RN VATIAdult Medical Surgical Assessment.
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A nurse is caring for a client who has atopic dermatitis and a prescription for
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triamcinolone ointment. The nurse should assess the client to monitor for which ofthe
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following adverse effects?
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(ANS-
Thinning of the skin. i i i
Only apply the ointment to dry patches of the skin to avoid atrophy.
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Topical Glucocorticoids Side
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effects(ANS-
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Tiamcinolone
- Hypopigmentation
- Excessive hair growth (hypertrichosis) i i i
- Thinning of the skin i i i
A nurse is assessing a client who has left-sided heart failure. Which of the following
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findings should the nurse identify as a manifestation of left-sided heartfailure?
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(ANS- Frothy sputum
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,Pink-tinged frothy sputum can be an early indication of pulmonary edema and canbe
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life-threatening. Therefore, the nurse should notify the provider immediately.
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Left Sided Heart
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Failure(ANS-
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- Frothy sputum i
- Dyspnea
- Wheezing
Treatment:
Fluid restriction & diuretics to decrease preload & pulmonary congestion
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Right heart sided i i
failure(ANS-
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- Dependent edma i
- Jugular distention i
- Weight gain i
A nurse is caring for a client who is experiencing anxiety as well as numbness and
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tingling of the lips and fingers.
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,The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2
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85 mm Hg. Which of the following acid-base imbalances should the nurse
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identifythat the client is experiencing?
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(ANS- Respiratory alkalosis
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- The pH is alkaline (increased)
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- PCO2 is decreased representing alveolar hyperventilation & resultant respiratory
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alkalosis
A nurse is assessing a client who has Cushing's syndrome. Which of the
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followingfindings should the nurse expect?
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(ANS- Osteoporosis i
Bone become thinner as a result of mineral loss & nitrogen depletion.
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A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurseshould
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identify which of the following lesion characteristics on the client's skin?
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(ANS- A pearly, waxy nodule.
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, - Basal cell carcinoma has a nodular lesion with well defined borders & pearly or
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waxy appearance resulting from overexposure to the sun. especially on the face,
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head, and neck.
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-A client who has melanoma has a lesion with irregular borders and variegated
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colors of red, white, and blue, most often on the upper back or lower legs.
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-A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion
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with a ulcerated center, resulting from sun exposure, chronic irritation, burns, or
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irradiation to the skin. i i i
Melanoma i
(ANS-
Irregular border and varigated colored lesions of red, white, blue.
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- Most often on the upper back or lower legs
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Squamous cell carcinoma i i
(ANS- Firm, nodular, and crusty lesion with an ulcerated center from sun
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exposure, chronic irritation, burns, or irradiation to the skin.
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weeping vescile i
(ANS- Herpes Zoster i i
