommended instead.
6. A client is postoperative day 1 following a total thyroidectomy. The nurse notes that the client has mild hoarseness, tingling around the mouth, and muscle twitching. Which medication should the nurse anticipate administering to manage this complication?
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Propylthiouracil (PTU) PO
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Potassium chloride IV
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Levothyroxine IV
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Calcium gluconate IV
Explanation
Explanation:
Correct Answer: (D) Calcium gluconate IV
The combination of tingling around the mouth (circumoral paresthesia), muscle twitching, and hoarseness following total thyroidectomy are classic signs of hypocalcemia caused by inadvertent damage or removal of the parathyroid glands during surgery. The parathyroid glands regulate calcium levels, and their disruption leads to a rapid drop in serum calcium. Calcium gluconate IV is the immediate treatment to restore calcium levels and prevent progression to tetany, laryngospasm, or seizures.
Why Other Options are Incorrect:
A. Propylthiouracil (PTU) PO — PTU is an antithyroid medication used to treat hyperthyroidism. It has no role in managing postoperative hypocalcemia following thyroidectomy.
B. Potassium chloride IV — Potassium replacement is used for hypokalemia. The symptoms described are specific to hypocalcemia, not hypokalemia, and potassium administration would not address this complication.
C. Levothyroxine IV — Levothyroxine is thyroid hormone replacement, which will be needed long-term after total thyroidectomy. However, it does not address the acute complication of hypocalcemia presenting in the immediate postoperative period.
Correct Answer: (D) Calcium gluconate IV
The combination of tingling around the mouth (circumoral paresthesia), muscle twitching, and hoarseness following total thyroidectomy are classic signs of hypocalcemia caused by inadvertent damage or removal of the parathyroid glands during surgery. The parathyroid glands regulate calcium levels, and their disruption leads to a rapid drop in serum calcium. Calcium gluconate IV is the immediate treatment to restore calcium levels and prevent progression to tetany, laryngospasm, or seizures.
Why Other Options are Incorrect:
A. Propylthiouracil (PTU) PO — PTU is an antithyroid medication used to treat hyperthyroidism. It has no role in managing postoperative hypocalcemia following thyroidectomy.
B. Potassium chloride IV — Potassium replacement is used for hypokalemia. The symptoms described are specific to hypocalcemia, not hypokalemia, and potassium administration would not address this complication.
C. Levothyroxine IV — Levothyroxine is thyroid hormone replacement, which will be needed long-term after total thyroidectomy. However, it does not address the acute complication of hypocalcemia presenting in the immediate postoperative period.
7. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who presents with dyspnea and fatigue. The provider suspects the client is developing acute respiratory failure (ARF). Which finding is most consistent with this diagnosis?
Laboratory Reference Ranges: pH: 7.35–7.45 PaCO2: 35–45 mmHg PaO2: 80–95 mmHg
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PaO2 of 55 mmHg on 4 liters of oxygen via nasal cannula
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SpO2 of 91% on room air and scattered expiratory wheezes
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Use of accessory muscles with a respiratory rate of 24 breaths/minute
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PaCO2 of 48 mmHg and pH of 7.38
Explanation
Explanation:
Correct Answer: (A) PaO2 of 55 mmHg on 4 liters of oxygen via nasal cannula
Acute respiratory failure is defined by a PaO2 below 60 mmHg despite supplemental oxygen therapy, indicating that the lungs are failing to adequately oxygenate the blood even with intervention. A PaO2 of 55 mmHg while already receiving 4 liters of oxygen via nasal cannula confirms that the client's respiratory system can no longer maintain adequate gas exchange, meeting the diagnostic threshold for acute hypoxemic respiratory failure. This is the most definitive and critical finding among the options presented.
Why Other Options are Incorrect:
B. SpO2 of 91% on room air and scattered expiratory wheezes — An SpO2 of 91% on room air is below normal and concerning in a COPD exacerbation, but it does not definitively confirm acute respiratory failure. Scattered wheezes are an expected finding in COPD and do not alone indicate ARF.
C. Use of accessory muscles with a respiratory rate of 24 breaths/minute — These are signs of increased work of breathing and respiratory distress, which are warning signs of impending respiratory failure. However, they are clinical indicators of effort rather than a definitive laboratory confirmation of ARF.
D. PaCO2 of 48 mmHg and pH of 7.38 — A mildly elevated PaCO2 with a near-normal pH suggests mild respiratory acidosis, which can be seen in chronic CO2 retention in COPD patients. This is not as definitive an indicator of acute respiratory failure as the critically low PaO2 seen in option A.
Correct Answer: (A) PaO2 of 55 mmHg on 4 liters of oxygen via nasal cannula
Acute respiratory failure is defined by a PaO2 below 60 mmHg despite supplemental oxygen therapy, indicating that the lungs are failing to adequately oxygenate the blood even with intervention. A PaO2 of 55 mmHg while already receiving 4 liters of oxygen via nasal cannula confirms that the client's respiratory system can no longer maintain adequate gas exchange, meeting the diagnostic threshold for acute hypoxemic respiratory failure. This is the most definitive and critical finding among the options presented.
Why Other Options are Incorrect:
B. SpO2 of 91% on room air and scattered expiratory wheezes — An SpO2 of 91% on room air is below normal and concerning in a COPD exacerbation, but it does not definitively confirm acute respiratory failure. Scattered wheezes are an expected finding in COPD and do not alone indicate ARF.
C. Use of accessory muscles with a respiratory rate of 24 breaths/minute — These are signs of increased work of breathing and respiratory distress, which are warning signs of impending respiratory failure. However, they are clinical indicators of effort rather than a definitive laboratory confirmation of ARF.
D. PaCO2 of 48 mmHg and pH of 7.38 — A mildly elevated PaCO2 with a near-normal pH suggests mild respiratory acidosis, which can be seen in chronic CO2 retention in COPD patients. This is not as definitive an indicator of acute respiratory failure as the critically low PaO2 seen in option A.
8. The nurse is assessing a client who has advanced bone cancer. Which client assessment finding(s) causes the nurse to suspect spinal cord compression? (Select all that apply.)
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Tingling in the right lower extremity
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Unsteady gait when ambulating to the bathroom
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Reports of difficulty sleeping
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Worsening mid-thoracic back pain
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Last bowel movement 6 days ago
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Decreased breath sounds in the left lung
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Reports of a headache for the past 7 hours
Explanation
Explanation
Correct Answers: (A) Tingling in the right lower extremity, (B) Unsteady gait when ambulating to the bathroom, (D) Worsening mid-thoracic back pain, and (E) Last bowel movement 6 days ago
Spinal cord compression is a serious oncologic emergency in patients with advanced bone cancer, particularly when metastases involve the vertebrae. Tingling or numbness in the extremities indicates sensory nerve compromise from cord compression. Unsteady gait reflects motor dysfunction due to impaired nerve conduction below the level of compression. Worsening mid-thoracic back pain is the most common early symptom of spinal cord compression, often preceding neurological deficits. Bowel dysfunction, including constipation and retention, results from compression of the autonomic nerve pathways controlling bowel function.
Why Other Options are Incorrect:
C. Reports of difficulty sleeping — Difficulty sleeping is a nonspecific complaint that may be related to pain, anxiety, or medication effects. It is not a clinical indicator of spinal cord compression.
F. Decreased breath sounds in the left lung — This finding suggests a pulmonary issue such as pleural effusion or pneumonia and is not associated with spinal cord compression.
G. Reports of a headache for the past 7 hours — Headache is not a manifestation of spinal cord compression. It may suggest increased intracranial pressure or other neurological conditions but is not specific to cord compression.
Correct Answers: (A) Tingling in the right lower extremity, (B) Unsteady gait when ambulating to the bathroom, (D) Worsening mid-thoracic back pain, and (E) Last bowel movement 6 days ago
Spinal cord compression is a serious oncologic emergency in patients with advanced bone cancer, particularly when metastases involve the vertebrae. Tingling or numbness in the extremities indicates sensory nerve compromise from cord compression. Unsteady gait reflects motor dysfunction due to impaired nerve conduction below the level of compression. Worsening mid-thoracic back pain is the most common early symptom of spinal cord compression, often preceding neurological deficits. Bowel dysfunction, including constipation and retention, results from compression of the autonomic nerve pathways controlling bowel function.
Why Other Options are Incorrect:
C. Reports of difficulty sleeping — Difficulty sleeping is a nonspecific complaint that may be related to pain, anxiety, or medication effects. It is not a clinical indicator of spinal cord compression.
F. Decreased breath sounds in the left lung — This finding suggests a pulmonary issue such as pleural effusion or pneumonia and is not associated with spinal cord compression.
G. Reports of a headache for the past 7 hours — Headache is not a manifestation of spinal cord compression. It may suggest increased intracranial pressure or other neurological conditions but is not specific to cord compression.
9. The nurse is caring for a client in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock?
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Decreased red blood cell production and fluid loss
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White blood cells are released to fight invading bacteria
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Bacterial toxins lead to vasodilation
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Microorganisms invade organs such as the kidneys and heart
Explanation
Explanation
Correct Answer: (C) Bacterial toxins lead to vasodilation
Septic shock develops when bacterial toxins, particularly lipopolysaccharides from gram-negative bacteria, trigger a massive systemic inflammatory response. This cascade causes widespread vasodilation and increased capillary permeability, leading to a dramatic drop in systemic vascular resistance. The result is distributive shock, where blood pools in the periphery and vital organs receive inadequate perfusion despite normal or increased cardiac output. This vasodilation is the defining pathophysiologic mechanism of septic shock.
Why Other Options are Incorrect:
A. Decreased red blood cell production and fluid loss — This describes anemia or hypovolemic shock, not septic shock. Septic shock is a distributive form of shock driven by vasodilation, not blood or fluid loss.
B. White blood cells are released to fight invading bacteria — While WBC release is part of the normal immune response to infection, it describes a physiological defense mechanism rather than the pathophysiologic cause of septic shock itself.
D. Microorganisms invade organs such as the kidneys and heart — Direct organ invasion by microorganisms describes septicemia or bacteremia. While organ dysfunction occurs in septic shock as a consequence, the primary mechanism that causes the shock state is the inflammatory response leading to vasodilation, not direct microbial invasion.
Correct Answer: (C) Bacterial toxins lead to vasodilation
Septic shock develops when bacterial toxins, particularly lipopolysaccharides from gram-negative bacteria, trigger a massive systemic inflammatory response. This cascade causes widespread vasodilation and increased capillary permeability, leading to a dramatic drop in systemic vascular resistance. The result is distributive shock, where blood pools in the periphery and vital organs receive inadequate perfusion despite normal or increased cardiac output. This vasodilation is the defining pathophysiologic mechanism of septic shock.
Why Other Options are Incorrect:
A. Decreased red blood cell production and fluid loss — This describes anemia or hypovolemic shock, not septic shock. Septic shock is a distributive form of shock driven by vasodilation, not blood or fluid loss.
B. White blood cells are released to fight invading bacteria — While WBC release is part of the normal immune response to infection, it describes a physiological defense mechanism rather than the pathophysiologic cause of septic shock itself.
D. Microorganisms invade organs such as the kidneys and heart — Direct organ invasion by microorganisms describes septicemia or bacteremia. While organ dysfunction occurs in septic shock as a consequence, the primary mechanism that causes the shock state is the inflammatory response leading to vasodilation, not direct microbial invasion.
10. The nurse is caring for a client in the emergency department who reports being hit in the head while playing football two days ago without wearing protective padding. The client states they do not remember the incident and now have a severe headache, clear nasal drainage, and bruising behind the ears. The nurse recognizes that these findings are consistent with which condition?
-
Increased intracranial pressure
-
Basilar skull fracture
-
Subdural hematoma
-
Cerebral contusion
Explanation
Explanation
Correct Answer: (B) Basilar skull fracture
The classic triad of clear nasal drainage (cerebrospinal fluid rhinorrhea), bruising behind the ears (Battle's sign), and amnesia following head trauma are hallmark indicators of a basilar skull fracture. Battle's sign results from blood tracking into the mastoid region, and CSF leakage through the nose occurs when the fracture disrupts the dura mater at the base of the skull.
Why Other Options are Incorrect:
A. Increased intracranial pressure — While ICP can cause headache, the specific combination of Battle's sign and CSF rhinorrhea points directly to a basilar skull fracture rather than general ICP elevation.
C. Subdural hematoma — A subdural hematoma results from venous bleeding between the dura and arachnoid layers and typically presents with gradual onset of confusion, headache, and neurological deficits. It does not produce Battle's sign or CSF nasal drainage.
D. Cerebral contusion — A cerebral contusion is bruising of brain tissue and may cause headache and amnesia, but it does not account for the specific physical signs of Battle's sign or cerebrospinal fluid rhinorrhea described here.
Correct Answer: (B) Basilar skull fracture
The classic triad of clear nasal drainage (cerebrospinal fluid rhinorrhea), bruising behind the ears (Battle's sign), and amnesia following head trauma are hallmark indicators of a basilar skull fracture. Battle's sign results from blood tracking into the mastoid region, and CSF leakage through the nose occurs when the fracture disrupts the dura mater at the base of the skull.
Why Other Options are Incorrect:
A. Increased intracranial pressure — While ICP can cause headache, the specific combination of Battle's sign and CSF rhinorrhea points directly to a basilar skull fracture rather than general ICP elevation.
C. Subdural hematoma — A subdural hematoma results from venous bleeding between the dura and arachnoid layers and typically presents with gradual onset of confusion, headache, and neurological deficits. It does not produce Battle's sign or CSF nasal drainage.
D. Cerebral contusion — A cerebral contusion is bruising of brain tissue and may cause headache and amnesia, but it does not account for the specific physical signs of Battle's sign or cerebrospinal fluid rhinorrhea described here.
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