Nurs 172 Exam 4 Questions And Answers +
Rationales With Complete Solutions
A 19-yr-old patient is brought to the emergency department
(ED) with multiple lacerations and tissue avulsion of the left
hand. When asked about tetanus immunization, the patient
denies having any previous vaccinations. What should the nurse
anticipate giving?
A. Tetanus immunoglobulin (TIG) only
B. TIG and tetanus-diphtheria toxoid (Td)
C. Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only
D. TIG and tetanus-diphtheria toxoid and pertussis vaccine
(Tdap) Correct Answers D. TIG and tetanus-diphtheria toxoid
and pertussis vaccine (Tdap)
Rationale: For an adult with no previous tetanus immunizations,
TIG and Tdap are recommended. The other immunizations are
not sufficient for this patient.
A 25-yr-old female patient with systemic lupus erythematosus
(SLE) has a facial rash and alopecia. She tells the nurse, "I never
leave my house because I hate the way I look." Which patient
problem should the nurse plan to address?
A. activity intolerance r/t fatigue and inactivity
B. impaired social isolation r/t lack of social skills
C. impaired skin integrity r/t itching and skin sloughing
,D. social isolation r/t embarrassment about the effects of SLE
Correct Answers D. social isolation r/t embarrassment about the
effects of SLE
A 29-yr-old woman is taking methotrexate to treat rheumatoid
arthritis. Considering this treatment, which information should
the nurse report to the health care provider?
a. The patient had a history of infectious mononucleosis as a
teenager.
b. The patient is trying to get pregnant before her disease
becomes more severe.
c. The patient has a family history of age-related macular
degeneration of the retina.
d. The patient has been using large doses of vitamins and health
foods to treat the RA Correct Answers b. The patient is trying
to get pregnant before her disease becomes more severe.
A mother and her children have been diagnosed with pediculosis
corporis at a health care clinic. An appropriate treatment is:
A. Topical application of griseofulvin
B. Moist compresses applied frequently
C/ Apply pyrethrins to the body
D. Administration of systemic antibiotics Correct Answers C.
Apply pyrethrins to the body
Rationale: Lewis textbook- Chapter 25, page 481- table 25.7
A patient informed of a positive rapid screening test result for
human immunodeficiency virus (HIV) is anxious and does not
, appear to hear what the nurse is saying. What action by the
nurse is most important at this time?
A. Teach the patient how to reduce risky behaviors
B. Inform the patient about available treatments
C. Remind the patient about the need to return for testing to
verify results
D. Ask the patient to identify individuals who have had intimate
contact with the patient. Correct Answers C. Remind the
patient about the need to return for testing to verify results
Rationale: After an initial positive antibody test result, the next
step is retesting to confirm the results. A patient who is anxious
is not likely to be able to take in new information or be willing
to disclose information about the HIV status of other
individuals.
A patient is taking methotrexate to treat rheumatoid arthritis
(RA). Which laboratory result is important for the nurse to
communicate to the health care provider?
a. Rheumatoid factor is positive.
b. Fasting blood glucose is 90 mg/dL.
c. The white blood cell count is 1500/μL.
d. The erythrocyte sedimentation rate is increased. Correct
Answers C. The white blood cell count is 1500/μL.
Bone marrow suppression is a possible side effect of
methotrexate, and the patient's low WBC count places the
patient at high risk for infection. The elevated erythrocyte
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