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Table of Contents
#art ) Test N(rsing #ractice I N(rsing #ractice II "oc! *oard E+amination Scope,Co-erage 3oundation of Nursing, Nursing 0esearch, 4rofessional Ad1ustment, 7eadership and 8anagement 8aternal and Child 9ealth, Community 9ealth Nursing, Communicable :iseases, 'ntegrated 8anagement of Childhood 'llness 8edical and ;urgical Nursing 8edical and ;urgical Nursing 4sychiatric Nursing
N(rsing #ractice III N(rsing #ractice I. N(rsing #ractice . #art / N(rsing #ractice I0. #art 2 #ractice Test ) Answers and Rationale #ractice Test / Answers and Rationale #ractice Test 2 Answers and Rationale #ractice Test 4 Answers and Rationale
Ans1ers and $ationale

Selected #ractice Test from N(rsing Crib3s 1ebsite
3oundation of Nursing 8aternal and Child 9ealth 8edical ;urgical Nursing 4sychiatric Nursing
#A$T I
N)0;'N< 40AC#'C. '
3oundation of 4rofessional Nursing 4ractice
TEST I 0 %o(ndation of #rofessional N(rsing #ractice 1. #he nurse 'n-charge in labor and delivery unit administered a dose of terbutaline to a client !ithout chec$ing the client5s pulse. #he standard that !ould be used to determine if the nurse !as negligent is* a. #he physician5s orders. b. #he action of a clinical nurse specialist !ho is recogni(ed e/pert in the field. c. #he statement in the drug literature about administration of terbutaline. d. #he actions of a reasonably prudent nurse !ith similar education and e/perience. 2. Nurse #rish is caring for a female client !ith a history of <' bleeding, sic$le cell disease, and a platelet count of 22,0006=l. #he female client is dehydrated and receiving de/trose >? in half-normal saline solution at 1>0 ml6hr. #he client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. 'n administering the medication, Nurse #rish should avoid !hich route@ a. b. c. d. '.A '.8 Bral ;.C
3. :r. <arcia !rites the follo!ing order for the client !ho has been recently admitted C:igo/in .12> mg 4.B. once daily.D #o prevent a dosage error, ho! should the nurse document this order onto the medication administration record@ a. b. c. d. C:igo/in .12>0 mg 4.B. once dailyD C:igo/in 0.12>0 mg 4.B. once dailyD C:igo/in 0.12> mg 4.B. once dailyD C:igo/in .12> mg 4.B. once dailyD
E. A ne!ly admitted female client !as diagnosed !ith deep vein thrombosis. 2hich nursing diagnosis should receive the highest priority@ a. b. c. d. 'neffective peripheral tissue perfusion related to venous congestion. 0is$ for in1ury related to edema. ./cess fluid volume related to peripheral vascular disease. 'mpaired gas e/change related to increased blood flo!.
>. Nurse -etty is assigned to the follo!ing clients. #he client that the nurse !ould see first after endorsement@ a. A FE year-old post operative appendectomy client of five hours !ho is complaining of pain. b. A EE year-old myocardial infarction 8'" client !ho is complaining of nausea. c. A 2G year-old client admitted for dehydration !hose intravenous 'A" has infiltrated. d. A GF year-old post operative5s abdominal hysterectomy client of three days !hose incisional dressing is saturated !ith serosanguinous fluid. G. Nurse <ail places a client in a four-point restraint follo!ing orders from the physician. #he client care plan should include* a. b. c. d. Assess temperature fre&uently. 4rovide diversional activities. Chec$ circulation every 1>-F0 minutes. ;ociali(e !ith other patients once a shift.
7. A male client !ho has severe burns is receiving 92 receptor antagonist therapy. #he nurse 'n-charge $no!s the purpose of this therapy is to* a. b. c. d. 4revent stress ulcer -loc$ prostaglandin synthesis 3acilitate protein synthesis. .nhance gas e/change
H. #he doctor orders hourly urine output measurement for a postoperative male client. #he nurse #rish records the follo!ing amounts of output for 2 consecutive hours* H a.m.* >0 mlI 9 a.m.* G0 ml. -ased on these amounts, !hich action should the nurse ta$e@ a. b. c. d. 'ncrease the '.A. fluid infusion rate 'rrigate the ind!elling urinary catheter Notify the physician Continue to monitor and record hourly urine output
9. #ony, a bas$etball player t!ist his right an$le !hile playing on the court and see$s care for an$le pain and s!elling. After the nurse applies ice to the an$le for F0 minutes, !hich statement by #ony suggests that ice application has been effective@ a. C8y an$le loo$s less s!ollen no!D. b. C8y an$le feels !armD.
c. C8y an$le appears redder no!D. d. C' need something stronger for pain reliefD 10. #he physician prescribes a loop diuretic for a client. 2hen administering this drug, the nurse anticipates that the client may develop !hich electrolyte imbalance@ a. b. c. d. 9ypernatremia 9yper$alemia 9ypo$alemia 9ypervolemia
11. ;he finds out that some managers have benevolent-authoritative style of management. 2hich of the follo!ing behaviors !ill she e/hibit most li$ely@ a. b. c. d. 9ave condescending trust and confidence in their subordinates. <ives economic and ego a!ards. Communicates do!n!ard to staffs. Allo!s decision ma$ing among subordinates.
12. Nurse Amy is a!are that the follo!ing is true about functional nursing a. 4rovides continuous, coordinated and comprehensive nursing services. b. Bne-to-one nurse patient ratio. c. .mphasi(e the use of group collaboration. d. Concentrates on tas$s and activities. 1F. 2hich type of medication order might read %Aitamin J 10 mg '.8. daily K F days@% a. b. c. d. ;ingle order ;tandard !ritten order ;tanding order ;tat order
1E. A female client !ith a fecal impaction fre&uently e/hibits !hich clinical manifestation@ a. b. c. d. 'ncreased appetite 7oss of urge to defecate 9ard, bro!n, formed stools 7i&uid or semi-li&uid stools
1>. Nurse 7inda prepares to perform an otoscopic e/amination on a female client. 3or proper visuali(ation, the nurse should position the client+s ear by* a. b. c. d. 4ulling the lobule do!n and bac$ 4ulling the heli/ up and for!ard 4ulling the heli/ up and bac$ 4ulling the lobule do!n and for!ard
16. 2hich instruction should nurse #om give to a male client !ho is having e/ternal radiation therapy* a. b. c. d. 4rotect the irritated s$in from sunlight. .at F to E hours before treatment. 2ash the s$in over regularly. Apply lotion or oil to the radiated area !hen it is red or sore.
1L. 'n assisting a female client for immediate surgery, the nurse 'n-charge is a!are that she should* a. b. c. d. .ncourage the client to void follo!ing preoperative medication. ./plore the client5s fears and an/ieties about the surgery. Assist the client in removing dentures and nail polish. .ncourage the client to drin$ !ater prior to surgery.
1H. A male client is admitted and diagnosed !ith acute pancreatitis after a holiday celebration of e/cessive food and alcohol. 2hich assessment finding reflects this diagnosis@ a. b. c. d. -lood pressure above normal range. 4resence of crac$les in both lung fields. 9yperactive bo!el sounds ;udden onset of continuous epigastric and bac$ pain.
19. 2hich dietary guidelines are important for nurse Bliver to implement in caring for the client !ith burns@ a. b. c. d. 4rovide high-fiber, high-fat diet 4rovide high-protein, high-carbohydrate diet. 8onitor inta$e to prevent !eight gain. 4rovide ice chips or !ater inta$e.
20. Nurse 9a(el !ill administer a unit of !hole blood, !hich priority information should the nurse have about the client@ a. -lood pressure and pulse rate.
b. 9eight and !eight. c. Calcium and potassium levels d. 9gb and 9ct levels. 21. Nurse 8ichelle !itnesses a female client sustain a fall and suspects that the leg may be bro$en. #he nurse ta$es !hich priority action@ a. b. c. d. #a$es a set of vital signs. Call the radiology department for M-ray. 0eassure the client that everything !ill be alright. 'mmobili(e the leg before moving the client.
22. A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. #he nurse in-charge !ould ta$e !hich priority action in the care of this client@ a. b. c. d. 4lace client on reverse isolation. Admit the client into a private room. .ncourage the client to ta$e fre&uent rest periods. .ncourage family and friends to visit.
2F. A ne!ly admitted female client !as diagnosed !ith agranulocytosis. #he nurse formulates !hich priority nursing diagnosis@ a. b. c. d. Constipation :iarrhea 0is$ for infection :eficient $no!ledge
2E. A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. 2hat is the priority action by the nurse@ a. b. c. d. Notify the physician. 4lace the client on the left side in the #rendelenburg position. 4lace the client in high-3o!lers position. ;top the total parenteral nutrition.
2>. Nurse 8ay attends an educational conference on leadership styles. #he nurse is sitting !ith a nurse employed at a large trauma center !ho states that the leadership style at the trauma center is tas$-oriented and directive. #he nurse determines that the leadership style used at the trauma center is* a. Autocratic. b. 7aisse(-faire.
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c. :emocratic. d. ;ituational 2G. #he physician orders :; >00 cc !ith JCl 10 m.&6liter at F0 cc6hr. #he nurse in-charge is going to hang a >00 cc bag. JCl is supplied 20 m.&610 cc. 9o! many cc5s of JCl !ill be added to the 'A solution@ a. b. c. d. .> cc > cc 1.> cc 2.> cc
2L. A child of 10 years old is to receive E00 cc of 'A fluid in an H hour shift. #he 'A drip factor is G0. #he 'A rate that !ill deliver this amount is* a. b. c. d. >0 cc6 hour >> cc6 hour 2E cc6 hour GG cc6 hour
2H. #he nurse is a!are that the most important nursing action !hen a client returns from surgery is* a. b. c. d. Assess the 'A for type of fluid and rate of flo!. Assess the client for presence of pain. Assess the 3oley catheter for patency and urine output Assess the dressing for drainage.
29. 2hich of the follo!ing vital sign assessments that may indicate cardiogenic shoc$ after myocardial infarction@ a. b. c. d. -4 N H06G0, 4ulse N 110 irregular -4 N 906>0, 4ulse N >0 regular -4 N 1F06H0, 4ulse N 100 regular -4 N 1H06100, 4ulse N 90 irregular
F0. 2hich is the most appropriate nursing action in obtaining a blood pressure measurement@ a. #a$e the proper e&uipment, place the client in a comfortable position, and record the appropriate information in the client5s chart. b. 8easure the client5s arm, if you are not sure of the si(e of cuff to use. c. 9ave the client recline or sit comfortably in a chair !ith the forearm at the level of the heart.
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d. :ocument the measurement, !hich e/tremity !as used, and the position that the client !as in during the measurement. F1. As$ing the &uestions to determine if the person understands the health teaching provided by the nurse !ould be included during !hich step of the nursing process@ a. b. . d. Assessment .valuation 'mplementation 4lanning and goals
F2. 2hich of the follo!ing item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person5s needs@ a. b. c. d. :iagnostic test results -iographical date 9istory of present illness 4hysical e/amination
FF. 'n preventing the development of an e/ternal rotation deformity of the hip in a client !ho must remain in bed for any period of time, the most appropriate nursing action !ould be to use* a. #rochanter roll e/tending from the crest of the ileum to the midthigh. b. 4illo!s under the lo!er legs. c. 3ootboard d. 9ip-abductor pillo! FE. 2hich stage of pressure ulcer development does the ulcer e/tend into the subcutaneous tissue@ a. b. c. d. ;tage ' ;tage '' ;tage ''' ;tage 'A
F>. 2hen the method of !ound healing is one in !hich !ound edges are not surgically appro/imated and integumentary continuity is restored by granulations, the !ound healing is termed a. ;econd intention healing b. 4rimary intention healing c. #hird intention healing
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d. 3irst intention healing FG. An H0-year-old male client is admitted to the hospital !ith a diagnosis of pneumonia. Nurse Bliver learns that the client lives alone and hasn5t been eating or drin$ing. 2hen assessing him for dehydration, nurse Bliver !ould e/pect to find* a. b. c. d. 9ypothermia 9ypertension :istended nec$ veins #achycardia
FL. #he physician prescribes meperidine :emerol", L> mg '.8. every E hours as needed, to control a client5s postoperative pain. #he pac$age insert is C8eperidine, 100 mg6ml.D 9o! many milliliters of meperidine should the client receive@ a. b. c. d. 0.L> 0.G 0.> 0.2>
38. A male client !ith diabetes mellitus is receiving insulin. 2hich statement correctly describes an insulin unit@ a. b. c. d. 't5s a common measurement in the metric system. 't5s the basis for solids in the avoirdupois system. 't5s the smallest measurement in the apothecary system. 't5s a measure of effect, not a standard measure of !eight or &uantity.
F9. Nurse Bliver measures a client5s temperature at 102O 3. 2hat is the e&uivalent Centigrade temperature@ a. b. c. d. E0.1 OC FH.9 OC EH OC FH OC
E0. #he nurse is assessing a EH-year-old client !ho has come to the physician5s office for his annual physical e/am. Bne of the first physical signs of aging is* a. Accepting limitations !hile developing assets. b. 'ncreasing loss of muscle tone. c. 3ailing eyesight, especially close vision.
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d. 9aving more fre&uent aches and pains. E1. #he physician inserts a chest tube into a female client to treat a pneumothora/. #he tube is connected to !ater-seal drainage. #he nurse in-charge can prevent chest tube air lea$s by* a. b. c. d. Chec$ing and taping all connections. Chec$ing patency of the chest tube. Jeeping the head of the bed slightly elevated. Jeeping the chest drainage system belo! the level of the chest.
E2. Nurse #rish must verify the client5s identity before administering medication. ;he is a!are that the safest !ay to verify identity is to* a. Chec$ the client5s identification band. b. As$ the client to state his name. c. ;tate the client5s name out loud and !ait a client to repeat it. d. Chec$ the room number and the client5s name on the bed. EF. #he physician orders de/trose > ? in !ater, 1,000 ml to be infused over H hours. #he '.A. tubing delivers 1> drops6ml. Nurse Pohn should run the '.A. infusion at a rate of* a. b. c. d. F0 drops6minute F2 drops6minute 20 drops6minute 1H drops6minute
EE. 'f a central venous catheter becomes disconnected accidentally, !hat should the nurse in-charge do immediately@ a. b. c. d. Clamp the catheter Call another nurse Call the physician Apply a dry sterile dressing to the site.
E>. A female client !as recently admitted. ;he has fever, !eight loss, and !atery diarrhea is being admitted to the facility. 2hile assessing the client, Nurse 9a(el inspects the client5s abdomen and notice that it is slightly concave. Additional assessment should proceed in !hich order* a. b. c. d. 4alpation, auscultation, and percussion. 4ercussion, palpation, and auscultation. 4alpation, percussion, and auscultation. Auscultation, percussion, and palpation.
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EG. Nurse -etty is assessing tactile fremitus in a client !ith pneumonia. 3or this e/amination, nurse -etty should use the* a. b. c. d. 3ingertips 3inger pads :orsal surface of the hand )lnar surface of the hand
EL. 2hich type of evaluation occurs continuously throughout the teaching and learning process@ a. b. c. d. ;ummative 'nformative 3ormative 0etrospective
EH. A E> year old client, has no family history of breast cancer or other ris$ factors for this disease. Nurse Pohn should instruct her to have mammogram ho! often@ a. b. c. d. #!ice per year Bnce per year .very 2 years Bnce, to establish baseline
E9. A male client has the follo!ing arterial blood gas values* p9 L.F0I 4ao2 H9 mm9gI 4aco2 >0 mm9gI and 9CBF 2Gm.&67. -ased on these values, Nurse 4atricia should e/pect !hich condition@ a. b. c. d. 0espiratory acidosis 0espiratory al$alosis 8etabolic acidosis 8etabolic al$alosis
>0. Nurse 7en refers a female client !ith terminal cancer to a local hospice. 2hat is the goal of this referral@ a. #o help the client find appropriate treatment options. b. #o provide support for the client and family in coping !ith terminal illness. c. #o ensure that the client gets counseling regarding health care costs. d. #o teach the client and family about cancer and its treatment.
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>1. 2hen caring for a male client !ith a F-cm stage ' pressure ulcer on the coccy/, !hich of the follo!ing actions can the nurse institute independently@ a. 8assaging the area !ith an astringent every 2 hours. b. Applying an antibiotic cream to the area three times per day. c. )sing normal saline solution to clean the ulcer and applying a protective dressing as necessary. d. )sing a povidone-iodine !ash on the ulceration three times per day. >2. Nurse Bliver must apply an elastic bandage to a client5s an$le and calf. 9e should apply the bandage beginning at the client5s* a. b. c. d. Jnee An$le 7o!er thigh 3oot
>F. A 10 year old child !ith type 1 diabetes develops diabetic $etoacidosis and receives a continuous insulin infusion. 2hich condition represents the greatest ris$ to this child@ a. b. c. d. 9ypernatremia 9ypo$alemia 9yperphosphatemia 9ypercalcemia
>E. Nurse 7en is administering sublingual nitrglycerin Nitrostat" to the ne!ly admitted client. 'mmediately after!ard, the client may e/perience* a. b. c. d. #hrobbing headache or di((iness Nervousness or paresthesia. :ro!siness or blurred vision. #innitus or diplopia.
>>. Nurse 8ichelle hears the alarm sound on the telemetry monitor. #he nurse &uic$ly loo$s at the monitor and notes that a client is in a ventricular tachycardia. #he nurse rushes to the client5s room. )pon reaching the client5s bedside, the nurse !ould ta$e !hich action first@ a. b. c. d. 4repare for cardioversion 4repare to defibrillate the client Call a code Chec$ the client5s level of consciousness
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>G. Nurse 9a(el is preparing to ambulate a female client. #he best and the safest position for the nurse in assisting the client is to stand* a. b. c. d. Bn the unaffected side of the client. Bn the affected side of the client. 'n front of the client. -ehind the client.
>L. Nurse Panah is monitoring the ongoing care given to the potential organ donor !ho has been diagnosed !ith brain death. #he nurse determines that the standard of care had been maintained if !hich of the follo!ing data is observed@ a. b. c. d. )rine output* E> ml6hr Capillary refill* > seconds ;erum p9* L.F2 -lood pressure* 906EH mm9g
58. Nurse Amy has an order to obtain a urinalysis from a male client !ith an ind!elling urinary catheter. #he nurse avoids !hich of the follo!ing, !hich contaminate the specimen@ a. b. c. d. 2iping the port !ith an alcohol s!ab before inserting the syringe. Aspirating a sample from the port on the drainage bag. Clamping the tubing of the drainage bag. Bbtaining the specimen from the urinary drainage bag.
>9. Nurse 8eredith is in the process of giving a client a bed bath. 'n the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. #he appropriate nursing action is to* a. 'mmediately !al$ out of the client5s room and ans!er the phone call. b. Cover the client, place the call light !ithin reach, and ans!er the phone call. c. 3inish the bed bath before ans!ering the phone call. d. 7eave the client5s door open so the client can be monitored and the nurse can ans!er the phone call. G0. Nurse Panah is collecting a sputum specimen for culture and sensitivity testing from a client !ho has a productive cough. Nurse Panah plans to implement !hich intervention to obtain the specimen@ a. As$ the client to e/pectorate a small amount of sputum into the emesis basin.
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b. As$ the client to obtain the specimen after brea$fast. c. )se a sterile plastic container for obtaining the specimen. d. 4rovide tissues for e/pectoration and obtaining the specimen. G1. Nurse 0on is observing a male client using a !al$er. #he nurse determines that the client is using the !al$er correctly if the client* a. 4uts all the four points of the !al$er flat on the floor, puts !eight on the hand pieces, and then !al$s into it. b. 4uts !eight on the hand pieces, moves the !al$er for!ard, and then !al$s into it. c. 4uts !eight on the hand pieces, slides the !al$er for!ard, and then !al$s into it. d. 2al$s into the !al$er, puts !eight on the hand pieces, and then puts all four points of the !al$er flat on the floor. G2. Nurse Amy has documented an entry regarding client care in the client5s medical record. 2hen chec$ing the entry, the nurse reali(es that incorrect information !as documented. 9o! does the nurse correct this error@ a. .rases the error and !rites in the correct information. b. )ses correction fluid to cover up the incorrect information and !rites in the correct information. c. :ra!s one line to cross out the incorrect information and then initials the change. d. Covers up the incorrect information completely using a blac$ pen and !rites in the correct information GF. Nurse 0on is assisting !ith transferring a client from the operating room table to a stretcher. #o provide safety to the client, the nurse should* a. b. c. d. 8oves the client rapidly from the table to the stretcher. )ncovers the client completely before transferring to the stretcher. ;ecures the client safety belts after transferring to the stretcher. 'nstructs the client to move self from the table to the stretcher.
GE. Nurse 8yrna is providing instructions to a nursing assistant assigned to give a bed bath to a client !ho is on contact precautions. Nurse 8yrna instructs the nursing assistant to use !hich of the follo!ing protective items !hen giving bed bath@ a. b. c. d. <o!n and goggles <o!n and gloves <loves and shoe protectors <loves and goggles
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G>. Nurse Bliver is caring for a client !ith impaired mobility that occurred as a result of a stro$e. #he client has right sided arm and leg !ea$ness. #he nurse !ould suggest that the client use !hich of the follo!ing assistive devices that !ould provide the best stability for ambulating@ a. b. c. d. Crutches ;ingle straight-legged cane Quad cane 2al$er
GG. A male client !ith a right pleural effusion noted on a chest M-ray is being prepared for thoracentesis. #he client e/periences severe di((iness !hen sitting upright. #o provide a safe environment, the nurse assists the client to !hich position for the procedure@ a. b. c. d. 4rone !ith head turned to!ard the side supported by a pillo!. ;ims5 position !ith the head of the bed flat. 0ight side-lying !ith the head of the bed elevated E> degrees. 7eft side-lying !ith the head of the bed elevated E> degrees.
GL. Nurse Pohn develops methods for data gathering. 2hich of the follo!ing criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration@ a. b. c. d. Aalidity ;pecificity ;ensitivity 0eliability
GH. 9arry $no!s that he has to protect the rights of human research sub1ects. 2hich of the follo!ing actions of 9arry ensures anonymity@ a. b. c. d. Jeep the identities of the sub1ect secret Bbtain informed consent 4rovide e&ual treatment to all the sub1ects of the study. 0elease findings only to the participants of the study
G9. 4atient5s refusal to divulge information is a limitation because it is beyond the control of #ifannyD. 2hat type of research is appropriate for this study@ a. b. c. d. :escriptive- correlational ./periment Quasi-e/periment 9istorical
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L0. Nurse 0onald is a!are that the best tool for data gathering is@ a. b. c. d. 'ntervie! schedule Questionnaire )se of laboratory data Bbservation
L1. 8onica is a!are that there are times !hen only manipulation of study variables is possible and the elements of control or randomi(ation are not attendant. 2hich type of research is referred to this@ a. b. c. d. 3ield study Quasi-e/periment ;olomon-3our group design 4ost-test only design
L2. Cherry notes do!n ideas that !ere derived from the description of an investigation !ritten by the person !ho conducted it. 2hich type of reference source refers to this@ a. b. c. d. 3ootnote -ibliography 4rimary source .ndnotes
LF. 2hen Nurse #rish is providing care to his patient, she must remember that her duty is bound not to do doing any action that !ill cause the patient harm. #his is the meaning of the bioethical principle* a. b. c. d. Non-maleficence -eneficence Pustice ;olidarity
LE. 2hen a nurse in-charge causes an in1ury to a female patient and the in1ury caused becomes the proof of the negligent act, the presence of the in1ury is said to e/emplify the principle of* a. b. c. d. 3orce ma1eure 0espondeat superior 0es ipsa lo&uitor 9oldover doctrine
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L>. Nurse 8yrna is a!are that the -oard of Nursing has &uasi-1udicial po!er. An e/ample of this po!er is* a. #he -oard can issue rules and regulations that !ill govern the practice of nursing b. #he -oard can investigate violations of the nursing la! and code of ethics c. #he -oard can visit a school applying for a permit in collaboration !ith C9.: d. #he -oard prepares the board e/aminations 76. 2hen the license of nurse Jrina is revo$ed, it means that she* a. 's no longer allo!ed to practice the profession for the rest of her life b. 2ill never have her6his license re-issued since it has been revo$ed c. 8ay apply for re-issuance of his6her license based on certain conditions stipulated in 0A 91LF d. 2ill remain unable to practice professional nursing LL. 0onald plans to conduct a research on the use of a ne! method of pain assessment scale. 2hich of the follo!ing is the second step in the conceptuali(ing phase of the research process@ a. b. c. d. 3ormulating the research hypothesis 0evie! related literature 3ormulating and delimiting the research problem :esign the theoretical and conceptual frame!or$
78. #he leader of the study $no!s that certain patients !ho are in a speciali(ed research setting tend to respond psychologically to the conditions of the study. #his referred to as * a. b. c. d. Cause and effect 9a!thorne effect 9alo effect 9orns effect
L9. 8ary finally decides to use 1udgment sampling on her research. 2hich of the follo!ing actions of is correct@ a. 4lans to include !hoever is there during his study. b. :etermines the different nationality of patients fre&uently admitted and decides to get representations samples from each. c. Assigns numbers for each of the patients, place these in a fishbo!l and dra! 10 from it.
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d. :ecides to get 20 samples from the admitted patients 80. #he nursing theorist !ho developed transcultural nursing theory is* a. b. c. d. 3lorence Nightingale 8adeleine 7eininger Albert 8oore ;r. Callista 0oy
H1. 8arion is a!are that the sampling method that gives e&ual chance to all units in the population to get pic$ed is* a. b. c. d. 0andom Accidental Quota Pudgment
H2. Pohn plans to use a 7i$ert ;cale to his study to determine the* a. b. c. d. :egree of agreement and disagreement Compliance to e/pected standards 7evel of satisfaction :egree of acceptance
HF. 2hich of the follo!ing theory addresses the four modes of adaptation@ a. b. c. d. 8adeleine 7eininger ;r. Callista 0oy 3lorence Nightingale Pean 2atson
HE. 8s. <arcia is responsible to the number of personnel reporting to her. #his principle refers to* a. b. c. d. ;pan of control )nity of command :o!n!ard communication 7eader
H>. .nsuring that there is an informed consent on the part of the patient before a surgery is done, illustrates the bioethical principle of* a. b. c. d. -eneficence Autonomy Aeracity Non-maleficence
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HG. Nurse 0eese is teaching a female client !ith peripheral vascular disease about foot careI Nurse 0eese should include !hich instruction@ a. b. c. d. Avoid !earing cotton soc$s. Avoid using a nail clipper to cut toenails. Avoid !earing canvas shoes. Avoid using cornstarch on feet.
HL. A client is admitted !ith multiple pressure ulcers. 2hen developing the client+s diet plan, the nurse should include* a. b. c. d. 3resh orange slices ;teamed broccoli 'ce cream <round beef patties
HH. #he nurse prepares to administer a cleansing enema. 2hat is the most common client position used for this procedure@ a. b. c. d. 7ithotomy ;upine 4rone ;ims5 left lateral
H9. Nurse 8arian is preparing to administer a blood transfusion. 2hich action should the nurse ta$e first@ a. Arrange for typing and cross matching of the client5s blood. b. Compare the client5s identification !ristband !ith the tag on the unit of blood. c. ;tart an '.A. infusion of normal saline solution. d. 8easure the client5s vital signs. 90. A G> years old male client re&uests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. 2hich type of nursing intervention is re&uired@ a. b. c. d. 'ndependent :ependent 'nterdependent 'ntradependent
91. A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. #he Nurse -etty notes that the client+s leg is pain-free, !ithout redness or edema. #he nurse+s actions reflect !hich step of the nursing process@
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a. b. c. d.
Assessment :iagnosis 'mplementation .valuation
92. Nursing care for a female client includes removing elastic stoc$ings once per day. #he Nurse -etty is a!are that the rationale for this intervention@ a. b. c. d. #o increase blood flo! to the heart #o observe the lo!er e/tremities #o allo! the leg muscles to stretch and rela/ #o permit veins in the legs to fill !ith blood.
9F. 2hich nursing intervention ta$es highest priority !hen caring for a ne!ly admitted client !ho+s receiving a blood transfusion@ a. b. c. d. 'nstructing the client to report any itching, s!elling, or dyspnea. 'nforming the client that the transfusion usually ta$e 1 R to 2 hours. :ocumenting blood administration in the client care record. Assessing the client5s vital signs !hen the transfusion ends.
9E. A male client complains of abdominal discomfort and nausea !hile receiving tube feedings. 2hich intervention is most appropriate for this problem@ a. b. c. d. <ive the feedings at room temperature. :ecrease the rate of feedings and the concentration of the formula. 4lace the client in semi-3o!ler+s position !hile feeding. Change the feeding container every 12 hours.
9>. Nurse 4atricia is reconstituting a po!dered medication in a vial. After adding the solution to the po!der, she nurse should* a. b. c. d. :o nothing. 'nvert the vial and let it stand for F to > minutes. ;ha$e the vial vigorously. 0oll the vial gently bet!een the palms.
9G. 2hich intervention should the nurse #rish use !hen administering o/ygen by face mas$ to a female client@ a. ;ecure the elastic band tightly around the client+s head. b. Assist the client to the semi-3o!ler position if possible. c. Apply the face mas$ from the client+s chin up over the nose.
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d. 7oosen the connectors bet!een the o/ygen e&uipment and humidifier. 9L. #he ma/imum transfusion time for a unit of pac$ed red blood cells 0-Cs" is* a. b. c. d. G hours E hours F hours 2 hours
9H. Nurse 8oni&ue is monitoring the effectiveness of a client+s drug therapy. 2hen should the nurse 8oni&ue obtain a blood sample to measure the trough drug level@ a. b. c. d. 1 hour before administering the ne/t dose. 'mmediately before administering the ne/t dose. 'mmediately after administering the ne/t dose. F0 minutes after administering the ne/t dose.
99. Nurse 8ay is a!are that the main advantage of using a floor stoc$ system is* a. b. c. d. #he nurse can implement medication orders &uic$ly. #he nurse receives input from the pharmacist. #he system minimi(es transcription errors. #he system reinforces accurate calculations.
100. Nurse Bliver is assessing a client+s abdomen. 2hich finding should the nurse report as abnormal@ a. b. c. d. :ullness over the liver. -o!el sounds occurring every 10 seconds. ;hifting dullness over the abdomen. Aascular sounds heard over the renal arteries.
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N)0;'N< 40AC#'C. ''
Comm(nity &ealth N(rsing and Care of the "other and Child
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TEST II 0 Comm(nity &ealth N(rsing and Care of the "other and Child 1. 8ay arrives at the health care clinic and tells the nurse that her last menstrual period !as 9 !ee$s ago. ;he also tells the nurse that a home pregnancy test !as positive but she began to have mild cramps and is no! having moderate vaginal bleeding. :uring the physical e/amination of the client, the nurse notes that 8ay has a dilated cervi/. #he nurse determines that 8ay is e/periencing !hich type of abortion@ a. b. c. d. 'nevitable 'ncomplete #hreatened ;eptic
2. Nurse 0eese is revie!ing the record of a pregnant client for her first prenatal visit. 2hich of the follo!ing data, if noted on the client5s record, !ould alert the nurse that the client is at ris$ for a spontaneous abortion@ a. b. c. d. Age FG years 9istory of syphilis 9istory of genital herpes 9istory of diabetes mellitus
F. Nurse 9a(el is preparing to care for a client !ho is ne!ly admitted to the hospital !ith a possible diagnosis of ectopic pregnancy. Nurse 9a(el develops a plan of care for the client and determines that !hich of the follo!ing nursing actions is the priority@ a. b. c. d. 8onitoring !eight Assessing for edema 8onitoring apical pulse 8onitoring temperature
E. Nurse Bliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. #he nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy re&uire* a. b. c. d. :ecreased caloric inta$e 'ncreased caloric inta$e :ecreased 'nsulin 'ncrease 'nsulin
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>. Nurse 8ichelle is assessing a 2E year old client !ith a diagnosis of hydatidiform mole. ;he is a!are that one of the follo!ing is unassociated !ith this condition@ a. b. c. d. ./cessive fetal activity. 7arger than normal uterus for gestational age. Aaginal bleeding .levated levels of human chorionic gonadotropin.
G. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension 4'9". #he clinical findings that !ould !arrant use of the antidote , calcium gluconate is* a. b. c. d. )rinary output 90 cc in 2 hours. Absent patellar refle/es. 0apid respiratory rate above E06min. 0apid rise in blood pressure.
L. :uring vaginal e/amination of Panah !ho is in labor, the presenting part is at station plus t!o. Nurse, correctly interprets it as* a. b. c. d. 4resenting part is 2 cm above the plane of the ischial spines. -iparietal diameter is at the level of the ischial spines. 4resenting part in 2 cm belo! the plane of the ischial spines. -iparietal diameter is 2 cm above the ischial spines.
H. A pregnant client is receiving o/ytocin 4itocin" for induction of labor. A condition that !arrant the nurse in-charge to discontinue '.A. infusion of 4itocin is* a. b. c. d. Contractions every 1 R minutes lasting L0-H0 seconds. 8aternal temperature 101.2 .arly decelerations in the fetal heart rate. 3etal heart rate baseline 1E0-1G0 bpm.
9. Calcium gluconate is being administered to a client !ith pregnancy induced hypertension 4'9". A nursing action that must be initiated as the plan of care throughout in1ection of the drug is* a. b. c. d. Aentilator assistance CA4 readings .J< tracings Continuous C40
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10. A trial for vaginal delivery after an earlier caesareans, !ould li$ely to be given to a gravida, !ho had* a. 3irst lo! transverse cesarean !as for active herpes type 2 infectionsI vaginal culture at F9 !ee$s pregnancy !as positive. b. 3irst and second caesareans !ere for cephalopelvic disproportion. c. 3irst caesarean through a classic incision as a result of severe fetal distress. d. 3irst lo! transverse caesarean !as for breech position. 3etus in this pregnancy is in a verte/ presentation. 11. Nurse 0yan is a!are that the best initial approach !hen trying to ta$e a crying toddler5s temperature is* a. b. c. d. #al$ to the mother first and then to the toddler. -ring e/tra help so it can be done &uic$ly. .ncourage the mother to hold the child. 'gnore the crying and screaming.
12. -aby #ina a F month old infant 1ust had a cleft lip and palate repair. 2hat should the nurse do to prevent trauma to operative site@ a. b. c. d. Avoid touching the suture line, even !hen cleaning. 4lace the baby in prone position. <ive the baby a pacifier. 4lace the infant5s arms in soft elbo! restraints.
13. 2hich action should nurse 8arian include in the care plan for a 2 month old !ith heart failure@ a. b. c. d. 3eed the infant !hen he cries. Allo! the infant to rest before feeding. -athe the infant and administer medications before feeding. 2eigh and bathe the infant before feeding.
1E. Nurse 9a(el is teaching a mother !ho plans to discontinue breast feeding after > months. #he nurse should advise her to include !hich foods in her infant5s diet@ a. b. c. d. ;$im mil$ and baby food. 2hole mil$ and baby food. 'ron-rich formula only. 'ron-rich formula and baby food.
1>. 8ommy 7inda is playing !ith her infant, !ho is sitting securely alone on the floor of the clinic. #he mother hides a toy behind her bac$ and the
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infant loo$s for it. #he nurse is a!are that estimated age of the infant !ould be* a. b. c. d. G months E months H months 10 months
1G. 2hich of the follo!ing is the most prominent feature of public health nursing@ a. 't involves providing home care to sic$ people !ho are not confined in the hospital. b. ;ervices are provided free of charge to people !ithin the catchments area. c. #he public health nurse functions as part of a team providing a public health nursing services. d. 4ublic health nursing focuses on preventive, not curative, services. 1L. 2hen the nurse determines !hether resources !ere ma/imi(ed in implementing 7igtas #igdas, she is evaluating a. b. c. d. .ffectiveness .fficiency Ade&uacy Appropriateness
1H. Aangie is a ne! -.;.N. graduate. ;he !ants to become a 4ublic 9ealth Nurse. 2here should she apply@ a. b. c. d. :epartment of 9ealth 4rovincial 9ealth Bffice 0egional 9ealth Bffice 0ural 9ealth )nit
19. #ony is a!are the Chairman of the 8unicipal 9ealth -oard is* a. b. c. d. 8ayor 8unicipal 9ealth Bfficer 4ublic 9ealth Nurse Any &ualified physician
20. 8yra is the public health nurse in a municipality !ith a total population of about 20,000. #here are F rural health mid!ives among the 09) personnel. 9o! many more mid!ife items !ill the 09) need@
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a. b. c. d.
1 2 F #he 09) does not need any more mid!ife item.
21. According to 3reeman and 9einrich, community health nursing is a developmental service. 2hich of the follo!ing best illustrates this statement@ a. #he community health nurse continuously develops himself personally and professionally. b. 9ealth education and community organi(ing are necessary in providing community health services. c. Community health nursing is intended primarily for health promotion and prevention and treatment of disease. d. #he goal of community health nursing is to provide nursing services to people in their o!n places of residence. 22. Nurse #ina is a!are that the disease declared through 4residential 4roclamation No. E as a target for eradication in the 4hilippines is@ a. b. c. d. 4oliomyelitis 8easles 0abies Neonatal tetanus
2F. 8ay $no!s that the step in community organi(ing that involves training of potential leaders in the community is* a. b. c. d. 'ntegration Community organi(ation Community study Core group formation
2E. -eth a public health nurse ta$es an active role in community participation. 2hat is the primary goal of community organi(ing@ a. #o educate the people regarding community health problems b. #o mobili(e the people to resolve community health problems c. #o ma/imi(e the community5s resources in dealing !ith health problems. d. #o ma/imi(e the community5s resources in dealing !ith health problems.
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2>. #ertiary prevention is needed in !hich stage of the natural history of disease@ a. b. c. d. 4re-pathogenesis 4athogenesis 4rodromal #erminal
2G. #he nurse is caring for a primigravid client in the labor and delivery area. 2hich condition !ould place the client at ris$ for disseminated intravascular coagulation :'C"@ a. b. c. d. 'ntrauterine fetal death. 4lacenta accreta. :ysfunctional labor. 4remature rupture of the membranes.
2L. A fullterm client is in labor. Nurse -etty is a!are that the fetal heart rate !ould be* a. b. c. d. H0 to 100 beats6minute 100 to 120 beats6minute 120 to 1G0 beats6minute 1G0 to 1H0 beats6minute
2H. #he s$in in the diaper area of a L month old infant is e/coriated and red. Nurse 9a(el should instruct the mother to* a. b. c. d. Change the diaper more often. Apply talc po!der !ith diaper changes. 2ash the area vigorously !ith each diaper change. :ecrease the infant5s fluid inta$e to decrease saturating diapers.
29. Nurse Carla $no!s that the common cardiac anomalies in children !ith :o!n ;yndrome tri-somy 21" is* a. b. c. d. Atrial septal defect 4ulmonic stenosis Aentricular septal defect .ndocardial cushion defect
F0. 8alou !as diagnosed !ith severe preeclampsia is no! receiving '.A. magnesium sulfate. #he adverse effects associated !ith magnesium sulfate is* a. Anemia
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b. :ecreased urine output c. 9yperrefle/ia d. 'ncreased respiratory rate F1. A 2F year old client is having her menstrual period every 2 !ee$s that last for 1 !ee$. #his type of menstrual pattern is bets defined by* a. b. c. d. 8enorrhagia 8etrorrhagia :yspareunia Amenorrhea
F2. Pannah is admitted to the labor and delivery unit. #he critical laboratory result for this client !ould be* a. b. c. d. B/ygen saturation 'ron binding capacity -lood typing ;erum Calcium
FF. Nurse <ina is a!are that the most common condition found during the second-trimester of pregnancy is* a. b. c. d. 8etabolic al$alosis 0espiratory acidosis 8astitis 4hysiologic anemia
FE. Nurse 7ynette is !or$ing in the triage area of an emergency department. ;he sees that several pediatric clients arrive simultaneously. #he client !ho needs to be treated first is* a. A crying > year old child !ith a laceration on his scalp. b. A E year old child !ith a bar$ing coughs and flushed appearance. c. A F year old child !ith :o!n syndrome !ho is pale and asleep in his mother5s arms. d. A 2 year old infant !ith stridorous breath sounds, sitting up in his mother5s arms and drooling. F>. 8aureen in her third trimester arrives at the emergency room !ith painless vaginal bleeding. 2hich of the follo!ing conditions is suspected@ a. b. c. d. 4lacenta previa Abruptio placentae 4remature labor ;e/ually transmitted disease
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FG. A young child named 0ichard is suspected of having pin!orms. #he community nurse collects a stool specimen to confirm the diagnosis. #he nurse should schedule the collection of this specimen for* a. b. c. d. Pust before bedtime After the child has been bathe Any time during the day .arly in the morning
FL. 'n doing a child5s admission assessment, Nurse -etty should be alert to note !hich signs or symptoms of chronic lead poisoning@ a. b. c. d. 'rritability and sei(ures :ehydration and diarrhea -radycardia and hypotension 4etechiae and hematuria
FH. #o evaluate a !oman5s understanding about the use of diaphragm for family planning, Nurse #rish as$s her to e/plain ho! she !ill use the appliance. 2hich response indicates a need for further health teaching@ a. C' should chec$ the diaphragm carefully for holes every time ' use itD b. C' may need a different si(e of diaphragm if ' gain or lose !eight more than 20 poundsD c. C#he diaphragm must be left in place for atleast G hours after intercourseD d. C' really need to use the diaphragm and 1elly most during the middle of my menstrual cycleD. F9. 9ypo/ia is a common complication of laryngotracheobronchitis. Nurse Bliver should fre&uently assess a child !ith laryngotracheobronchitis for* a. b. c. d. :rooling 8uffled voice 0estlessness 7o!-grade fever
E0. 9o! should Nurse 8ichelle guide a child !ho is blind to !al$ to the playroom@ a. 2ithout touching the child, tal$ continuously as the child !al$s do!n the hall. b. 2al$ one step ahead, !ith the child5s hand on the nurse5s elbo!. c. 2al$ slightly behind, gently guiding the child for!ard. d. 2al$ ne/t to the child, holding the child5s hand.
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E1. 2hen assessing a ne!born diagnosed !ith ductus arteriosus, Nurse Blivia should e/pect that the child most li$ely !ould have an* a. b. c. d. 7oud, machinery-li$e murmur. -luish color to the lips. :ecreased -4 reading in the upper e/tremities 'ncreased -4 reading in the upper e/tremities.
E2. #he reason nurse 8ay $eeps the neonate in a neutral thermal environment is that !hen a ne!born becomes too cool, the neonate re&uires* a. b. c. d. 7ess o/ygen, and the ne!born5s metabolic rate increases. 8ore o/ygen, and the ne!born5s metabolic rate decreases. 8ore o/ygen, and the ne!born5s metabolic rate increases. 7ess o/ygen, and the ne!born5s metabolic rate decreases.
EF. -efore adding potassium to an infant5s '.A. line, Nurse 0on must be sure to assess !hether this infant has* a. b. c. d. ;table blood pressure 4atant fontanelles 8oro5s refle/ Aoided
EE. Nurse Carla should $no! that the most common causative factor of dermatitis in infants and younger children is* a. b. c. d. -aby oil -aby lotion 7aundry detergent 4o!der !ith cornstarch
E>. :uring tube feeding, ho! far above an infant5s stomach should the nurse hold the syringe !ith formula@ a. b. c. d. G inches 12 inches 1H inches 2E inches
46. 'n a mothers5 class, Nurse 7hynnete discussed childhood diseases such as chic$en po/. 2hich of the follo!ing statements about chic$en po/ is correct@
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a. #he older one gets, the more susceptible he becomes to the complications of chic$en po/. b. A single attac$ of chic$en po/ !ill prevent future episodes, including conditions such as shingles. c. #o prevent an outbrea$ in the community, &uarantine may be imposed by health authorities. d. Chic$en po/ vaccine is best given !hen there is an impending outbrea$ in the community. EL. -arangay 4inoy had an outbrea$ of <erman measles. #o prevent congenital rubella, !hat is the -.;# advice that you can give to !omen in the first trimester of pregnancy in the barangay 4inoy@ a. b. c. d. Advice them on the signs of <erman measles. Avoid cro!ded places, such as mar$ets and movie houses. Consult at the health center !here rubella vaccine may be given. Consult a physician !ho may give them rubella immunoglobulin.
EH. 8yrna a public health nurse $no!s that to determine possible sources of se/ually transmitted infections, the -.;# method that may be underta$en is* a. b. c. d. Contact tracing Community survey 8ass screening tests 'ntervie! of suspects
E9. A FF-year old female client came for consultation at the health center !ith the chief complaint of fever for a !ee$. Accompanying symptoms !ere muscle pains and body malaise. A !ee$ after the start of fever, the client noted yello!ish discoloration of his sclera. 9istory sho!ed that he !aded in flood !aters about 2 !ee$s before the onset of symptoms. -ased on her history, !hich disease condition !ill you suspect@ a. b. c. d. 9epatitis A 9epatitis #etanus 7eptospirosis
>0. 8ic$ey a F-year old client !as brought to the health center !ith the chief complaint of severe diarrhea and the passage of Crice !aterD stools. #he client is most probably suffering from !hich condition@ a. <iardiasis b. Cholera . Amebiasis
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d. :ysentery >1. #he most prevalent form of meningitis among children aged 2 months to F years is caused by !hich microorganism@ a. b. c. d. 9emophilus influen(ae 8orbillivirus ;teptococcus pneumoniae Neisseria meningitidis
>2. #he student nurse is a!are that the pathognomonic sign of measles is Jopli$5s spot and you may see Jopli$5s spot by inspecting the* a. b. c. d. Nasal mucosa -uccal mucosa ;$in on the abdomen ;$in on nec$
>F. Angel !as diagnosed as having :engue fever. ,ou !ill say that there is slo! capillary refill !hen the color of the nailbed that you pressed does not return !ithin ho! many seconds@ a. b. c. d. F seconds G seconds 9 seconds 10 seconds
>E. 'n 'ntegrated 8anagement of Childhood 'llness, the nurse is a!are that the severe conditions generally re&uire urgent referral to a hospital. 2hich of the follo!ing severe conditions :B.; NB# al!ays re&uire urgent referral to a hospital@ a. b. c. d. 8astoiditis ;evere dehydration ;evere pneumonia ;evere febrile disease
>>. 8yrna a public health nurse !ill conduct outreach immuni(ation in a barangay 8asay !ith a population of about 1>00. #he estimated number of infants in the barangay !ould be* a. b. c. d. E> infants >0 infants >> infants G> infants
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>G. #he community nurse is a!are that the biological used in ./panded 4rogram on 'mmuni(ation .4'" should NB# be stored in the free(er@ a. b. c. d. :4# Bral polio vaccine 8easles vaccine 880
>L. 't is the most effective !ay of controlling schistosomiasis in an endemic area@ a. b. c. d. )se of molluscicides -uilding of foot bridges 4roper use of sanitary toilets )se of protective foot!ear, such as rubber boots
>H. ;everal clients is ne!ly admitted and diagnosed !ith leprosy. 2hich of the follo!ing clients should be classified as a case of multibacillary leprosy@ a. b. c. d. F s$in lesions, negative slit s$in smear F s$in lesions, positive slit s$in smear > s$in lesions, negative slit s$in smear > s$in lesions, positive slit s$in smear
>9. Nurses are a!are that diagnosis of leprosy is highly dependent on recognition of symptoms. 2hich of the follo!ing is an early sign of leprosy@ a. b. c. d. 8acular lesions 'nability to close eyelids #hic$ened painful nerves ;in$ing of the nosebridge
G0. 8arie brought her 10 month old infant for consultation because of fever, started E days prior to consultation. 'n determining malaria ris$, !hat !ill you do@ a. b. c. d. 4erform a tourni&uet test. As$ !here the family resides. <et a specimen for blood smear. As$ if the fever is present everyday.
G1. ;usie brought her E years old daughter to the 09) because of cough and colds. 3ollo!ing the '8C' assessment guide, !hich of the follo!ing is a danger sign that indicates the need for urgent referral to a hospital@
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a. b. c. d.
'nability to drin$ 9igh grade fever ;igns of severe dehydration Cough for more than F0 days
G2. Pimmy a 2-year old child revealed Cbaggy pantsD. As a nurse, using the '8C' guidelines, ho! !ill you manage Pimmy@ a. 0efer the child urgently to a hospital for confinement. b. Coordinate !ith the social !or$er to enroll the child in a feeding program. c. 8a$e a teaching plan for the mother, focusing on menu planning for her child. d. Assess and treat the child for health problems li$e infections and intestinal parasitism. GF. <ina is using Bresol in the management of diarrhea of her F-year old child. ;he as$ed you !hat to do if her child vomits. As a nurse you !ill tell her to* a. b. c. d. -ring the child to the nearest hospital for further assessment. -ring the child to the health center for intravenous fluid therapy. -ring the child to the health center for assessment by the physician. 7et the child rest for 10 minutes then continue giving Bresol more slo!ly.
GE. Ni$$i a >-month old infant !as brought by his mother to the health center because of diarrhea for E to > times a day. 9er s$in goes bac$ slo!ly after a s$in pinch and her eyes are sun$en. )sing the '8C' guidelines, you !ill classify this infant in !hich category@ a. b. c. d. No signs of dehydration ;ome dehydration ;evere dehydration #he data is insufficient.
G>. Chris a E-month old infant !as brought by her mother to the health center because of cough. 9is respiratory rate is E26minute. )sing the 'ntegrated 8anagement of Child 'llness '8C'" guidelines of assessment, his breathing is considered as* a. b. c. d. 3ast ;lo! Normal 'nsignificant
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GG. 8aylene had 1ust received her Eth dose of tetanus to/oid. ;he is a!are that her baby !ill have protection against tetanus for a. b. c. d. 1 year F years > years 7ifetime
GL. Nurse 0on is a!are that unused -C< should be discarded after ho! many hours of reconstitution@ a. b. c. d. 2 hours E hours H hours At the end of the day
GH. #he nurse e/plains to a breastfeeding mother that breast mil$ is sufficient for all of the baby5s nutrient needs only up to* a. b. c. d. > months G months 1 year 2 years
G9. Nurse 0on is a!are that the gestational age of a conceptus that is considered viable able to live outside the !omb" is* a. b. . d. H !ee$s 12 !ee$s 2E !ee$s F2 !ee$s
L0. 2hen teaching parents of a neonate the proper position for the neonate5s sleep, the nurse 4atricia stresses the importance of placing the neonate on his bac$ to reduce the ris$ of !hich of the follo!ing@ a. b. . d. Aspiration ;udden infant death syndrome ;':;" ;uffocation <astroesophageal reflu/ <.0"
L1. 2hich finding might be seen in baby Pames a neonate suspected of having an infection@ a. 3lushed chee$s b. 'ncreased temperature
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. :ecreased temperature d. 'ncreased activity level L2. -aby Penny !ho is small-for-gestation is at increased ris$ during the transitional period for !hich complication@ a. b. . d. Anemia probably due to chronic fetal hyposia 9yperthermia due to decreased glycogen stores 9yperglycemia due to decreased glycogen stores 4olycythemia probably due to chronic fetal hypo/ia
LF. 8ar1orie has 1ust given birth at E2 !ee$s5 gestation. 2hen the nurse assessing the neonate, !hich physical finding is e/pected@ a. b. . d. A sleepy, lethargic baby 7anugo covering the body :es&uamation of the epidermis Aerni/ caseosa covering the body
LE. After revie!ing the 8yrna5s maternal history of magnesium sulfate during labor, !hich condition !ould nurse 0ichard anticipate as a potential problem in the neonate@ a. b. . d. 9ypoglycemia Pitteriness 0espiratory depression #achycardia
L>. 2hich symptom !ould indicate the -aby Ale/andra !as adapting appropriately to e/tra-uterine life !ithout difficulty@ a. b. . d. Nasal flaring 7ight audible grunting 0espiratory rate E0 to G0 breaths6minute 0espiratory rate G0 to H0 breaths6minute
LG. 2hen teaching umbilical cord care for Pennifer a ne! mother, the nurse Penny !ould include !hich information@ a. b. . d. Apply pero/ide to the cord !ith each diaper change Cover the cord !ith petroleum 1elly after bathing Jeep the cord dry and open to air 2ash the cord !ith soap and !ater each day during a tub bath.
LL. Nurse Pohn is performing an assessment on a neonate. 2hich of the follo!ing findings is considered common in the healthy neonate@
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a. b. . d.
;imian crease Con1unctival hemorrhage Cystic hygroma -ulging fontanelle
LH. :r. .steves decides to artificially rupture the membranes of a mother !ho is on labor. 3ollo!ing this procedure, the nurse 9a(el chec$s the fetal heart tones for !hich the follo!ing reasons@ a. b. c. d. #o determine fetal !ell-being. #o assess for prolapsed cord #o assess fetal position #o prepare for an imminent delivery.
L9. 2hich of the follo!ing !ould be least li$ely to indicate anticipated bonding behaviors by ne! parents@ a. b. c. d. #he parents5 !illingness to touch and hold the ne! born. #he parent5s e/pression of interest about the si(e of the ne! born. #he parents5 indication that they !ant to see the ne!born. #he parents5 interactions !ith each other.
H0. 3ollo!ing a precipitous delivery, e/amination of the client+s vagina reveals a fourth-degree laceration. 2hich of the follo!ing !ould be contraindicated !hen caring for this client@ a. Applying cold to limit edema during the first 12 to 2E hours. b. 'nstructing the client to use t!o or more peripads to cushion the area. c. 'nstructing the client on the use of sit( baths if ordered. d. 'nstructing the client about the importance of perineal $egel" e/ercises. H1. A pregnant !oman accompanied by her husband, see$s admission to the labor and delivery area. ;he states that she+s in labor and says she attended the facility clinic for prenatal care. 2hich &uestion should the nurse Bliver as$ her first@ a. b. c. d. C:o you have any chronic illnesses@D C:o you have any allergies@D C2hat is your e/pected due date@D C2ho !ill be !ith you during labor@D
H2. A neonate begins to gag and turns a dus$y color. 2hat should the nurse do first@
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a. b. c. d.
HF. 2hen
Calm the neonate. Notify the physician. 4rovide o/ygen via face mas$ as ordered Aspirate the neonate5s nose and mouth !ith a bulb syringe.
a client states that her %!ater bro$e,% !hich of the follo!ing actions !ould be inappropriate for the nurse to do@ a. b. c. d. Bbserving the pooling of stra!-colored fluid. Chec$ing vaginal discharge !ith nitra(ine paper. Conducting a bedside ultrasound for an amniotic fluid inde/. Bbserving for fla$es of verni/ in the vaginal discharge.
HE. A baby girl is born H !ee$s premature. At birth, she has no spontaneous respirations but is successfully resuscitated. 2ithin several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. ;he+s diagnosed !ith respiratory distress syndrome, intubated, and placed on a ventilator. 2hich nursing action should be included in the baby+s plan of care to prevent retinopathy of prematurity@ a. b. c. d. Cover his eyes !hile receiving o/ygen. Jeep her body temperature lo!. 8onitor partial pressure of o/ygen 4ao2" levels. 9umidify the o/ygen.
H>. 2hich of the follo!ing is normal ne!born calorie inta$e@ a. b. c. d. 110 to 1F0 calories per $g. F0 to E0 calories per lb of body !eight. At least 2 ml per feeding 90 to 100 calories per $g
HG. Nurse Pohn is $no!ledgeable that usually individual t!ins !ill gro! appropriately and at the same rate as singletons until ho! many !ee$s@ a. 1G to 1H !ee$s b. 1H to 22 !ee$s c. F0 to F2 !ee$s d. FH to E0 !ee$s HL. 2hich of the follo!ing classifications applies to mono(ygotic t!ins for !hom the cleavage of the fertili(ed ovum occurs more than 1F days after fertili(ation@ a. con1oined t!ins b. diamniotic dichorionic t!ins
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c. diamniotic monochorionic t!in d. monoamniotic monochorionic t!ins HH. #yra e/perienced painless vaginal bleeding has 1ust been diagnosed as having a placenta previa. 2hich of the follo!ing procedures is usually performed to diagnose placenta previa@ a. b. c. d. Amniocentesis :igital or speculum e/amination ./ternal fetal monitoring )ltrasound
H9. Nurse Arnold $no!s that the follo!ing changes in respiratory functioning during pregnancy is considered normal* a. b. c. d. 'ncreased tidal volume 'ncreased e/piratory volume :ecreased inspiratory capacity :ecreased o/ygen consumption
90. .mily has gestational diabetes and it is usually managed by !hich of the follo!ing therapy@ a. b. c. d. :iet 7ong-acting insulin Bral hypoglycemic Bral hypoglycemic drug and insulin
91. 8agnesium sulfate is given to Pemma !ith preeclampsia to prevent !hich of the follo!ing condition@ a. b. c. d. 9emorrhage 9ypertension 9ypomagnesemia ;ei(ure
92. Cammile !ith sic$le cell anemia has an increased ris$ for having a sic$le cell crisis during pregnancy. Aggressive management of a sic$le cell crisis includes !hich of the follo!ing measures@ a. b. c. d. Antihypertensive agents :iuretic agents '.A. fluids Acetaminophen #ylenol" for pain
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9F. 2hich of the follo!ing drugs is the antidote for magnesium to/icity@ a. b. c. d. Calcium gluconate Jalcinate" 9ydrala(ine Apresoline" Nalo/one Narcan" 0ho :" immune globulin 0ho<A8"
9E. 8arlyn is screened for tuberculosis during her first prenatal visit. An intradermal in1ection of purified protein derivative 44:" of the tuberculin bacilli is given. ;he is considered to have a positive test for !hich of the follo!ing results@ a. An indurated !heal under 10 mm in diameter appears in G to 12 hours. b. An indurated !heal over 10 mm in diameter appears in EH to L2 hours. c. A flat circumcised area under 10 mm in diameter appears in G to 12 hours. d. A flat circumcised area over 10 mm in diameter appears in EH to L2 hours. 9>. :ianne, 2E year-old is 2L !ee$s5 pregnant arrives at her physician5s office !ith complaints of fever, nausea, vomiting, malaise, unilateral flan$ pain, and costovertebral angle tenderness. 2hich of the follo!ing diagnoses is most li$ely@ a. b. c. d. Asymptomatic bacteriuria -acterial vaginosis 4yelonephritis )rinary tract infection )#'"
9G. 0h isoimmuni(ation in a pregnant client develops during !hich of the follo!ing conditions@ a. 0h-positive maternal blood crosses into fetal blood, stimulating fetal antibodies. b. 0h-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. c. 0h-negative fetal blood crosses into maternal blood, stimulating maternal antibodies. d. 0h-negative maternal blood crosses into fetal blood, stimulating fetal antibodies. 9L. #o promote comfort during labor, the nurse Pohn advises a client to assume certain positions and avoid others. 2hich position may cause maternal hypotension and fetal hypo/ia@ a. 7ateral position b. ;&uatting position c. ;upine position
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d. ;tanding position 9H. Celeste !ho used heroin during her pregnancy delivers a neonate. 2hen assessing the neonate, the nurse 7hynnette e/pects to find* a. b. c. d. 7ethargy 2 days after birth. 'rritability and poor suc$ing. A flattened nose, small eyes, and thin lips. Congenital defects such as limb anomalies.
99. #he uterus returns to the pelvic cavity in !hich of the follo!ing time frames@ a. b. . d. Lth to 9th day postpartum. 2 !ee$s postpartum. .nd of Gth !ee$ postpartum. 2hen the lochia changes to alba.
100. 8aureen, a primigravida client, age 20, has 1ust completed a difficult, forceps-assisted delivery of t!ins. 9er labor !as unusually long and re&uired o/ytocin 4itocin" augmentation. #he nurse !ho+s caring for her should stay alert for* a. b. c. d. )terine inversion )terine atony )terine involution )terine discomfort
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N)0;'N< 40AC#'C. '''
Care of Clients 1ith #hysiologic and #sychosocial Alterations
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TEST III 0 Care of Clients 1ith #hysiologic and #sychosocial Alterations 1. Nurse 8ichelle should $no! that the drainage is normal E days after a sigmoid colostomy !hen the stool is* a. b. c. d. <reen li&uid ;olid formed 7oose, bloody ;emiformed
2. 2here !ould nurse Jristine place the call light for a male client !ith a right-sided brain attac$ and left homonymous hemianopsia@ a. b. c. d. Bn the client5s right side Bn the client5s left side :irectly in front of the client 2here the client li$e
F. A male client is admitted to the emergency department follo!ing an accident. 2hat are the first nursing actions of the nurse@ a. b. c. d. Chec$ respiration, circulation, neurological response. Align the spine, chec$ pupils, and chec$ for hemorrhage. Chec$ respirations, stabili(e spine, and chec$ circulation. Assess level of consciousness and circulation.
E. 'n evaluating the effect of nitroglycerin, Nurse Arthur should $no! that it reduces preload and relieves angina by* a. b. c. d. 'ncreasing contractility and slo!ing heart rate. 'ncreasing AA conduction and heart rate. :ecreasing contractility and o/ygen consumption. :ecreasing venous return through vasodilation.
>. Nurse 4atricia finds a female client !ho is post-myocardial infarction 8'" slumped on the side rails of the bed and unresponsive to sha$ing or shouting. 2hich is the nurse ne/t action@ a. b. c. d. Call for help and note the time. Clear the air!ay <ive t!o sharp thumps to the precordium, and chec$ the pulse. Administer t!o &uic$ blo!s.
G. Nurse 8onett is caring for a client recovering from gastro-intestinal bleeding. #he nurse should*
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a. 4lan care so the client can receive H hours of uninterrupted sleep each night. b. 8onitor vital signs every 2 hours. c. 8a$e sure that the client ta$es food and medications at prescribed intervals. d. 4rovide mil$ every 2 to F hours. L. A male client !as on !arfarin Coumadin" before admission, and has been receiving heparin '.A. for 2 days. #he partial thromboplastin time 4##" is GH seconds. 2hat should Nurse Carla do@ a. b. c. d. ;top the '.A. infusion of heparin and notify the physician. Continue treatment as ordered. ./pect the !arfarin to increase the 4##. 'ncrease the dosage, because the level is lo!er than normal.
H. A client undergone ileostomy, !hen should the drainage appliance be applied to the stoma@ a. b. c. d. 2E hours later, !hen edema has subsided. 'n the operating room. After the ileostomy begin to function. 2hen the client is able to begin self-care procedures.
9. A client undergone spinal anesthetic, it !ill be important that the nurse immediately position the client in* a. b. c. d. Bn the side, to prevent obstruction of air!ay by tongue. 3lat on bac$. Bn the bac$, !ith $nees fle/ed 1> degrees. 3lat on the stomach, !ith the head turned to the side.
10. 2hile monitoring a male client several hours after a motor vehicle accident, !hich assessment data suggest increasing intracranial pressure@ a. -lood pressure is decreased from 1G0690 to 1106L0. b. 4ulse is increased from HL to 9>, !ith an occasional s$ipped beat. c. #he client is oriented !hen aroused from sleep, and goes bac$ to sleep immediately. d. #he client refuses dinner because of anore/ia. 11. 8rs. Cru(, H0 years old is diagnosed !ith pneumonia. 2hich of the follo!ing symptoms may appear first@ a. Altered mental status and dehydration
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b. 3ever and chills c. 9emoptysis and :yspnea d. 4leuritic chest pain and cough 12. A male client has active tuberculosis #-". 2hich of the follo!ing symptoms !ill be e/hibit@ a. b. c. d. Chest and lo!er bac$ pain Chills, fever, night s!eats, and hemoptysis 3ever of more than 10EO3 E0OC" and nausea 9eadache and photophobia
1F. 8ar$, a L-year-old client is brought to the emergency department. 9e5s tachypneic and afebrile and has a respiratory rate of FG breaths6minute and has a nonproductive cough. 9e recently had a cold. 3orm this historyI the client may have !hich of the follo!ing conditions@ a. b. c. d. Acute asthma -ronchial pneumonia Chronic obstructive pulmonary disease CB4:" .mphysema
1E. 8arichu !as given morphine sulfate for pain. ;he is sleeping and her respiratory rate is E breaths6minute. 'f action isn5t ta$en &uic$ly, she might have !hich of the follo!ing reactions@ a. b. c. d. Asthma attac$ 0espiratory arrest ;ei(ure 2a$e up on his o!n
1>. A LL-year-old male client is admitted for elective $nee surgery. 4hysical e/amination reveals shallo! respirations but no sign of respiratory distress. 2hich of the follo!ing is a normal physiologic change related to aging@ a. b. c. d. 'ncreased elastic recoil of the lungs 'ncreased number of functional capillaries in the alveoli :ecreased residual volume :ecreased vital capacity
1G. Nurse Pohn is caring for a male client receiving lidocaine '.A. 2hich factor is the most relevant to administration of this medication@ a. :ecrease in arterial o/ygen saturation ;aB2" !hen measured !ith a pulse o/imeter. b. 'ncrease in systemic blood pressure.
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c. 4resence of premature ventricular contractions 4ACs" on a cardiac monitor. d. 'ncrease in intracranial pressure 'C4". 1L. Nurse 0on is caring for a male client ta$ing an anticoagulant. #he nurse should teach the client to* a. b. c. d. 0eport incidents of diarrhea. Avoid foods high in vitamin J )se a straight ra(or !hen shaving. #a$e aspirin to pain relief.
1H. Nurse 7hynnette is preparing a site for the insertion of an '.A. catheter. #he nurse should treat e/cess hair at the site by* a. b. c. d. 7eaving the hair intact ;having the area Clipping the hair in the area 0emoving the hair !ith a depilatory.
19. Nurse 8ichelle is caring for an elderly female !ith osteoporosis. 2hen teaching the client, the nurse should include information about !hich ma1or complication* a. b. c. d. -one fracture 7oss of estrogen Negative calcium balance :o!ager5s hump
20. Nurse 7en is teaching a group of !omen to perform -;.. #he nurse should e/plain that the purpose of performing the e/amination is to discover* a. b. c. d. Cancerous lumps Areas of thic$ness or fullness Changes from previous e/aminations. 3ibrocystic masses
21. 2hen caring for a female client !ho is being treated for hyperthyroidism, it is important to* a. 4rovide e/tra blan$ets and clothing to $eep the client !arm. b. 8onitor the client for signs of restlessness, s!eating, and e/cessive !eight loss during thyroid replacement therapy. c. -alance the client5s periods of activity and rest. d. .ncourage the client to be active to prevent constipation.
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22. Nurse Jris is teaching a client !ith history of atherosclerosis. #o decrease the ris$ of atherosclerosis, the nurse should encourage the client to* a. b. c. d. Avoid focusing on his !eight. 'ncrease his activity level. 3ollo! a regular diet. Continue leading a high-stress lifestyle.
2F. Nurse <reta is !or$ing on a surgical floor. Nurse <reta must logroll a client follo!ing a* a. b. c. d. 7aminectomy #horacotomy 9emorrhoidectomy Cystectomy.
2E. A >>-year old client under!ent cataract removal !ith intraocular lens implant. Nurse Bliver is giving the client discharge instructions. #hese instructions should include !hich of the follo!ing@ a. b. c. d. Avoid lifting ob1ects !eighing more than > lb 2.2> $g". 7ie on your abdomen !hen in bed Jeep rooms brightly lit. Avoiding straining during bo!el movement or bending at the !aist.
2>. <eorge should be taught about testicular e/aminations during* a. b. c. d. !hen se/ual activity starts After age G9 After age E0 -efore age 20.
2G. A male client undergone a colon resection. 2hile turning him, !ound dehiscence !ith evisceration occurs. Nurse #rish first response is to* a. b. c. d. Call the physician 4lace a saline-soa$ed sterile dressing on the !ound. #a$e a blood pressure and pulse. 4ull the dehiscence closed.
2L. Nurse Audrey is caring for a client !ho has suffered a severe cerebrovascular accident. :uring routine assessment, the nurse notices Cheyne;tro$es respirations. Cheyne-stro$es respirations are* a. A progressively deeper breaths follo!ed by shallo!er breaths !ith apneic periods.
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b. 0apid, deep breathing !ith abrupt pauses bet!een each breath. c. 0apid, deep breathing and irregular breathing !ithout pauses. d. ;hallo! breathing !ith an increased respiratory rate. 2H. Nurse -ea is assessing a male client !ith heart failure. #he breath sounds commonly auscultated in clients !ith heart failure are* a. b. c. d. #racheal 3ine crac$les Coarse crac$les 3riction rubs
29. #he nurse is caring for Jenneth e/periencing an acute asthma attac$. #he client stops !hee(ing and breath sounds aren5t audible. #he reason for this change is that* a. b. c. d. #he attac$ is over. #he air!ays are so s!ollen that no air cannot get through. #he s!elling has decreased. Crac$les have replaced !hee(es.
F0. 8i$e !ith epilepsy is having a sei(ure. :uring the active sei(ure phase, the nurse should* a. 4lace the client on his bac$ remove dangerous ob1ects, and insert a bite bloc$. b. 4lace the client on his side, remove dangerous ob1ects, and insert a bite bloc$. c. 4lace the client o his bac$, remove dangerous ob1ects, and hold do!n his arms. d. 4lace the client on his side, remove dangerous ob1ects, and protect his head. F1. After insertion of a cheat tube for a pneumothora/, a client becomes hypotensive !ith nec$ vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothora/ has occurred. 2hat cause of tension pneumothora/ should the nurse chec$ for@ a. b. c. d. 'nfection of the lung. Jin$ed or obstructed chest tube ./cessive !ater in the !ater-seal chamber ./cessive chest tube drainage
F2. Nurse 8aureen is tal$ing to a male client, the client begins cho$ing on his lunch. 9e5s coughing forcefully. #he nurse should*
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a. ;tand him up and perform the abdominal thrust maneuver from behind. b. 7ay him do!n, straddle him, and perform the abdominal thrust maneuver. c. 7eave him to get assistance d. ;tay !ith him but not intervene at this time. FF. Nurse 0on is ta$ing a health history of an HE year old client. 2hich information !ill be most useful to the nurse for planning care@ a. b. c. d. <eneral health for the last 10 years. Current health promotion activities. 3amily history of diseases. 8arital status.
FE. 2hen performing oral care on a comatose client, Nurse Jrina should* a. Apply lemon glycerin to the client5s lips at least every 2 hours. b. -rush the teeth !ith client lying supine. c. 4lace the client in a side lying position, !ith the head of the bed lo!ered. d. Clean the client5s mouth !ith hydrogen pero/ide. F>. A LL-year-old male client is admitted !ith a diagnosis of dehydration and change in mental status. 9e5s being hydrated !ith 7.A. fluids. 2hen the nurse ta$es his vital signs, she notes he has a fever of 10FO3 F9.EOC" a cough producing yello! sputum and pleuritic chest pain. #he nurse suspects this client may have !hich of the follo!ing conditions@ a. b. c. d. Adult respiratory distress syndrome A0:;" 8yocardial infarction 8'" 4neumonia #uberculosis
FG. Nurse Bliver is !or$ing in a out patient clinic. 9e has been alerted that there is an outbrea$ of tuberculosis #-". 2hich of the follo!ing clients entering the clinic today most li$ely to have #-@ a. b. c. d. A 1G-year-old female high school student A FF-year-old day-care !or$er A EF-yesr-old homeless man !ith a history of alcoholism A >E-year-old businessman
FL. Airgie !ith a positive 8antou/ test result !ill be sent for a chest M-ray. #he nurse is a!are that !hich of the follo!ing reasons this is done@ a. #o confirm the diagnosis
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b. #o determine if a repeat s$in test is needed c. #o determine the e/tent of lesions d. #o determine if this is a primary or secondary infection FH. Jennedy !ith acute asthma sho!ing inspiratory and e/piratory !hee(es and a decreased forced e/piratory volume should be treated !ith !hich of the follo!ing classes of medication right a!ay@ a. b. c. d. -eta-adrenergic bloc$ers -ronchodilators 'nhaled steroids Bral steroids
F9. 8r. Aas&ue( >G-year-old client !ith a E0-year history of smo$ing one to t!o pac$s of cigarettes per day has a chronic cough producing thic$ sputum, peripheral edema and cyanotic nail beds. -ased on this information, he most li$ely has !hich of the follo!ing conditions@ a. b. c. d. Adult respiratory distress syndrome A0:;" Asthma Chronic obstructive bronchitis .mphysema
;ituation* 3rancis, age EG is admitted to the hospital !ith diagnosis of Chronic 7ymphocytic 7eu$emia. E0. #he treatment for patients !ith leu$emia is bone marro! transplantation. 2hich statement about bone marro! transplantation is not correct@ a. b. c. d. #he patient is under local anesthesia during the procedure #he aspirated bone marro! is mi/ed !ith heparin. #he aspiration site is the posterior or anterior iliac crest. #he recipient receives cyclophosphamide Cyto/an" for E consecutive days before the procedure.
E1. After several days of admission, 3rancis becomes disoriented and complains of fre&uent headaches. #he nurse in-charge first action !ould be* a. b. c. d. Call the physician :ocument the patient5s status in his charts. 4repare o/ygen treatment 0aise the side rails
E2. :uring routine care, 3rancis as$s the nurse, C9o! can ' be anemic if this disease causes increased my !hite blood cell production@D #he nurse in-charge best response !ould be that the increased number of !hite blood cells 2-C" is*
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a. b. c. d.
Cro!d red blood cells Are not responsible for the anemia. )ses nutrients from other cells 9ave an abnormally short life span of cells.
EF. :iagnostic assessment of 3rancis !ould probably not reveal* a. b. c. d. 4redominance of lymhoblasts 7eu$ocytosis Abnormal blast cells in the bone marro! .levated thrombocyte counts
EE. 0obert, a >L-year-old client !ith acute arterial occlusion of the left leg undergoes an emergency embolectomy. ;i/ hours later, the nurse isn5t able to obtain pulses in his left foot using :oppler ultrasound. #he nurse immediately notifies the physician, and as$s her to prepare the client for surgery. As the nurse enters the client5s room to prepare him, he states that he !on5t have any more surgery. 2hich of the follo!ing is the best initial response by the nurse@ a. b. c. d. ./plain the ris$s of not having the surgery Notifying the physician immediately Notifying the nursing supervisor 0ecording the client5s refusal in the nurses5 notes
E>. :uring the endorsement, !hich of the follo!ing clients should the on-duty nurse assess first@ a. #he >H-year-old client !ho !as admitted 2 days ago !ith heart failure, blood pressure of 12G6LG mm 9g, and a respiratory rate of 22 breaths6 minute. b. #he H9-year-old client !ith end-stage right-sided heart failure, blood pressure of LH6>0 mm 9g, and a Cdo not resuscitateD order c. #he G2-year-old client !ho !as admitted 1 day ago !ith thrombophlebitis and is receiving 7.A. heparin d. #he L>-year-old client !ho !as admitted 1 hour ago !ith ne!-onset atrial fibrillation and is receiving 7.A. dilitia(em Cardi(em" EG. 9oney, a 2F-year old client complains of substernal chest pain and states that her heart feels li$e Cit5s racing out of the chestD. ;he reports no history of cardiac disorders. #he nurse attaches her to a cardiac monitor and notes sinus tachycardia !ith a rate of 1FGbeats6minutes. -reath sounds are clear and the respiratory rate is 2G breaths6minutes. 2hich of the follo!ing drugs should the nurse &uestion the client about using@ a. -arbiturates
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b. Bpioids c. Cocaine d. -en(odia(epines EL. A >1-year-old female client tells the nurse in-charge that she has found a painless lump in her right breast during her monthly self-e/amination. 2hich assessment finding !ould strongly suggest that this client+s lump is cancerous@ a. b. c. d. .version of the right nipple and mobile mass Nonmobile mass !ith irregular edges 8obile mass that is soft and easily delineated Nonpalpable right a/illary lymph nodes
EH. A F>-year-old client !ith vaginal cancer as$s the nurse, %2hat is the usual treatment for this type of cancer@% 2hich treatment should the nurse name@ a. b. c. d. ;urgery Chemotherapy 0adiation 'mmunotherapy
E9. Cristina undergoes a biopsy of a suspicious lesion. #he biopsy report classifies the lesion according to the #N8 staging system as follo!s* #';, N0, 80. 2hat does this classification mean@ a. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis c. Can+t assess tumor or regional lymph nodes and no evidence of metastasis d. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis >0. 7ydia undergoes a laryngectomy to treat laryngeal cancer. 2hen teaching the client ho! to care for the nec$ stoma, the nurse should include !hich instruction@ a. %Jeep the stoma uncovered.% b. %Jeep the stoma dry.% c. %9ave a family member perform stoma care initially until you get used to the procedure.% d. %Jeep the stoma moist.%
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>1. A FL-year-old client !ith uterine cancer as$s the nurse, %2hich is the most common type of cancer in !omen@% #he nurse replies that it+s breast cancer. 2hich type of cancer causes the most deaths in !omen@ a. b. c. d. -reast cancer 7ung cancer -rain cancer Colon and rectal cancer
>2. Antonio !ith lung cancer develops 9orner+s syndrome !hen the tumor invades the ribs and affects the sympathetic nerve ganglia. 2hen assessing for signs and symptoms of this syndrome, the nurse should note* a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. b. chest pain, dyspnea, cough, !eight loss, and fever. c. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side. d. hoarseness and dysphagia. >F. Aic as$s the nurse !hat 4;A is. #he nurse should reply that it stands for* a. prostate-specific antigen, !hich is used to screen for prostate cancer. b. protein serum antigen, !hich is used to determine protein levels. c. pneumococcal strep antigen, !hich is a bacteria that causes pneumonia. d. 4apanicolaou-specific antigen, !hich is used to screen for cervical cancer. >E. 2hat is the most important postoperative instruction that nurse Jate must give a client !ho has 1ust returned from the operating room after receiving a subarachnoid bloc$@ a. b. c. d. %Avoid drin$ing li&uids until the gag refle/ returns.% %Avoid eating mil$ products for 2E hours.% %Notify a nurse if you e/perience blood in your urine.% %0emain supine for the time specified by the physician.%
>>. A male client suspected of having colorectal cancer !ill re&uire !hich diagnostic study to confirm the diagnosis@ a. b. c. d. ;tool 9ematest Carcinoembryonic antigen C.A" ;igmoidoscopy Abdominal computed tomography C#" scan
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>G. :uring a breast e/amination, !hich finding most strongly suggests that the 7u( has breast cancer@ a. ;light asymmetry of the breasts. b. A fi/ed nodular mass !ith dimpling of the overlying s$in c. -loody discharge from the nipple d. 8ultiple firm, round, freely movable masses that change !ith the menstrual cycle >L. A female client !ith cancer is being evaluated for possible metastasis. 2hich of the follo!ing is one of the most common metastasis sites for cancer cells@ a. b. c. d. 7iver Colon 0eproductive tract 2hite blood cells 2-Cs"
>H. Nurse 8andy is preparing a client for magnetic resonance imaging 80'" to confirm or rule out a spinal cord lesion. :uring the 80' scan, !hich of the follo!ing !ould pose a threat to the client@ a. b. c. d. #he client lies still. #he client as$s &uestions. #he client hears thumping sounds. #he client !ears a !atch and !edding band.
>9. Nurse Cecile is teaching a female client about preventing osteoporosis. 2hich of the follo!ing teaching points is correct@ a. Bbtaining an M-ray of the bones every F years is recommended to detect bone loss. b. #o avoid fractures, the client should avoid strenuous e/ercise. c. #he recommended daily allo!ance of calcium may be found in a !ide variety of foods. d. Bbtaining the recommended daily allo!ance of calcium re&uires ta$ing a calcium supplement. G0. -efore Pacob undergoes arthroscopy, the nurse revie!s the assessment findings for contraindications for this procedure. 2hich finding is a contraindication@ a. Point pain b. Point deformity c. Point fle/ion of less than >0? d. Point stiffness
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G1. 8r. 0odrigue( is admitted !ith severe pain in the $nees. 2hich form of arthritis is characteri(ed by urate deposits and 1oint pain, usually in the feet and legs, and occurs primarily in men over age F0@ a. b. c. d. ;eptic arthritis #raumatic arthritis 'ntermittent arthritis <outy arthritis
G2. A heparin infusion at 1,>00 unit6hour is ordered for a GE-year-old client !ith stro$e in evolution. #he infusion contains 2>,000 units of heparin in >00 ml of saline solution. 9o! many milliliters per hour should be given@ a. 1> ml6hour b. F0 ml6hour c. E> ml6hour d. >0 ml6hour GF. A LG-year-old male client had a thromboembolic right stro$eI his left arm is s!ollen. 2hich of the follo!ing conditions may cause s!elling after a stro$e@ a. b. c. d. .lbo! contracture secondary to spasticity 7oss of muscle contraction decreasing venous return :eep vein thrombosis :A#" due to immobility of the ipsilateral side 9ypoalbuminemia due to protein escaping from an inflamed glomerulus
GE. 9eberden5s nodes are a common sign of osteoarthritis. 2hich of the follo!ing statement is correct about this deformity@ a. b. c. d. 't appears only in men 't appears on the distal interphalangeal 1oint 't appears on the pro/imal interphalangeal 1oint 't appears on the dorsolateral aspect of the interphalangeal 1oint.
G>. 2hich of the follo!ing statements e/plains the main difference bet!een rheumatoid arthritis and osteoarthritis@ a. b. c. d. Bsteoarthritis is gender-specific, rheumatoid arthritis isn5t Bsteoarthritis is a locali(ed disease rheumatoid arthritis is systemic Bsteoarthritis is a systemic disease, rheumatoid arthritis is locali(ed Bsteoarthritis has dislocations and sublu/ations, rheumatoid arthritis doesn5t
GG. 8rs. Cru( uses a cane for assistance in !al$ing. 2hich of the follo!ing statements is true about a cane or other assistive devices@
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a. b. c. d.
A !al$er is a better choice than a cane. #he cane should be used on the affected side #he cane should be used on the unaffected side A client !ith osteoarthritis should be encouraged to ambulate !ithout the cane
GL. A male client !ith type 1 diabetes is scheduled to receive F0 ) of L06F0 insulin. #here is no L06F0 insulin available. As a substitution, the nurse may give the client* a. 9 ) regular insulin and 21 ) neutral protamine 9agedorn N49". b. 21 ) regular insulin and 9 ) N49. c. 10 ) regular insulin and 20 ) N49. d. 20 ) regular insulin and 10 ) N49. GH. Nurse 7en should e/pect to administer !hich medication to a client !ith gout@ a. b. c. d. aspirin furosemide 7asi/" colchicines calcium gluconate Jalcinate"
G9. 8r. :omingo !ith a history of hypertension is diagnosed !ith primary hyperaldosteronism. #his diagnosis indicates that the client+s hypertension is caused by e/cessive hormone secretion from !hich of the follo!ing glands@ a. b. c. d. Adrenal corte/ 4ancreas Adrenal medulla 4arathyroid
L0. 3or a diabetic male client !ith a foot ulcer, the doctor orders bed rest, a !etto-dry dressing change every shift, and blood glucose monitoring before meals and bedtime. 2hy are !et-to-dry dressings used for this client@ a. b. c. d. #hey contain e/udate and provide a moist !ound environment. #hey protect the !ound from mechanical trauma and promote healing. #hey debride the !ound and promote healing by secondary intention. #hey prevent the entrance of microorganisms and minimi(e !ound discomfort.
L1. Nurse Seny is caring for a client in acute addisonian crisis. 2hich laboratory data !ould the nurse e/pect to find@ a. 9yper$alemia
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b. 0educed blood urea nitrogen -)N" c. 9ypernatremia d. 9yperglycemia L2. A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone ;'A:9". 2hich nursing intervention is appropriate@ a. b. c. d. 'nfusing '.A. fluids rapidly as ordered .ncouraging increased oral inta$e 0estricting fluids Administering glucose-containing '.A. fluids as ordered
LF. A female client tells nurse Ni$$i that she has been !or$ing hard for the last F months to control her type 2 diabetes mellitus !ith diet and e/ercise. #o determine the effectiveness of the client+s efforts, the nurse should chec$* a. b. c. d. urine glucose level. fasting blood glucose level. serum fructosamine level. glycosylated hemoglobin level.
LE. Nurse #rinity administered neutral protamine 9agedorn N49" insulin to a diabetic client at L a.m. At !hat time !ould the nurse e/pect the client to be most at ris$ for a hypoglycemic reaction@ a. b. c. d. 10*00 am Noon E*00 pm 10*00 pm
L>. #he adrenal corte/ is responsible for producing !hich substances@ a. b. c. d. <lucocorticoids and androgens Catecholamines and epinephrine 8ineralocorticoids and catecholamines Norepinephrine and epinephrine
LG. Bn the third day after a partial thyroidectomy, 4roserfina e/hibits muscle t!itching and hyperirritability of the nervous system. 2hen &uestioned, the client reports numbness and tingling of the mouth and fingertips. ;uspecting a lifethreatening electrolyte disturbance, the nurse notifies the surgeon immediately. 2hich electrolyte disturbance most commonly follo!s thyroid surgery@ a. 9ypocalcemia b. 9yponatremia c. 9yper$alemia
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d. 9ypermagnesemia LL. 2hich laboratory test value is elevated in clients !ho smo$e and can+t be used as a general indicator of cancer@ a. b. c. d. Acid phosphatase level ;erum calcitonin level Al$aline phosphatase level Carcinoembryonic antigen level
LH. 3rancis !ith anemia has been admitted to the medical-surgical unit. 2hich assessment findings are characteristic of iron-deficiency anemia@ a. b. c. d. Nights s!eats, !eight loss, and diarrhea :yspnea, tachycardia, and pallor Nausea, vomiting, and anore/ia 'tching, rash, and 1aundice
L9. 'n teaching a female client !ho is 9'A-positive about pregnancy, the nurse !ould $no! more teaching is necessary !hen the client says* a. #he baby can get the virus from my placenta.% b. %'+m planning on starting on birth control pills.% c. %Not everyone !ho has the virus gives birth to a baby !ho has the virus.% d. %'+ll need to have a C-section if ' become pregnant and have a baby.% H0. 2hen preparing Pudy !ith ac&uired immunodeficiency syndrome A':;" for discharge to the home, the nurse should be sure to include !hich instruction@ a. b. c. d. %4ut on disposable gloves before bathing.% %;terili(e all plates and utensils in boiling !ater.% %Avoid sharing such articles as toothbrushes and ra(ors.% %Avoid eating foods from serving dishes shared by other family members.%
H1. Nurse 8arie is caring for a F2-year-old client admitted !ith pernicious anemia. 2hich set of findings should the nurse e/pect !hen assessing the client@ a. b. c. d. 4allor, bradycardia, and reduced pulse pressure 4allor, tachycardia, and a sore tongue ;ore tongue, dyspnea, and !eight gain Angina, double vision, and anore/ia
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H2. After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is e/periencing anaphylactic shoc$. 2hat should the nurse do first@ a. 4age an anesthesiologist immediately and prepare to intubate the client. b. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. c. Administer the antidote for penicillin, as prescribed, and continue to monitor the client+s vital signs. d. 'nsert an ind!elling urinary catheter and begin to infuse '.A. fluids as ordered. HF. 8r. 8ar&ue( !ith rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. 2hen teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. #hese include* a. b. c. d. !eight gain. fine motor tremors. respiratory acidosis. bilateral hearing loss.
HE. A 2F-year-old client is diagnosed !ith human immunodeficiency virus 9'A". After recovering from the initial shoc$ of the diagnosis, the client e/presses a desire to learn as much as possible about 9'A and ac&uired immunodeficiency syndrome A':;". 2hen teaching the client about the immune system, the nurse states that adaptive immunity is provided by !hich type of !hite blood cell@ a. b. c. d. Neutrophil -asophil 8onocyte 7ymphocyte
H>. 'n an individual !ith ;1Tgren+s syndrome, nursing care should focus on* a. b. c. d. moisture replacement. electrolyte balance. nutritional supplementation. arrhythmia management.
HG. :uring chemotherapy for lymphocytic leu$emia, 8athe! develops abdominal pain, fever, and %horse barn% smelling diarrhea. 't !ould be most important for the nurse to advise the physician to order* a. en(yme-lin$ed immunosuppressant assay .7';A" test. b. electrolyte panel and hemogram.
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. stool for Clostridium difficile test. d. flat plate M-ray of the abdomen. HL. A male client see$s medical evaluation for fatigue, night s!eats, and a 20-lb !eight loss in G !ee$s. #o confirm that the client has been infected !ith the human immunodeficiency virus 9'A", the nurse e/pects the physician to order* a. b. c. d. .-rosette immunofluorescence. &uantification of #-lymphocytes. en(yme-lin$ed immunosorbent assay .7';A". 2estern blot test !ith .7';A.
HH. A complete blood count is commonly performed before a Poe goes into surgery. 2hat does this test see$ to identify@ a. 4otential hepatic dysfunction indicated by decreased blood urea nitrogen -)N" and creatinine levels b. 7o! levels of urine constituents normally e/creted in the urine c. Abnormally lo! hematocrit 9C#" and hemoglobin 9b" levels d. .lectrolyte imbalance that could affect the blood+s ability to coagulate properly H9. 2hile monitoring a client for the development of disseminated intravascular coagulation :'C", the nurse should ta$e note of !hat assessment parameters@ a. b. c. d. 4latelet count, prothrombin time, and partial thromboplastin time 4latelet count, blood glucose levels, and !hite blood cell 2-C" count #hrombin time, calcium levels, and potassium levels 3ibrinogen level, 2-C, and platelet count
90. 2hen ta$ing a dietary history from a ne!ly admitted female client, Nurse 7en should remember that !hich of the follo!ing foods is a common allergen@ a. b. c. d. -read Carrots Brange ;tra!berries
91. Nurse Pohn is caring for clients in the outpatient clinic. 2hich of the follo!ing phone calls should the nurse return first@ a. A client !ith hepatitis A !ho states, C8y arms and legs are itching.D b. A client !ith cast on the right leg !ho states, C' have a funny feeling in my right leg.D c. A client !ith osteomyelitis of the spine !ho states, C' am so nauseous that ' can5t eat.D
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d. A client !ith rheumatoid arthritis !ho states, C' am having trouble sleeping.D 92. Nurse ;arah is caring for clients on the surgical floor and has 1ust received report from the previous shift. 2hich of the follo!ing clients should the nurse see first@ a. A F>-year-old admitted three hours ago !ith a gunshot !oundI 1.> cm area of dar$ drainage noted on the dressing. b. A EF-year-old !ho had a mastectomy t!o days agoI 2F ml of serosanguinous fluid noted in the Pac$son-4ratt drain. c. A >9-year-old !ith a collapsed lung due to an accidentI no drainage noted in the previous eight hours. d. A G2-year-old !ho had an abdominal-perineal resection three days agoI client complaints of chills. 9F. Nurse .ve is caring for a client !ho had a thyroidectomy 12 hours ago for treatment of <rave5s disease. #he nurse !ould be most concerned if !hich of the follo!ing !as observed@ a. -lood pressure 1FH6H2, respirations 1G, oral temperature 99 degrees 3ahrenheit. b. #he client supports his head and nec$ !hen turning his head to the right. c. #he client spontaneously fle/es his !rist !hen the blood pressure is obtained. d. #he client is dro!sy and complains of sore throat. 9E. Pulius is admitted !ith complaints of severe pain in the lo!er right &uadrant of the abdomen. #o assist !ith pain relief, the nurse should ta$e !hich of the follo!ing actions@ a. b. c. d. .ncourage the client to change positions fre&uently in bed. Administer :emerol >0 mg '8 & E hours and 40N. Apply !armth to the abdomen !ith a heating pad. )se comfort measures and pillo!s to position the client.
9>. Nurse #ina prepares a client for peritoneal dialysis. 2hich of the follo!ing actions should the nurse ta$e first@ a. b. c. d. Assess for a bruit and a thrill. 2arm the dialysate solution. 4osition the client on the left side. 'nsert a 3oley catheter
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9G. Nurse Pannah teaches an elderly client !ith right-sided !ea$ness ho! to use cane. 2hich of the follo!ing behaviors, if demonstrated by the client to the nurse, indicates that the teaching !as effective@ a. #he client holds the cane !ith his right hand, moves the can for!ard follo!ed by the right leg, and then moves the left leg. b. #he client holds the cane !ith his right hand, moves the cane for!ard follo!ed by his left leg, and then moves the right leg. c. #he client holds the cane !ith his left hand, moves the cane for!ard follo!ed by the right leg, and then moves the left leg. d. #he client holds the cane !ith his left hand, moves the cane for!ard follo!ed by his left leg, and then moves the right leg. 9L. An elderly client is admitted to the nursing home setting. #he client is occasionally confused and her gait is often unsteady. 2hich of the follo!ing actions, if ta$en by the nurse, is most appropriate@ a. As$ the !oman5s family to provide personal items such as photos or mementos. b. ;elect a room !ith a bed by the door so the !oman can loo$ do!n the hall. c. ;uggest the !oman eat her meals in the room !ith her roommate. d. .ncourage the !oman to ambulate in the halls t!ice a day. 9H. Nurse .vangeline teaches an elderly client ho! to use a standard aluminum !al$er. 2hich of the follo!ing behaviors, if demonstrated by the client, indicates that the nurse5s teaching !as effective@ a. #he client slo!ly pushes the !al$er for!ard 12 inches, then ta$es small steps for!ard !hile leaning on the !al$er. b. #he client lifts the !al$er, moves it for!ard 10 inches, and then ta$es several small steps for!ard. c. #he client supports his !eight on the !al$er !hile advancing it for!ard, then ta$es small steps !hile balancing on the !al$er. d. #he client slides the !al$er 1H inches for!ard, then ta$es small steps !hile holding onto the !al$er for balance. 99. Nurse :eric is supervising a group of elderly clients in a residential home setting. #he nurse $no!s that the elderly are at greater ris$ of developing sensory deprivation for !hat reason@ a. b. c. d. 'ncreased sensitivity to the side effects of medications. :ecreased visual, auditory, and gustatory abilities. 'solation from their families and familiar surroundings. :ecrease musculos$eletal function and mobility.
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100. A male client !ith emphysema becomes restless and confused. 2hat step should nurse Pasmine ta$e ne/t@ a. b. c. d. .ncourage the client to perform pursed lip breathing. Chec$ the client5s temperature. Assess the client5s potassium level. 'ncrease the client5s o/ygen flo! rate.
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N)0;'N< 40AC#'C. 'A
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TEST I. 0 Care of Clients 1ith #hysiologic and #sychosocial Alterations 1. 0andy has undergone $idney transplant, !hat assessment !ould prompt Nurse Jatrina to suspect organ re1ection@ a. b. . d. ;udden !eight loss 4olyuria 9ypertension ;hoc$
2. #he immediate ob1ective of nursing care for an over!eight, mildly hypertensive male client !ith ureteral colic and hematuria is to decrease* a. b. c. d. 4ain 2eight 9ematuria 9ypertension
F. 8atilda, !ith hyperthyroidism is to receive 7ugol5s iodine solution before a subtotal thyroidectomy is performed. #he nurse is a!are that this medication is given to* a. b. c. d. :ecrease the total basal metabolic rate. 8aintain the function of the parathyroid glands. -loc$ the formation of thyro/ine by the thyroid gland. :ecrease the si(e and vascularity of the thyroid gland.
E. 0icardo, !as diagnosed !ith type ' diabetes. #he nurse is a!are that acute hypoglycemia also can develop in the client !ho is diagnosed !ith* a. b. . d. 7iver disease 9ypertension #ype 2 diabetes 9yperthyroidism
>. #racy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse 0uby should monitor the client for the systemic side effect of* a. b. c. d. Ascites Nystagmus 7eu$openia 4olycythemia
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G. Norma, !ith recent colostomy e/presses concern about the inability to control the passage of gas. Nurse Bliver should suggest that the client plan to* a. b. c. d. .liminate foods high in cellulose. :ecrease fluid inta$e at meal times. Avoid foods that in the past caused flatus. Adhere to a bland diet prior to social events.
L. Nurse 0on begins to teach a male client ho! to perform colostomy irrigations. #he nurse !ould evaluate that the instructions !ere understood !hen the client states, C' should* a. 7ie on my left side !hile instilling the irrigating solution.D b. Jeep the irrigating container less than 1H inches above the stoma.D c. 'nstill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bo!el.D d. 'nsert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.D H. 4atric$ is in the oliguric phase of acute tubular necrosis and is e/periencing fluid and electrolyte imbalances. #he client is some!hat confused and complains of nausea and muscle !ea$ness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse !ould e/pect to* a. b. c. d. Administer Jaye/alate 0estrict foods high in protein 'ncrease oral inta$e of cheese and mil$. Administer large amounts of normal saline via '.A.
9. 8ario has burn in1ury. After 3ortyEH hours, the physician orders for 8ario 2 liters of 'A fluid to be administered &12 h. #he drop factor of the tubing is 10 gtt6ml. #he nurse should set the flo! to provide* a. 1H gtt6min b. 2H gtt6min c. F2 gtt6min d. FG gtt6min 10. #erence suffered form burn in1ury. )sing the rule of nines, !hich has the largest percent of burns@ a. 3ace and nec$ b. 0ight upper arm and penis
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c. 0ight thigh and penis d. )pper trun$ 11. 9erbert, a E> year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. 2hen assessing the client, the nurse !ould be most concerned if the assessment revealed* a. 0eactive pupils b. A depressed fontanel c. -leeding from ears d. An elevated temperature 12. Nurse ;herry is teaching male client regarding his permanent artificial pacema$er. 2hich information given by the nurse sho!s her $no!ledge deficit about the artificial cardiac pacema$er@ a. ta$e the pulse rate once a day, in the morning upon a!a$ening b. 8ay be allo!ed to use electrical appliances c. 9ave regular follo! up care d. 8ay engage in contact sports 1F. #he nurse is !are that the most relevant $no!ledge about o/ygen administration to a male client !ith CB4: is a. B/ygen at 1-276min is given to maintain the hypo/ic stimulus for breathing. b. 9ypo/ia stimulates the central chemoreceptors in the medulla that ma$es the client breath. c. B/ygen is administered best using a non-rebreathing mas$ d. -lood gases are monitored using a pulse o/imeter. 1E. #onny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle !ater-seal drainage is instituted in the operating room. 'n the postanesthesia care unit #onny is placed in 3o!ler+s position on either his right side or on his bac$. #he nurse is a!are that this position* a. b. c. d. 0educe incisional pain. 3acilitate ventilation of the left lung. .&uali(e pressure in the pleural space. 'ncrease venous return
1>. Jristine is scheduled for a bronchoscopy. 2hen teaching Jristine !hat to e/pect after!ard, the nurse+s highest priority of information !ould be*
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a. b. c. d.
3ood and fluids !ill be !ithheld for at least 2 hours. 2arm saline gargles !ill be done & 2h. Coughing and deep-breathing e/ercises !ill be done &2h. Bnly ice chips and cold li&uids !ill be allo!ed initially.
1G. Nurse #ristan is caring for a male client in acute renal failure. #he nurse should e/pect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat* a. b. c. d. hypernatremia. hypo$alemia. hyper$alemia. hypercalcemia.
1L. 8s. M has 1ust been diagnosed !ith condylomata acuminata genital !arts". 2hat information is appropriate to tell this client@ a. #his condition puts her at a higher ris$ for cervical cancerI therefore, she should have a 4apanicolaou 4ap" smear annually. b. #he most common treatment is metronida(ole 3lagyl", !hich should eradicate the problem !ithin L to 10 days. c. #he potential for transmission to her se/ual partner !ill be eliminated if condoms are used every time they have se/ual intercourse. d. #he human papillomavirus 94A", !hich causes condylomata acuminata, can+t be transmitted during oral se/. 1H. 8aritess !as recently diagnosed !ith a genitourinary problem and is being e/amined in the emergency department. 2hen palpating the her $idneys, the nurse should $eep !hich anatomical fact in mind@ a. #he left $idney usually is slightly higher than the right one. b. #he $idneys are situated 1ust above the adrenal glands. c. #he average $idney is appro/imately > cm 2%" long and 2 to F cm U% to 1-16H%" !ide. d. #he $idneys lie bet!een the 10th and 12th thoracic vertebrae. 19. Pestoni !ith chronic renal failure C03" is admitted to the urology unit. #he nurse is a!are that the diagnostic test are consistent !ith C03 if the result is* a. 'ncreased p9 !ith decreased hydrogen ions. b. 'ncreased serum levels of potassium, magnesium, and calcium. c. -lood urea nitrogen -)N" 100 mg6dl and serum creatinine G.> mg6 dl.
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d. )ric acid analysis F.> mg6dl and phenolsulfonphthalein 4;4" e/cretion L>?. 20. Jatrina has an abnormal result on a 4apanicolaou test. After admitting that she read her chart !hile the nurse !as out of the room, Jatrina as$s !hat dysplasia means. 2hich definition should the nurse provide@ a. 4resence of completely undifferentiated tumor cells that don+t resemble cells of the tissues of their origin. b. 'ncrease in the number of normal cells in a normal arrangement in a tissue or an organ. c. 0eplacement of one type of fully differentiated cell by another in tissues !here the second type normally isn+t found. d. Alteration in the si(e, shape, and organi(ation of differentiated cells. 21. :uring a routine chec$up, Nurse 8ariane assesses a male client !ith ac&uired immunodeficiency syndrome A':;" for signs and symptoms of cancer. 2hat is the most common A':;-related cancer@ a. b. c. d. ;&uamous cell carcinoma 8ultiple myeloma 7eu$emia Japosi+s sarcoma
22. 0icardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal subarachnoid" bloc$ during surgery. 'n the operating room, the nurse positions the client according to the anesthesiologist+s instructions. 2hy does the client re&uire special positioning for this type of anesthesia@ a. b. c. d. #o prevent confusion #o prevent sei(ures #o prevent cerebrospinal fluid C;3" lea$age #o prevent cardiac arrhythmias
2F. A male client had a nephrectomy 2 days ago and is no! complaining of abdominal pressure and nausea. #he first nursing action should be to* a. b. c. d. Auscultate bo!el sounds. 4alpate the abdomen. Change the client+s position. 'nsert a rectal tube.
2E. 2ilfredo !ith a recent history of rectal bleeding is being prepared for a colonoscopy. 9o! should the nurse 4atricia position the client for this test initially@
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a. b. c. d.
7ying on the right side !ith legs straight 7ying on the left side !ith $nees bent 4rone !ith the torso elevated -ent over !ith hands touching the floor
2>. A male client !ith inflammatory bo!el disease undergoes an ileostomy. Bn the first day after surgery, Nurse Bliver notes that the client+s stoma appears dus$y. 9o! should the nurse interpret this finding@ a. b. c. d. -lood supply to the stoma has been interrupted. #his is a normal finding 1 day after surgery. #he ostomy bag should be ad1usted. An intestinal obstruction has occurred.
2G. Anthony suffers burns on the legs, !hich nursing intervention helps prevent contractures@ a. b. c. d. Applying $nee splints .levating the foot of the bed 9ypere/tending the client+s palms 4erforming shoulder range-of-motion e/ercises
2L. Nurse 0on is assessing a client admitted !ith second- and third-degree burns on the face, arms, and chest. 2hich finding indicates a potential problem@ a. b. c. d. 4artial pressure of arterial o/ygen 4aB2" value of H0 mm 9g. )rine output of 20 ml6hour. 2hite pulmonary secretions. 0ectal temperature of 100.GO 3 FHO C".
28. 8r. 8endo(a !ho has suffered a cerebrovascular accident CAA" is too !ea$ to move on his o!n. #o help the client avoid pressure ulcers, Nurse Celia should* a. b. c. d. #urn him fre&uently. 4erform passive range-of-motion 0B8" e/ercises. 0educe the client+s fluid inta$e. .ncourage the client to use a footboard.
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29. Nurse 8aria plans to administer de/amethasone cream to a female client !ho has dermatitis over the anterior chest. 9o! should the nurse apply this topical agent@ a. 2ith a circular motion, to enhance absorption. b. 2ith an up!ard motion, to increase blood supply to the affected area c. 'n long, even, out!ard, and do!n!ard stro$es in the direction of hair gro!th d. 'n long, even, out!ard, and up!ard stro$es in the direction opposite hair gro!th F0. Nurse Jate is a!are that one of the follo!ing classes of medication protect the ischemic myocardium by bloc$ing catecholamines and sympathetic nerve stimulation is* a. b. c. d. -eta -adrenergic bloc$ers Calcium channel bloc$er Narcotics Nitrates
F1. A male client has 1ugular distention. Bn !hat position should the nurse place the head of the bed to obtain the most accurate reading of 1ugular vein distention@ a. b. c. d. 9igh 3o!ler5s 0aised 10 degrees 0aised F0 degrees ;upine position
F2. #he nurse is a!are that one of the follo!ing classes of medications ma/imi(es cardiac performance in clients !ith heart failure by increasing ventricular contractility@ a. b. c. d. -eta-adrenergic bloc$ers Calcium channel bloc$er :iuretics 'notropic agents
FF. A male client has a reduced serum high-density lipoprotein 9:7" level and an elevated lo!-density lipoprotein 7:7" level. 2hich of the follo!ing dietary modifications is not appropriate for this client@ a. 3iber inta$e of 2> to F0 g daily
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b. 7ess than F0? of calories form fat c. Cholesterol inta$e of less than F00 mg daily d. 7ess than 10? of calories from saturated fat FE. A FL-year-old male client !as admitted to the coronary care unit CC)" 2 days ago !ith an acute myocardial infarction. 2hich of the follo!ing actions !ould breach the client confidentiality@ a. #he CC) nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit b. #he CC) nurse notifies the on-call physician about a change in the client5s condition c. #he emergency department nurse calls up the latest electrocardiogram results to chec$ the client5s progress. d. At the client5s re&uest, the CC) nurse updates the client5s !ife on his condition F>. A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics !ho are giving ventilations through an endotracheal .#" tube that they placed in the client5s home. :uring a pause in compressions, the cardiac monitor sho!s narro! Q0; comple/es and a heart rate of beats6minute !ith a palpable pulse. 2hich of the follo!ing actions should the nurse ta$e first@ a. ;tart an 7.A. line and administer amiodarone Cardarone", F00 mg 7.A. over 10 minutes. b. Chec$ endotracheal tube placement. c. Bbtain an arterial blood gas A-<" sample. d. Administer atropine, 1 mg 7.A. FG. After cardiac surgery, a client5s blood pressure measures 12G6H0 mm 9g. Nurse Jatrina determines that mean arterial pressure 8A4" is !hich of the follo!ing@ a. b. c. d. EG mm 9g H0 mm 9g 9> mm 9g 90 mm 9g
FL. A female client arrives at the emergency department !ith chest and stomach pain and a report of blac$ tarry stool for several months. 2hich of the follo!ing order should the nurse Bliver anticipate@ a. Cardiac monitor, o/ygen, creatine $inase and lactate dehydrogenase levels b. 4rothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values.
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c. .lectrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel. d. .lectroencephalogram, al$aline phosphatase and aspartate aminotransferase levels, basic serum metabolic panel FH. 8acario had coronary artery bypass graft CA-<" surgery F days ago. 2hich of the follo!ing conditions is suspected by the nurse !hen a decrease in platelet count from 2F0,000 ul to >,000 ul is noted@ a. b. c. d. 4ancytopenia 'diopathic thrombocytopemic purpura '#4" :isseminated intravascular coagulation :'C" 9eparin-associated thrombosis and thrombocytopenia 9A##"
F9. 2hich of the follo!ing drugs !ould be ordered by the physician to improve the platelet count in a male client !ith idiopathic thrombocytopenic purpura '#4"@ a. b. c. d. Acetylsalicylic acid A;A" Corticosteroids 8ethotre(ate Aitamin J
E0. A female client is scheduled to receive a heart valve replacement !ith a porcine valve. 2hich of the follo!ing types of transplant is this@ a. b. c. d. Allogeneic Autologous ;yngeneic Menogeneic
E1. 8arco falls off his bicycle and in1uries his an$le. 2hich of the follo!ing actions sho!s the initial response to the in1ury in the e/trinsic path!ay@ a. b. c. d. 0elease of Calcium 0elease of tissue thromboplastin Conversion of factors M'' to factor M''a Conversion of factor A''' to factor A'''a
E2. 'nstructions for a client !ith systemic lupus erythematosus ;7." !ould include information about !hich of the follo!ing blood dyscrasias@ a. :ressler5s syndrome b. 4olycythemia c. .ssential thrombocytopenia
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d. Aon 2illebrand5s disease EF. #he nurse is a!are that the follo!ing symptoms is most commonly an early indication of stage 1 9odg$in5s disease@ a. b. c. d. 4ericarditis Night s!eat ;plenomegaly 4ersistent hypothermia
EE. 3rancis !ith leu$emia has neutropenia. 2hich of the follo!ing functions must fre&uently assessed@ a. b. c. d. -lood pressure -o!el sounds 9eart sounds -reath sounds
E>. #he nurse $no!s that neurologic complications of multiple myeloma 88" usually involve !hich of the follo!ing body system@ a. b. c. d. -rain 8uscle spasm 0enal dysfunction 8yocardial irritability
EG. Nurse 4atricia is a!are that the average length of time from human immunodeficiency virus 9'A" infection to the development of ac&uired immunodeficiency syndrome A':;"@ a. b. c. d. 7ess than > years > to L years 10 years 8ore than 10 years
EL. An 1H-year-old male client admitted !ith heat stro$e begins to sho! signs of disseminated intravascular coagulation :'C". 2hich of the follo!ing laboratory findings is most consistent !ith :'C@ a. b. c. d. 7o! platelet count .levated fibrinogen levels 7o! levels of fibrin degradation products 0educed prothrombin time
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EH. 8ario comes to the clinic complaining of fever, drenching night s!eats, and une/plained !eight loss over the past F months. 4hysical e/amination reveals a single enlarged supraclavicular lymph node. 2hich of the follo!ing is the most probable diagnosis@ a. b. c. d. 'nfluen(a ;ic$le cell anemia 7eu$emia 9odg$in5s disease
E9. A male client !ith a gunshot !ound re&uires an emergency blood transfusion. 9is blood type is A- negative. 2hich blood type !ould be the safest for him to receive@ a. b. c. d. A- 0h-positive A 0h-positive A 0h-negative B 0h-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy. >0. ;tacy is discharged from the hospital follo!ing her chemotherapy treatments. 2hich statement of ;tacy5s mother indicated that she understands !hen she !ill contact the physician@ a. b. c. d. C' should contact the physician if ;tacy has difficulty in sleepingD. C' !ill call my doctor if ;tacy has persistent vomiting and diarrheaD. C8y physician should be called if ;tacy is irritable and unhappyD. C;hould ;tacy have continued hair loss, ' need to call the doctorD.
>1. ;tacy5s mother states to the nurse that it is hard to see ;tacy !ith no hair. #he best response for the nurse is* a. C;tacy loo$s very nice !earing a hatD. b. C,ou should not !orry about her hair, 1ust be glad that she is aliveD. c. C,es it is upsetting. -ut try to cover up your feelings !hen you are !ith her or else she may be upsetD. d. C#his is only temporaryI ;tacy !ill re-gro! ne! hair in F-G months, but may be different in te/tureD. >2. ;tacy has beginning stomatitis. #o promote oral hygiene and comfort, the nurse in-charge should* a. 4rovide fre&uent mouth!ash !ith normal saline.
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b. Apply viscous 7idocaine to oral ulcers as needed. c. )se lemon glycerine s!abs every 2 hours. d. 0inse mouth !ith 9ydrogen 4ero/ide. >F. :uring the administration of chemotherapy agents, Nurse Bliver observed that the 'A site is red and s!ollen, !hen the 'A is touched ;tacy shouts in pain. #he first nursing action to ta$e is* a. b. c. d. Notify the physician 3lush the 'A line !ith saline solution 'mmediately discontinue the infusion Apply an ice pac$ to the site, follo!ed by !arm compress.
>E. #he term Cblue bloaterD refers to a male client !hich of the follo!ing conditions@ a. b. c. d. Adult respiratory distress syndrome A0:;" Asthma Chronic obstructive bronchitis .mphysema
>>. #he term Cpin$ pufferD refers to the female client !ith !hich of the follo!ing conditions@ a. b. c. d. Adult respiratory distress syndrome A0:;" Asthma Chronic obstructive bronchitis .mphysema
>G. Pose is in danger of respiratory arrest follo!ing the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Bliver !ould e/pect the paco2 to be !hich of the follo!ing values@ a. b. c. d. 1> mm 9g F0 mm 9g E0 mm 9g H0 mm 9g
>L. #imothy5s arterial blood gas A-<" results are as follo!sI p9 L.1GI 4aco2 H0 mm 9gI 4ao2 EG mm 9gI 9CBF- 2Em.&67I ;ao2 H1?. #his A-< result represents !hich of the follo!ing conditions@ a. 8etabolic acidosis b. 8etabolic al$alosis c. 0espiratory acidosis
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d. 0espirator y al$alosis >H. Norma has started a ne! drug for hypertension. #hirty minutes after she ta$es the drug, she develops chest tightness and becomes short of breath and tachypneic. ;he has a decreased level of consciousness. #hese signs indicate !hich of the follo!ing conditions@ a. b. c. d. Asthma attac$ 4ulmonary embolism 0espiratory failure 0heumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and aundice. !o rule out cirrhosis o" the li#er: >9. 2hich laboratory test indicates liver cirrhosis@ a. b. c. d. :ecreased red blood cell count :ecreased serum acid phosphate level .levated !hite blood cell count .levated serum aminotransferase
G0.#he biopsy of 8r. <on(ales confirms the diagnosis of cirrhosis. 8r. <on(ales is at increased ris$ for e/cessive bleeding primarily because of* a. b. c. d. 'mpaired clotting mechanism Aari/ formation 'nade&uate nutrition #rauma of invasive procedure
G1. 8r. <on(ales develops hepatic encephalopathy. 2hich clinical manifestation is most common !ith this condition@ a. b. c. d. 'ncreased urine output Altered level of consciousness :ecreased tendon refle/ 9ypotension
G2. 2hen 8r. <on(ales regained consciousness, the physician orders >0 ml of 7actose p.o. every 2 hours. 8r. <o(ales develops diarrhea. #he nurse best action !ould be* a. C'5ll see if your physician is in the hospitalD. b. C8aybe your reacting to the drugI ' !ill !ithhold the ne/t doseD.
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c. C'5ll lo!er the dosage as ordered so the drug causes only 2 to E stools a dayD. d. C3re&uently, bo!el movements are needed to reduce sodium levelD. GF. 2hich of the follo!ing groups of symptoms indicates a ruptured abdominal aortic aneurysm@ a. 7o!er bac$ pain, increased blood pressure, decreased re blood cell 0-C" count, increased !hite blood 2-C" count. b. ;evere lo!er bac$ pain, decreased blood pressure, decreased 0-C count, increased 2-C count. c. ;evere lo!er bac$ pain, decreased blood pressure, decreased 0-C count, decreased 0-C count, decreased 2-C count. d. 'ntermitted lo!er bac$ pain, decreased blood pressure, decreased 0-C count, increased 2-C count. GE. After undergoing a cardiac catheteri(ation, #racy has a large puddle of blood under his buttoc$s. 2hich of the follo!ing steps should the nurse ta$e first@ a. b. c. d. Call for help. Bbtain vital signs As$ the client to Clift upD Apply gloves and assess the groin site
G>. 2hich of the follo!ing treatment is a suitable surgical intervention for a client !ith unstable angina@ a. b. c. d. Cardiac catheteri(ation .chocardiogram Nitroglycerin 4ercutaneous transluminal coronary angioplasty 4#CA"
GG. #he nurse is a!are that the follo!ing terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is* a. b. c. d. Anaphylactic shoc$ Cardiogenic shoc$ :istributive shoc$ 8yocardial infarction 8'"
GL. A client !ith hypertension as$ the nurse !hich factors can cause blood pressure to drop to normal levels@ a. Jidneys5 e/cretion to sodium only. b. Jidneys5 retention of sodium and !ater c. Jidneys5 e/cretion of sodium and !ater
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d. Jidneys5 retention of sodium and e/cretion of !ater GH. Nurse 0ose is a!are that the statement that best e/plains !hy furosemide 7asi/" is administered to treat hypertension is* a. b. c. d. 't dilates peripheral blood vessels. 't decreases sympathetic cardioacceleration. 't inhibits the angiotensin-coverting en(ymes 't inhibits reabsorption of sodium and !ater in the loop of 9enle.
G9. Nurse Ni$$i $no!s that laboratory results supports the diagnosis of systemic lupus erythematosus ;7." is* a. b. c. d. .lavated serum complement level #hrombocytosis, elevated sedimentation rate 4ancytopenia, elevated antinuclear antibody ANA" titer 7eu$ocysis, elevated blood urea nitrogen -)N" and creatinine levels
L0. Arnold, a 19-year-old client !ith a mild concussion is discharged from the emergency department. -efore discharge, he complains of a headache. 2hen offered acetaminophen, his mother tells the nurse the headache is severe and she !ould li$e her son to have something stronger. 2hich of the follo!ing responses by the nurse is appropriate@ a. C,our son had a mild concussion, acetaminophen is strong enough.D b. CAspirin is avoided because of the danger of 0eye5s syndrome in children or young adults.D c. CNarcotics are avoided after a head in1ury because they may hide a !orsening condition.D d. ;tronger medications may lead to vomiting, !hich increases the intracarnial pressure 'C4".D L1. 2hen evaluating an arterial blood gas from a male client !ith a subdural hematoma, the nurse notes the 4aco2 is F0 mm 9g. 2hich of the follo!ing responses best describes the result@ a. AppropriateI lo!ering carbon dio/ide CB2" reduces intracranial pressure 'C4" b. .mergentI the client is poorly o/ygenated c. Normal d. ;ignificantI the client has alveolar hypoventilation L2. 2hen prioriti(ing care, !hich of the follo!ing clients should the nurse Blivia assess first@
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a. b. c. d.
A 1L-year-old clients 2E-hours postappendectomy A FF-year-old client !ith a recent diagnosis of <uillain--arre syndrome A >0-year-old client F days postmyocardial infarction A >0-year-old client !ith diverticulitis
LF. P4 has been diagnosed !ith gout and !ants to $no! !hy colchicine is used in the treatment of gout. 2hich of the follo!ing actions of colchicines e/plains !hy it5s effective for gout@ a. b. c. d. 0eplaces estrogen :ecreases infection :ecreases inflammation :ecreases bone deminerali(ation
LE. Norma as$s for information about osteoarthritis. 2hich of the follo!ing statements about osteoarthritis is correct@ a. b. c. d. Bsteoarthritis is rarely debilitating Bsteoarthritis is a rare form of arthritis Bsteoarthritis is the most common form of arthritis Bsteoarthritis afflicts people over G0
L>. 0uby is receiving thyroid replacement therapy develops the flu and forgets to ta$e her thyroid replacement medicine. #he nurse understands that s$ipping this medication !ill put the client at ris$ for developing !hich of the follo!ing lifethreatening complications@ a. b. c. d. ./ophthalmos #hyroid storm 8y/edema coma #ibial my/edema
LG. Nurse ;ugar is assessing a client !ith Cushing+s syndrome. 2hich observation should the nurse report to the physician immediately@ a. b. c. d. 4itting edema of the legs An irregular apical pulse :ry mucous membranes 3re&uent urination
LL. Cyrill !ith severe head trauma sustained in a car accident is admitted to the intensive care unit. #hirty-si/ hours later, the client+s urine output suddenly rises above 200 ml6hour, leading the nurse to suspect diabetes insipidus. 2hich laboratory findings support the nurse+s suspicion of diabetes insipidus@
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a. Above-normal urine and serum osmolality levels b. -elo!-normal urine and serum osmolality levels c. Above-normal urine osmolality level, belo!-normal serum osmolality level d. -elo!-normal urine osmolality level, above-normal serum osmolality level LH. Pomari is diagnosed !ith hyperosmolar hyperglycemic non$etotic syndrome 99N;" is stabili(ed and prepared for discharge. 2hen preparing the client for discharge and home management, !hich of the follo!ing statements indicates that the client understands her condition and ho! to control it@ a. %' can avoid getting sic$ by not becoming dehydrated and by paying attention to my need to urinate, drin$, or eat more than usual.% b. %'f ' e/perience trembling, !ea$ness, and headache, ' should drin$ a glass of soda that contains sugar.% c. %' !ill have to monitor my blood glucose level closely and notify the physician if it+s constantly elevated.% d. %'f ' begin to feel especially hungry and thirsty, '+ll eat a snac$ high in carbohydrates.% L9. A GG-year-old client has been complaining of sleeping more, increased urination, anore/ia, !ea$ness, irritability, depression, and bone pain that interferes !ith her going outdoors. -ased on these assessment findings, the nurse !ould suspect !hich of the follo!ing disorders@ a. b. c. d. :iabetes mellitus :iabetes insipidus 9ypoparathyroidism 9yperparathyroidism
H0. Nurse 7ourdes is teaching a client recovering from addisonian crisis about the need to ta$e fludrocortisone acetate and hydrocortisone at home. 2hich statement by the client indicates an understanding of the instructions@ a. %'+ll ta$e my hydrocortisone in the late afternoon, before dinner.% b. %'+ll ta$e all of my hydrocortisone in the morning, right after ' !a$e up.% c. %'+ll ta$e t!o-thirds of the dose !hen ' !a$e up and one-third in the late afternoon.% d. %'+ll ta$e the entire dose at bedtime.% H1..2hich of the follo!ing laboratory test results !ould suggest to the nurse 7en that a client has a corticotropin-secreting pituitary adenoma@ a. 9igh corticotropin and lo! cortisol levels
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b. 7o! corticotropin and high cortisol levels c. 9igh corticotropin and high cortisol levels d. 7o! corticotropin and lo! cortisol levels H2. A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. 4reoperatively, the nurse should assess for potential complications by doing !hich of the follo!ing@ a. b. c. d. #esting for $etones in the urine #esting urine specific gravity Chec$ing temperature every E hours 4erforming capillary glucose testing every E hours
HF. Capillary glucose monitoring is being performed every E hours for a client diagnosed !ith diabetic $etoacidosis. 'nsulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 2>0 mg6dl for !hich he receives H ) of regular insulin. Nurse 8ariner should e/pect the dose+s* a. b. c. d. onset to be at 2 p.m. and its pea$ to be at F p.m. onset to be at 2*1> p.m. and its pea$ to be at F p.m. onset to be at 2*F0 p.m. and its pea$ to be at E p.m. onset to be at E p.m. and its pea$ to be at G p.m.
HE. #he physician orders laboratory tests to confirm hyperthyroidism in a female client !ith classic signs and symptoms of this disorder. 2hich test result !ould confirm the diagnosis@ a. No increase in the thyroid-stimulating hormone #;9" level after F0 minutes during the #;9 stimulation test b. A decreased #;9 level c. An increase in the #;9 level after F0 minutes during the #;9 stimulation test d. -elo!-normal levels of serum triiodothyronine #F" and serum thyro/ine #E" as detected by radioimmunoassay H>. 0ico !ith diabetes mellitus must learn ho! to self-administer insulin. #he physician has prescribed 10 ) of )-100 regular insulin and F> ) of )-100 isophane insulin suspension N49" to be ta$en before brea$fast. 2hen teaching the client ho! to select and rotate insulin in1ection sites, the nurse should provide !hich instruction@ a. %'n1ect insulin into healthy tissue !ith large blood vessels and nerves.% b. %0otate in1ection sites !ithin the same anatomic region, not among different regions.%
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c. %Administer insulin into areas of scar tissue or hypotrophy !henever possible.% d. %Administer insulin into sites above muscles that you plan to e/ercise heavily later that day.% HG. Nurse ;arah e/pects to note an elevated serum glucose level in a client !ith hyperosmolar hyperglycemic non$etotic syndrome 99N;". 2hich other laboratory finding should the nurse anticipate@ a. b. c. d. .levated serum acetone level ;erum $etone bodies ;erum al$alosis -elo!-normal serum potassium level
HL. 3or a client !ith <raves+ disease, !hich nursing intervention promotes comfort@ a. b. c. d. 0estricting inta$e of oral fluids 4lacing e/tra blan$ets on the client+s bed 7imiting inta$e of high-carbohydrate foods 8aintaining room temperature in the lo!-normal range
HH. 4atric$ is treated in the emergency department for a Colles+ fracture sustained during a fall. 2hat is a Colles+ fracture@ a. b. c. d. 3racture of the distal radius 3racture of the olecranon 3racture of the humerus 3racture of the carpal scaphoid
H9. Cleo is diagnosed !ith osteoporosis. 2hich electrolytes are involved in the development of this disorder@ a. b. c. d. Calcium and sodium Calcium and phosphorous 4hosphorous and potassium 4otassium and sodium
90. Pohnny a firefighter !as involved in e/tinguishing a house fire and is being treated to smo$e inhalation. 9e develops severe hypo/ia EH hours after the incident, re&uiring intubation and mechanical ventilation. 9e most li$ely has developed !hich of the follo!ing conditions@ a. Adult respiratory distress syndrome A0:;" b. Atelectasis c. -ronchitis
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d. 4neumonia 91. A GL-year-old client develops acute shortness of breath and progressive hypo/ia re&uiring right femur. #he hypo/ia !as probably caused by !hich of the follo!ing conditions@ a. b. c. d. Asthma attac$ Atelectasis -ronchitis 3at embolism
92. A client !ith shortness of breath has decreased to absent breath sounds on the right side, from the ape/ to the base. 2hich of the follo!ing conditions !ould best e/plain this@ a. b. c. d. Acute asthma Chronic bronchitis 4neumonia ;pontaneous pneumothora/
9F. A G2-year-old male client !as in a motor vehicle accident as an unrestrained driver. 9e5s no! in the emergency department complaining of difficulty of breathing and chest pain. Bn auscultation of his lung field, no breath sounds are present in the upper lobe. #his client may have !hich of the follo!ing conditions@ a. b. c. d. -ronchitis 4neumonia 4neumothora/ #uberculosis #-"
9E. 'f a client re&uires a pneumonectomy, !hat fills the area of the thoracic cavity@ a. b. c. d. #he space remains filled !ith air only #he surgeon fills the space !ith a gel ;erous fluids fills the space and consolidates the region #he tissue from the other lung gro!s over to the other side
9>. 9emoptysis may be present in the client !ith a pulmonary embolism because of !hich of the follo!ing reasons@ a. Alveolar damage in the infracted area b. 'nvolvement of ma1or blood vessels in the occluded area c. 7oss of lung parenchyma
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d. 7oss of lung tissue 9G. Aldo !ith a massive pulmonary embolism !ill have an arterial blood gas analysis performed to determine the e/tent of hypo/ia. #he acid-base disorder that may be present is@ a. b. c. d. 8etabolic acidosis 8etabolic al$alosis 0espiratory acidosis 0espiratory al$alosis
9L. After a motor vehicle accident, Armand an 22-year-old client is admitted !ith a pneumothora/. #he surgeon inserts a chest tube and attaches it to a chest drainage system. -ubbling soon appears in the !ater seal chamber. 2hich of the follo!ing is the most li$ely cause of the bubbling@ a. b. c. d. Air lea$ Ade&uate suction 'nade&uate suction Jin$ed chest tube
9H. Nurse 8ichelle calculates the 'A flo! rate for a postoperative client. #he client receives F,000 ml of 0inger5s lactate solution 'A to run over 2E hours. #he 'A infusion set has a drop factor of 10 drops per milliliter. #he nurse should regulate the client5s 'A to deliver ho! many drops per minute@ a. b. c. d. 1H 21 F> E0
99. 8ic$ey, a G-year-old child !ith a congenital heart disorder is admitted !ith congestive heart failure. :igo/in lano/in" 0.12 mg is ordered for the child. #he bottle of 7ano/in contains .0> mg of 7ano/in in 1 ml of solution. 2hat amount should the nurse administer to the child@ a. b. c. d. 1.2 ml 2.E ml F.> ml E.2 ml
100. Nurse Ale/andra teaches a client about elastic stoc$ings. 2hich of the follo!ing statements, if made by the client, indicates to the nurse that the teaching !as successful@
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a. b. c. d.
C' !ill !ear the stoc$ings until the physician tells me to remove them.D C' should !ear the stoc$ings even !hen ' am sleep.D C.very four hours ' should remove the stoc$ings for a half hour.D C' should put on the stoc$ings before getting out of bed in the morning.D
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N)0;'N< 40AC#'C. A
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TEST . 0 Care of Clients 1ith #hysiologic and #sychosocial Alterations 1. 8r. 8ar&ue( reports of losing his 1ob, not being able to sleep at night, and feeling upset !ith his !ife. Nurse Pohn responds to the client, C,ou may !ant to tal$ about your employment situation in group today.D #he Nurse is using !hich therapeutic techni&ue@ a. b. c. d. Bbservations 0estating ./ploring 3ocusing
2. #ony refuses his evening dose of 9aloperidol 9aldol", then becomes e/tremely agitated in the dayroom !hile other clients are !atching television. 9e begins cursing and thro!ing furniture. Nurse Bliver first action is to* a. Chec$ the client5s medical record for an order for an as-needed '.8. dose of medication for agitation. b. 4lace the client in full leather restraints. c. Call the attending physician and report the behavior. d. 0emove all other clients from the dayroom. F. #ina !ho is manic, but not yet on medication, comes to the drug treatment center. #he nurse !ould not let this client 1oin the group session because* a. b. c. d. #he client is disruptive. #he client is harmful to self. #he client is harmful to others. #he client needs to be on medication first.
E. :ervid, an adolescent boy !as admitted for substance abuse and hallucinations. #he client5s mother as$s Nurse Armando to tal$ !ith his husband !hen he arrives at the hospital. #he mother says that she is afraid of !hat the father might say to the boy. #he most appropriate nursing intervention !ould be to* a. 'nform the mother that she and the father can !or$ through this problem themselves. b. 0efer the mother to the hospital social !or$er. c. Agree to tal$ !ith the mother and the father together. d. ;uggest that the father and son !or$ things out. >. 2hat is Nurse Pohn li$ely to note in a male client being admitted for alcohol !ithdra!al@
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a. b. c. d.
4erceptual disorders. 'mpending coma. 0ecent alcohol inta$e. :epression !ith mutism.
G. Aira has ta$en amitriptyline 9C7 .lavil" for F days, but no! complains that it Cdoesn5t helpD and refuses to ta$e it. 2hat should the nurse say or do@ a. b. c. d. 2ithhold the drug. 0ecord the client5s response. .ncourage the client to tell the doctor. ;uggest that it ta$es a!hile before seeing the results.
L. :ervid, an adolescent has a history of truancy from school, running a!ay from home and Cbarro!ingD other people5s things !ithout their permission. #he adolescent denies stealing, rationali(ing instead that as long as no one !as using the items, it !as all right to borro! them. 't is important for the nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental defect related to the* a. b. c. d. 'd .go ;uperego Bedipal comple/
H. 'n preparing a female client for electroconvulsive therapy .C#", Nurse 8ichelle $no!s that succinylcoline Anectine" !ill be administered for !hich therapeutic effect@ a. b. c. d. ;hort-acting anesthesia :ecreased oral and respiratory secretions. ;$eletal muscle paralysis. Analgesia.
9. Nurse <ina is a!are that the dietary implications for a client in manic phase of bipolar disorder is* a. ;erve the client a bo!l of soup, buttered 3rench bread, and apple slices. b. 'ncrease calories, decrease fat, and decrease protein. c. <ive the client pieces of cut-up stea$, carrots, and an apple. d. 'ncrease calories, carbohydrates, and protein. 10. 2hat parental behavior to!ard a child during an admission procedure should cause Nurse 0on to suspect child abuse@
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a. b. c. d.
3lat affect ./pressing guilt Acting overly solicitous to!ard the child. 'gnoring the child.
11. Nurse 7ynnette notices that a female client !ith obsessive-compulsive disorder !ashes her hands for long periods each day. 9o! should the nurse respond to this compulsive behavior@ a. -y designating times during !hich the client can focus on the behavior. b. -y urging the client to reduce the fre&uency of the behavior as rapidly as possible. c. -y calling attention to or attempting to prevent the behavior. d. -y discouraging the client from verbali(ing an/ieties. 12. After see$ing help at an outpatient mental health clinic, 0uby !ho !as raped !hile !al$ing her dog is diagnosed !ith posttraumatic stress disorder 4#;:". #hree months later, 0uby returns to the clinic, complaining of fear, loss of control, and helpless feelings. 2hich nursing intervention is most appropriate for 0uby@ a. 0ecommending a high-protein, lo!-fat diet. b. <iving sleep medication, as prescribed, to restore a normal sleep!a$e cycle. c. Allo!ing the client time to heal. d. ./ploring the meaning of the traumatic event !ith the client. 1F. 8eryl, age 19, is highly dependent on her parents and fears leaving home to go a!ay to college. ;hortly before the semester starts, she complains that her legs are paraly(ed and is rushed to the emergency department. 2hen physical e/amination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit !here she is diagnosed !ith conversion disorder. 8eryl as$s the nurse, %2hy has this happened to me@% 2hat is the nurse+s best response@ a. %,ou+ve developed this paralysis so you can stay !ith your parents. ,ou must deal !ith this conflict if you !ant to !al$ again.% b. %'t must be a!ful not to be able to move your legs. ,ou may feel better if you reali(e the problem is psychological, not physical.% c. %,our problem is real but there is no physical basis for it. 2e+ll !or$ on !hat is going on in your life to find out !hy it+s happened.% d. %'t isn+t uncommon for someone !ith your personality to develop a conversion disorder during times of stress.%
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1E. Nurse Jrina $no!s that the follo!ing drugs have been $no!n to be effective in treating obsessive-compulsive disorder BC:"* a. b. c. d. ben(tropine Cogentin" and diphenhydramine -enadryl". chlordia(epo/ide 7ibrium" and dia(epam Aalium" fluvo/amine 7uvo/" and clomipramine Anafranil" divalproe/ :epa$ote" and lithium 7ithobid"
1>. Alfred !as ne!ly diagnosed !ith an/iety disorder. #he physician prescribed buspirone -u;par". #he nurse is a!are that the teaching instructions for ne!ly prescribed buspirone should include !hich of the follo!ing@ a. A !arning about the drugs delayed therapeutic effect, !hich is from 1E to F0 days. b. A !arning about the incidence of neuroleptic malignant syndrome N8;". c. A reminder of the need to schedule blood !or$ in 1 !ee$ to chec$ blood levels of the drug. d. A !arning that immediate sedation can occur !ith a resultant drop in pulse. 1G. 0ichard !ith agoraphobia has been symptom-free for E months. Classic signs and symptoms of phobias include* a. b. c. d. 'nsomnia and an inability to concentrate. ;evere an/iety and fear. :epression and !eight loss. 2ithdra!al and failure to distinguish reality from fantasy.
1L. 2hich medications have been found to help reduce or eliminate panic attac$s@ a. b. c. d. Antidepressants Anticholinergics Antipsychotics 8ood stabili(ers
1H. A client see$s care because she feels depressed and has gained !eight. #o treat her atypical depression, the physician prescribes tranylcypromine sulfate 4arnate", 10 mg by mouth t!ice per day. 2hen this drug is used to treat atypical depression, !hat is its onset of action@ a. 1 to 2 days b. F to > days c. G to H days
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d. 10 to 1E days 19. A G> years old client is in the first stage of Al(heimer+s disease. Nurse 4atricia should plan to focus this client+s care on* a. Bffering nourishing finger foods to help maintain the client+s nutritional status. b. 4roviding emotional support and individual counseling. c. 8onitoring the client to prevent minor illnesses from turning into ma1or problems. d. ;uggesting ne! activities for the client and family to do together. 20. #he nurse is assessing a client !ho has 1ust been admitted to the emergency department. 2hich signs !ould suggest an overdose of an antian/iety agent@ a. b. c. d. Combativeness, s!eating, and confusion Agitation, hyperactivity, and grandiose ideation .motional lability, euphoria, and impaired memory ;uspiciousness, dilated pupils, and increased blood pressure
21. #he nurse is caring for a client diagnosed !ith antisocial personality disorder. #he client has a history of fighting, cruelty to animals, and stealing. 2hich of the follo!ing traits !ould the nurse be most li$ely to uncover during assessment@ a. b. c. d. 9istory of gainful employment 3re&uent e/pression of guilt regarding antisocial behavior :emonstrated ability to maintain close, stable relationships A lo! tolerance for frustration
22. Nurse Amy is providing care for a male client undergoing opiate !ithdra!al. Bpiate !ithdra!al causes severe physical discomfort and can be life-threatening. #o minimi(e these effects, opiate users are commonly deto/ified !ith* a. b. c. d. -arbiturates Amphetamines 8ethadone -en(odia(epines
2F. Nurse Cristina is caring for a client !ho e/periences false sensory perceptions !ith no basis in reality. #hese perceptions are $no!n as* a. :elusions b. 9allucinations
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c. 7oose associations d. Neologisms 24. Nurse 8arco is developing a plan of care for a client !ith anore/ia nervosa. 2hich action should the nurse include in the plan@ a. 0estricts visits !ith the family and friends until the client begins to eat. b. 4rovide privacy during meals. c. ;et up a strict eating plan for the client. d. .ncourage the client to e/ercise, !hich !ill reduce her an/iety. 2>. #im is admitted !ith a diagnosis of delusions of grandeur. #he nurse is a!are that this diagnosis reflects a belief that one is* a. b. c. d. 9ighly important or famous. -eing persecuted Connected to events unrelated to oneself 0esponsible for the evil in the !orld.
2G. Nurse Pen is caring for a male client !ith manic depression. #he plan of care for a client in a manic state !ould include* a. Bffering a high-calorie meals and strongly encouraging the client to finish all food. b. 'nsisting that the client remain active through the day so that he5ll sleep at night. c. Allo!ing the client to e/hibit hyperactive, demanding, manipulative behavior !ithout setting limits. d. 7istening attentively !ith a neutral attitude and avoiding po!er struggles. 2L. 0amon is admitted for deto/ification after a cocaine overdose. #he client tells the nurse that he fre&uently uses cocaine but that he can control his use if he chooses. 2hich coping mechanism is he using@ a. b. c. d. 2ithdra!al 7ogical thin$ing 0epression :enial
2H. 0ichard is admitted !ith a diagnosis of schi(otypal personality disorder. 2hich signs !ould this client e/hibit during social situations@ a. Aggressive behavior b. 4aranoid thoughts
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c. .motional affect d. 'ndependence needs 29. Nurse 8ic$ey is caring for a client diagnosed !ith bulimia. #he most appropriate initial goal for a client diagnosed !ith bulimia is to* a. b. c. d. Avoid shopping for large amounts of food. Control eating impulses. 'dentify an/iety-causing situations .at only three meals per day.
F0. 0udolf is admitted for an overdose of amphetamines. 2hen assessing the client, the nurse should e/pect to see* a. b. c. d. #ension and irritability ;lo! pulse 9ypotension Constipation
F1. Nicolas is e/periencing hallucinations tells the nurse, C#he voices are telling me '5m no good.D #he client as$s if the nurse hears the voices. #he most appropriate response by the nurse !ould be* a. C't is the voice of your conscience, !hich only you can control.D b. CNo, ' do not hear your voices, but ' believe you can hear themD. c. C#he voices are coming from !ithin you and only you can hear them.D d. CBh, the voices are a symptom of your illnessI don5t pay any attention to them.D F2. #he nurse is a!are that the side effect of electroconvulsive therapy that a client may e/perience* a. b. c. d. 7oss of appetite 4ostural hypotension Confusion for a time after treatment Complete loss of memory for a time
FF. A dying male client gradually moves to!ard resolution of feelings regarding impending death. -asing care on the theory of Jubler-0oss, Nurse #rish plans to use nonverbal interventions !hen assessment reveals that the client is in the* a. Anger stage b. :enial stage c. -argaining stage
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d. Acceptance stage FE. #he outcome that is unrelated to a crisis state is* a. b. c. d. 7earning more constructive coping s$ills :ecompensation to a lo!er level of functioning. Adaptation and a return to a prior level of functioning. A higher level of an/iety continuing for more than F months.
F>. 8iranda a psychiatric client is to be discharged !ith orders for haloperidol haldol" therapy. 2hen developing a teaching plan for discharge, the nurse should include cautioning the client against* a. b. c. d. :riving at night ;taying in the sun 'ngesting !ines and cheeses #a$ing medications containing aspirin
FG. Pen a nursing student is an/ious about the upcoming board e/amination but is able to study intently and does not become distracted by a roommate5s tal$ing and loud music. #he student5s ability to ignore distractions and to focus on studying demonstrates* a. b. c. d. 8ild-level an/iety 4anic-level an/iety ;evere-level an/iety 8oderate-level an/iety
FL. 2hen assessing a premorbid personality characteristics of a client !ith a ma1or depression, it !ould be unusual for the nurse to find that this client demonstrated* a. b. c. d. 0igidity ;tubbornness :iverse interest Bver meticulousness
FH. Nurse Jrina recogni(es that the suicidal ris$ for depressed client is greatest* a. b. c. d. As their depression begins to improve 2hen their depression is most severe -efore nay type of treatment is started As they lose interest in the environment
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F9. Nurse Jate !ould e/pect that a client !ith vascular dementis !ould e/perience* a. b. c. d. 7oss of remote memory related to ano/ia 7oss of abstract thin$ing related to emotional state 'nability to concentrate related to decreased stimuli :isturbance in recalling recent events related to cerebral hypo/ia.
E0. Posefina is to be discharged on a regimen of lithium carbonate. 'n the teaching plan for discharge the nurse should include* a. b. c. d. Advising the client to !atch the diet carefully ;uggesting that the client ta$e the pills !ith mil$ 0eminding the client that a C-C must be done once a month. .ncouraging the client to have blood levels chec$ed as ordered.
E1. #he psychiatrist orders lithium carbonate G00 mg p.o t.i.d for a female client. Nurse Jatrina !ould be a!are that the teaching about the side effects of this drug !ere understood !hen the client state, C' !ill call my doctor immediately if ' notice any* a. b. c. d. ;ensitivity to bright light or sun 3ine hand tremors or slurred speech ;e/ual dysfunction or breast enlargement 'nability to urinate or difficulty !hen urinating
E2. Nurse 8ylene recogni(es that the most important factor necessary for the establishment of trust in a critical care area is* a. b. c. d. 4rivacy 0espect .mpathy 4resence
EF. 2hen establishing an initial nurse-client relationship, Nurse 9a(el should e/plore !ith the client the* a. b. c. d. Client5s perception of the presenting problem. Bccurrence of fantasies the client may e/perience. :etails of any ritualistic acts carried out by the client Client5s feelings !hen e/ternalI controls are instituted.
EE. #ranylcypromine sulfate 4arnate" is prescribed for a depressed client !ho has not responded to the tricyclic antidepressants. After teaching the client about the medication, Nurse 8arian evaluates that learning has occurred !hen the client states, C' !ill avoid*
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a. b. c. d.
Citrus fruit, tuna, and yello! vegetables.D Chocolate mil$, aged cheese, and yogurt5D <reen leafy vegetables, chic$en, and mil$.D 2hole grains, red meats, and carbonated soda.D
E>. Nurse Pohn is a a!are that most crisis situations should resolve in about* a. b. c. d. 1 to 2 !ee$s E to G !ee$s E to G months G to 12 months
EG. Nurse Pudy $no!s that statistics sho! that in adolescent suicide behavior* a. b. c. d. 3emales use more dramatic methods than males 8ales account for more attempts than do females 3emales tal$ more about suicide before attempting it 8ales are more li$ely to use lethal methods than are females
47. :ervid !ith paranoid schi(ophrenia repeatedly uses profanity during an activity therapy session. 2hich response by the nurse !ould be most appropriate@ a. %,our behavior !on+t be tolerated. <o to your room immediately.% b. %,ou+re 1ust doing this to get bac$ at me for ma$ing you come to therapy.% c. %,our cursing is interrupting the activity. #a$e time out in your room for 10 minutes.% d. %'+m disappointed in you. ,ou can+t control yourself even for a fe! minutes.% EH. Nurse 8aureen $no!s that the nonantipsychotic medication used to treat some clients !ith schi(oaffective disorder is* a. b. c. d. phenel(ine Nardil" chlordia(epo/ide 7ibrium" lithium carbonate 7ithane" imipramine #ofranil"
E9. 2hich information is most important for the nurse #rinity to include in a teaching plan for a male schi(ophrenic client ta$ing clo(apine Clo(aril"@ a. 8onthly blood tests !ill be necessary. b. 0eport a sore throat or fever to the physician immediately.
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c. -lood pressure must be monitored for hypertension. d. ;top the medication !hen symptoms subside. >0. 0ic$y !ith chronic schi(ophrenia ta$es neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. #hese findings suggest !hich lifethreatening reaction* a. b. c. d. #ardive dys$inesia. :ystonia. Neuroleptic malignant syndrome. A$athisia.
>1. 2hich nursing intervention !ould be most appropriate if a male client develop orthostatic hypotension !hile ta$ing amitriptyline .lavil"@ a. Consulting !ith the physician about substituting a different type of antidepressant. b. Advising the client to sit up for 1 minute before getting out of bed. c. 'nstructing the client to double the dosage until the problem resolves. d. 'nforming the client that this adverse reaction should disappear !ithin 1 !ee$. >2. 8r. Cru( visits the physician+s office to see$ treatment for depression, feelings of hopelessness, poor appetite, insomnia, fatigue, lo! selfesteem, poor concentration, and difficulty ma$ing decisions. #he client states that these symptoms began at least 2 years ago. -ased on this report, the nurse #yfany suspects* a. b. c. d. Cyclothymic disorder. Atypical affective disorder. 8a1or depression. :ysthymic disorder.
53. After ta$ing an overdose of phenobarbital -arbita", 8ario is admitted to the emergency department. :r. #rinidad prescribes activated charcoal Charcocaps" to be administered by mouth immediately. -efore administering the dose, the nurse verifies the dosage ordered. 2hat is the usual minimum dose of activated charcoal@ a. b. c. d. > g mi/ed in 2>0 ml of !ater 1> g mi/ed in >00 ml of !ater F0 g mi/ed in 2>0 ml of !ater G0 g mi/ed in >00 ml of !ater
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>E. 2hat herbal medication for depression, !idely used in .urope, is no! being prescribed in the )nited ;tates@ a. b. c. d. <in$go biloba .chinacea ;t. Pohn+s !ort .phedra
>>. Cely !ith manic episodes is ta$ing lithium. 2hich electrolyte level should the nurse chec$ before administering this medication@ a. b. c. d. Calcium ;odium Chloride 4otassium
>G. Nurse Posefina is caring for a client !ho has been diagnosed !ith delirium. 2hich statement about delirium is true@ a. 't+s characteri(ed by an acute onset and lasts about 1 month. b. 't+s characteri(ed by a slo!ly evolving onset and lasts about 1 !ee$. c. 't+s characteri(ed by a slo!ly evolving onset and lasts about 1 month. d. 't+s characteri(ed by an acute onset and lasts hours to a number of days. >L. .d!ard, a GG year old client !ith slight memory impairment and poor concentration is diagnosed !ith primary degenerative dementia of the Al(heimer+s type. .arly signs of this dementia include subtle personality changes and !ithdra!al from social interactions. #o assess for progression to the middle stage of Al(heimer+s disease, the nurse should observe the client for* a. b. c. d. Bccasional irritable outbursts. 'mpaired communication. 7ac$ of spontaneity. 'nability to perform self-care activities.
>H. 'sabel !ith a diagnosis of depression is started on imipramine #ofranil", L> mg by mouth at bedtime. #he nurse should tell the client that* a. #his medication may be habit forming and !ill be discontinued as soon as the client feels better. b. #his medication has no serious adverse effects.
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c. #he client should avoid eating such foods as aged cheeses, yogurt, and chic$en livers !hile ta$ing the medication. d. #his medication may initially cause tiredness, !hich should become less bothersome over time. >9. Jathleen is admitted to the psychiatric clinic for treatment of anore/ia nervosa. #o promote the client+s physical health, the nurse should plan to* a. ;everely restrict the client+s physical activities. b. 2eigh the client daily, after the evening meal. c. 8onitor vital signs, serum electrolyte levels, and acid-base balance. d. 'nstruct the client to $eep an accurate record of food and fluid inta$e. G0. Celia !ith a history of polysubstance abuse is admitted to the facility. ;he complains of nausea and vomiting 2E hours after admission. #he nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. #he nurse suspects that the client is going through !hich of the follo!ing !ithdra!als@ a. b. c. d. Alcohol !ithdra!al Cannibis !ithdra!al Cocaine !ithdra!al Bpioid !ithdra!al
G1. 8r. <arcia, an attorney !ho thro!s boo$s and furniture around the office after losing a case is referred to the psychiatric nurse in the la! firm+s employee assistance program. Nurse -eatri( $no!s that the client+s behavior most li$ely represents the use of !hich defense mechanism@ a. b. c. d. 0egression 4ro1ection 0eaction-formation 'ntellectuali(ation
G2. Nurse Anne is caring for a client !ho has been treated long term !ith antipsychotic medication. :uring the assessment, Nurse Anne chec$s the client for tardive dys$inesia. 'f tardive dys$inesia is present, Nurse Anne !ould most li$ely observe* a. Abnormal movements and involuntary movements of the mouth, tongue, and face. b. Abnormal breathing through the nostrils accompanied by a Cthrill.D c. ;evere headache, flushing, tremors, and ata/ia. d. ;evere hypertension, migraine headache,
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GF. :ennis has a lithium level of 2.E m.&67. #he nurse immediately !ould assess the client for !hich of the follo!ing signs or symptoms@ a. b. c. d. 2ea$ness :iarrhea -lurred vision 3ecal incontinence
GE. Nurse Pannah is monitoring a male client !ho has been placed inrestraints because of violent behavior. Nurse determines that it !ill be safe to remove the restraints !hen* a. #he client verbali(es the reasons for the violent behavior. b. #he client apologi(es and tells the nurse that it !ill never happen again. c. No acts of aggression have been observed !ithin 1 hour after the release of t!o of the e/tremity restraints. d. #he administered medication has ta$en effect. G>. Nurse 'rish is a!are that 0italin is the drug of choice for a child !ith A:9:. #he side effects of the follo!ing may be noted by the nurse* a. b. c. d. 'ncreased attention span and concentration 'ncrease in appetite ;leepiness and lethargy -radycardia and diarrhea
GG. Jitty, a 9 year old child has very limited vocabulary and interaction s$ills. ;he has an '.Q. of E>. ;he is diagnosed to have 8ental retardation of this classification* a. b. c. d. 4rofound 8ild 8oderate ;evere
GL. #he therapeutic approach in the care of Armand an autistic child include the follo!ing .MC.4#* a. b. c. d. .ngage in diversionary activities !hen acting -out 4rovide an atmosphere of acceptance 4rovide safety measures 0earrange the environment to activate the child
GH. Peremy is brought to the emergency room by friends !ho state that he too$ something an hour ago. 9e is actively hallucinating, agitated, !ith
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irritated nasal septum. a. b. c. d. 9eroin Cocaine 7;: 8ari1uana
G9. Nurse 4auline is a!are that :ementia unli$e delirium is characteri(ed by* a. b. c. d. ;lurred speech 'nsidious onset Clouding of consciousness ;ensory perceptual change
L0. A F> year old female has intense fear of riding an elevator. ;he claims C As if ' !ill die inside.D #he client is suffering from* a. Agoraphobia b. ;ocial phobia c. Claustrophobia d. Menophobia L1. Nurse 8yrna develops a counter-transference reaction. #his is evidenced by* a. 0evealing personal information to the client b. 3ocusing on the feelings of the client. c. Confronting the client about discrepancies in verbal or non-verbal behavior d. #he client feels angry to!ards the nurse !ho resembles his mother. L2. #ristan is on 7ithium has suffered from diarrhea and vomiting. 2hat should the nurse in-charge do first* a. 0ecogni(e this as a drug interaction b. <ive the client Cogentin c. 0eassure the client that these are common side effects of lithium therapy d. 9old the ne/t dose and obtain an order for a stat serum lithium level LF. Nurse ;arah ensures a therapeutic environment for all the client. 2hich of the follo!ing best describes a therapeutic milieu@ a. A therapy that re!ards adaptive behavior b. A cognitive approach to change behavior c. A living, learning or !or$ing environment.
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d. A permissive and congenial environment LE. Anthony is very hostile to!ard one of the staff for no apparent reason. 9e is manifesting* a. b. c. d. ;plitting #ransference Countertransference 0esistance
L>. 8arielle, 1L years old !as se/ually attac$ed !hile on her !ay home from school. ;he is brought to the hospital by her mother. 0ape is an e/ample of !hich type of crisis* a. b. c. d. ;ituational Adventitious :evelopmental 'nternal
76. Nurse <reta is a!are that the follo!ing is classified as an A/is ' disorder by the Diagnosis and Statistical Manual of Mental Disorders, #e/t 0evision :;8-'A-#0" is* a. b. c. d. Bbesity -orderline personality disorder 8a1or depression 9ypertension
LL. Jatrina, a ne!ly admitted is e/tremely hostile to!ard a staff member she has 1ust met, !ithout apparent reason. According to 3reudian theory, the nurse should suspect that the client is e/periencing !hich of the follo!ing phenomena@ a. b. c. d. 'ntellectuali(ation #ransference #riangulation ;plitting
LH. An HFyear-old male client is in e/tended care facility is an/ious most of the time and fre&uently complains of a number of vague symptoms that interfere !ith his ability to eat. #hese symptoms indicate !hich of the follo!ing disorders@ a. Conversion disorder b. 9ypochondriasis c. ;evere an/iety
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d. ;ublimation L9. Charina, a college student !ho fre&uently visited the health center during the past year !ith multiple vague complaints of <' symptoms before course e/aminations. Although physical causes have been eliminated, the student continues to e/press her belief that she has a serious illness. #hese symptoms are typically of !hich of the follo!ing disorders@ a. b. c. d. Conversion disorder :epersonali(ation 9ypochondriasis ;omati(ation disorder
H0. Nurse :aisy is a!are that the follo!ing pharmacologic agents are sedativehypnotic medication is used to induce sleep for a client e/periencing a sleep disorder is* a. b. c. d. #ria(olam 9alcion" 4aro/etine 4a/il"V 3luo/etine 4ro(ac" 0isperidone 0isperdal"
H1. Aldo, !ith a somatoform pain disorder may obtain secondary gain. 2hich of the follo!ing statement refers to a secondary gain@ a. b. c. d. 't brings some stability to the family 't decreases the preoccupation !ith the physical illness 't enables the client to avoid some unpleasant activity 't promotes emotional support or attention for the client
H2. :ervid is diagnosed !ith panic disorder !ith agoraphobia is tal$ing !ith the nurse in-charge about the progress made in treatment. 2hich of the follo!ing statements indicates a positive client response@ a. b. c. d. C' !ent to the mall !ith my friends last ;aturdayD C'5m hyperventilating only !hen ' have a panic attac$D C#oday ' decided that ' can stop ta$ing my medicationD C7ast night ' decided to eat more than a bo!l of cerealD
HF. #he effectiveness of monoamine o/idase 8AB" inhibitor drug therapy in a client !ith posttraumatic stress disorder can be demonstrated by !hich of the follo!ing client self Nreports@ a. C'5m sleeping better and don5t have nightmaresD b. C'5m not losing my temper as muchD c. C'5ve lost my craving for alcoholD
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d. '5ve lost my phobia for !aterD HE. 8ar$, !ith a diagnosis of generali(ed an/iety disorder !ants to stop ta$ing his lora(epam Ativan". 2hich of the follo!ing important facts should nurse -etty discuss !ith the client about discontinuing the medication@ a. b. c. d. ;topping the drug may cause depression ;topping the drug increases cognitive abilities ;topping the drug decreases sleeping difficulties ;topping the drug can cause !ithdra!al symptoms
H>. Pennifer, an adolescent !ho is depressed and reported by his parents as having difficulty in school is brought to the community mental health center to be evaluated. 2hich of the follo!ing other health problems !ould the nurse suspect@ a. b. c. d. An/iety disorder -ehavioral difficulties Cognitive impairment 7abile moods
HG. 0icardo, an outpatient in psychiatric facility is diagnosed !ith dysthymic disorder. 2hich of the follo!ing statement about dysthymic disorder is true@ a. b. c. d. 't involves a mood range from moderate depression to hypomania 't involves a single manic depression 't5s a form of depression that occurs in the fall and !inter 't5s a mood disorder similar to ma1or depression but of mild to moderate severity
HL. #he nurse is a!are that the follo!ing !ays in vascular dementia different from Al(heimer5s disease is* a. b. c. d. Aascular dementia has more abrupt onset #he duration of vascular dementia is usually brief 4ersonality change is common in vascular dementia #he inability to perform motor activities occurs in vascular dementia
HH. 7oretta, a ne!ly admitted client !as diagnosed !ith delirium and has history of hypertension and an/iety. ;he had been ta$ing digo/in, furosemide 7asi/", and dia(epam Aalium" for an/iety. #his client5s impairment may be related to !hich of the follo!ing conditions@ a. 'nfection b. 8etabolic acidosis
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c. :rug into/ication d. 9epatic encephalopathy H9. Nurse 0on enters a client5s room, the client says, C#hey5re cra!ling on my sheetsW <et them off my bedWD 2hich of the follo!ing assessment is the most accurate@ a. b. c. d. #he client is e/periencing aphasia #he client is e/periencing dysarthria #he client is e/periencing a flight of ideas #he client is e/periencing visual hallucination
90. 2hich of the follo!ing descriptions of a client5s e/perience and behavior can be assessed as an illusion@ a. #he client tries to hit the nurse !hen vital signs must be ta$en b. #he client says, C' $eep hearing a voice telling me to run a!ayD c. #he client becomes an/ious !henever the nurse leaves the bedside d. #he client loo$s at the shado! on a !all and tells the nurse she sees frightening faces on the !all. 91. :uring conversation of Nurse Pohn !ith a client, he observes that the client shift from one topic to the ne/t on a regular basis. 2hich of the follo!ing terms describes this disorder@ a. b. c. d. 3light of ideas Concrete thin$ing 'deas of reference 7oose association
92. 3rancis tells the nurse that her co!or$ers are sabotaging the computer. 2hen the nurse as$s &uestions, the client becomes argumentative. #his behavior sho!s personality traits associated !ith !hich of the follo!ing personality disorder@ a. b. c. d. Antisocial 9istrionic 4aranoid ;chi(otypal
9F. 2hich of the follo!ing interventions is important for a Cely e/periencing !ith paranoid personality disorder ta$ing olan(apine Sypre/a"@ a. ./plain effects of serotonin syndrome b. #each the client to !atch for e/trapyramidal adverse reaction
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c. ./plain that the drug is less affective if the client smo$es d. :iscuss the need to report parado/ical effects such as euphoria 9E. Nurse Ale/andra notices other clients on the unit avoiding a client diagnosed !ith antisocial personality disorder. 2hen discussing appropriate behavior in group therapy, !hich of the follo!ing comments is e/pected about this client by his peers@ a. b. c. d. 7ac$ of honesty -elief in superstition ;ho! of temper tantrums Constant need for attention
9>. #ommy, !ith dependent personality disorder is !or$ing to increase his selfesteem. 2hich of the follo!ing statements by the #ommy sho!s teaching !as successful@ a. b. c. d. C'5m not going to loo$ 1ust at the negative things about myselfD C'5m most concerned about my level of competence and progressD C'5m not as envious of the things other people have as ' used to beD C' find ' can5t stop myself from ta$ing over things other should be doingD
9G. Norma, a E2-year-old client !ith a diagnosis of chronic undifferentiated schi(ophrenia lives in a rooming house that has a !ee$ly nursing clinic. ;he scratches !hile she tells the nurse she feels creatures eating a!ay at her s$in. 2hich of the follo!ing interventions should be done first@ a. b. c. d. #al$ about his hallucinations and fears 0efer him for anticholinergic adverse reactions Assess for possible physical problems such as rash Call his physician to get his medication increased to control his psychosis
9L. 'vy, !ho is on the psychiatric unit is copying and imitating the movements of her primary nurse. :uring recovery, she says, C' thought the nurse !as my mirror. ' felt connected only !hen ' sa! my nurse.D #his behavior is $no!n by !hich of the follo!ing terms@ a. b. c. d. 8odeling .chopra/ia .go-syntonicity 0itualism
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9H. Pun approaches the nurse and tells that he hears a voice telling him that he5s evil and deserves to die. 2hich of the follo!ing terms describes the client5s perception@ a. b. c. d. :elusion :isorgani(ed speech 9allucination 'dea of reference
99. 8i$e is admitted to a psychiatric unit !ith a diagnosis of undifferentiated schi(ophrenia. 2hich of the follo!ing defense mechanisms is probably used by mi$e@ a. b. c. d. 4ro1ection 0ationali(ation 0egression 0epression
100. 0oc$y has started ta$ing haloperidol 9aldol". 2hich of the follo!ing instructions is most appropriate for 0ic$y before ta$ing haloperidol@ a. b. c. d. ;hould report feelings of restlessness or agitation at once )se a sunscreen outdoors on a year-round basis -e a!are you5ll feel increased energy ta$ing this drug #his drug !ill indirectly control essential hypertension
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#A$T II
AN;2.0; X 0A#'BNA7.
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TEST I Ans1ers and $ationale 5 %o(ndation of #rofessional N(rsing #ractice 1. Ans1er: :" #he actions of a reasonably prudent nurse !ith similar education and e/perience. $ationale* #he standard of care is determined by the average degree of s$ill, care, and diligence by nurses in similar circumstances. 2. Ans1er* -" '.8 $ationale: 2ith a platelet count of 22,0006=l, the clients tends to bleed easily. #herefore, the nurse should avoid using the '.8. route because the area is a highly vascular and can bleed readily !hen penetrated by a needle. #he bleeding can be difficult to stop. 3. Ans1er: C" C:igo/in 0.12> mg 4.B. once dailyD $ationale: #he nurse should al!ays place a (ero before a decimal point so that no one misreads the figure, !hich could result in a dosage error. #he nurse should never insert a (ero at the end of a dosage that includes a decimal point because this could be misread, possibly leading to a tenfold increase in the dosage. 4. Ans1er: A" 'neffective peripheral tissue perfusion related to venous congestion. $ationale: 'neffective peripheral tissue perfusion related to venous congestion ta$es the highest priority because venous inflammation and clot formation impede blood flo! in a client !ith deep vein thrombosis. 5. Ans1er* -" A EE year-old myocardial infarction 8'" client !ho is complaining of nausea. $ationale: Nausea is a symptom of impending myocardial infarction 8'" and should be assessed immediately so that treatment can be instituted and further damage to the heart is avoided. 6. Ans1er: C" Chec$ circulation every 1>-F0 minutes. $ationale* 0estraints encircle the limbs, !hich place the client at ris$ for circulation being restricted to the distal areas of the e/tremities. Chec$ing the client5s circulation every 1>-F0 minutes !ill allo! the nurse to ad1ust the restraints before in1ury from decreased blood flo! occurs. 7. Ans1er: A" 4revent stress ulcer $ationale: Curling5s ulcer occurs as a generali(ed stress response in burn patients. #his results in a decreased production of mucus and increased secretion of gastric acid. #he best treatment for this prophylactic use of antacids and 92 receptor bloc$ers. 8. Ans1er: :" Continue to monitor and record hourly urine output
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$ationale: Normal urine output for an adult is appro/imately 1 ml6minute G0 ml6hour". #herefore, this client+s output is normal. -eyond continued evaluation, no nursing action is !arranted. 9. Ans1er: -" C8y an$le feels !armD. $ationale: 'ce application decreases pain and s!elling. Continued or increased
pain, redness, and increased !armth are signs of inflammation that shouldn+t occur after ice application
10. Ans1er: -" 9yper$alemia $ationale: A loop diuretic removes !ater and, along !ith it, sodium and potassium. #his may result in hypo$alemia, hypovolemia, and hyponatremia. 11. Ans1er* A" 9ave condescending trust and confidence in their subordinates $ationale* -enevolent-authoritative managers pretentiously sho! their trust and confidence to their follo!ers. 12. Ans1er: A" 4rovides continuous, coordinated and comprehensive nursing services. $ationale: 3unctional nursing is focused on tas$s and activities and not on the care of the patients. 13. Ans1er: -" ;tandard !ritten order $ationale: #his is a standard !ritten order. 4rescribers !rite a single order for medications given only once. A stat order is !ritten for medications given immediately for an urgent client problem. A standing order, also $no!n as a protocol, establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. 3acilities also may institute medication protocols that specifically designate drugs that a nurse may not give. 14. Ans1er* :" 7i&uid or semi-li&uid stools $ationale* 4assage of li&uid or semi-li&uid stools results from seepage of unformed bo!el contents around the impacted stool in the rectum. Clients !ith fecal impaction don+t pass hard, bro!n, formed stools because the feces can+t move past the impaction. #hese clients typically report the urge to defecate although they can+t pass stool" and a decreased appetite. 15. Ans1er* C" 4ulling the heli/ up and bac$ $ationale: #o perform an otoscopic e/amination on an adult, the nurse grasps the heli/ of the ear and pulls it up and bac$ to straighten the ear canal. 3or a child, the nurse grasps the heli/ and pulls it do!n to straighten the ear canal. 4ulling the lobule in any direction !ouldn+t straighten the ear canal for visuali(ation. 16. Ans1er: A" 4rotect the irritated s$in from sunlight. Nursing Crib Student Nurses Community 116
$ationale: 'rradiated s$in is very sensitive and must be protected !ith clothing or sunbloc$. #he priority approach is the avoidance of strong sunlight. 17. Ans1er: C" Assist the client in removing dentures and nail polish. $ationale: :entures, hairpins, and combs must be removed. Nail polish must be removed so that cyanosis can be easily monitored by observing the nail beds. 18. Ans1er: :" ;udden onset of continuous epigastric and bac$ pain. $ationale: #he autodigestion of tissue by the pancreatic en(ymes results in pain from inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric or bac$ pain reflects the inflammatory process in the pancreas. 19. Ans1er: -" 4rovide high-protein, high-carbohydrate diet. $ationale: A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as >000 calories per day. 20. Ans1er: A" -lood pressure and pulse rate. $ationale* #he baseline must be established to recogni(e the signs of an anaphylactic or hemolytic reaction to the transfusion. 21. Ans1er: :" 'mmobili(e the leg before moving the client. $ationale: 'f the nurse suspects a fracture, splinting the area before moving the client is imperative. #he nurse should call for emergency help if the client is not hospitali(ed and call for a physician for the hospitali(ed client. 22. Ans1er: -" Admit the client into a private room. $ationale: #he client !ho has a radiation implant is placed in a private room and has a limited number of visitors. #his reduces the e/posure of others to the radiation. 23. Ans1er: C" 0is$ for infection $ationale: Agranulocytosis is characteri(ed by a reduced number of leu$ocytes leucopenia" and neutrophils neutropenia" in the blood. #he client is at high ris$ for infection because of the decreased body defenses against microorganisms. :eficient $no!ledge related to the nature of the disorder may be appropriate diagnosis but is not the priority. 24. Ans1er: -" 4lace the client on the left side in the #rendelenburg position. $ationale: 7ying on the left side may prevent air from flo!ing into the pulmonary veins. #he #rendelenburg position increases intrathoracic pressure, !hich decreases the amount of blood pulled into the vena cava during aspiration.
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25. Ans1er: A" Autocratic. $ationale: #he autocratic style of leadership is a tas$-oriented and directive. 26. Ans1er* :" 2.> cc $ationale* 2.> cc is to be added, because only a >00 cc bag of solution is being medicated instead of a 1 liter. 27. Ans1er* A" >0 cc6 hour $ationale: A rate of >0 cc6hr. #he child is to receive E00 cc over a period of H hours Y >0 cc6hr. 28. Ans1er: -" Assess the client for presence of pain. $ationale: Assessing the client for pain is a very important measure. 4ostoperative pain is an indication of complication. #he nurse should also assess the client for pain to provide for the client5s comfort. 29. Ans1er: A" -4 N H06G0, 4ulse N 110 irregular $ationale* #he classic signs of cardiogenic shoc$ are lo! blood pressure, rapid and !ea$ irregular pulse, cold, clammy s$in, decreased urinary output, and cerebral hypo/ia. 30. Ans1er: A" #a$e the proper e&uipment, place the client in a comfortable position, and record the appropriate information in the client5s chart. $ationale: 't is a general or comprehensive statement about the correct procedure, and it includes the basic ideas !hich are found in the other options 31. Ans1er* -" .valuation $ationale: .valuation includes observing the person, as$ing &uestions, and comparing the patient5s behavioral responses !ith the e/pected outcomes. 32. Ans1er: C" 9istory of present illness $ationale: #he history of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person5s needs. 33. Ans1er: A" #rochanter roll e/tending from the crest of the ileum to the mid-thigh. $ationale: A trochanter roll, properly placed, provides resistance to the e/ternal rotation of the hip. 34. Ans1er* C" ;tage '''
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$ationale: Clinically, a deep crater or !ithout undermining of ad1acent tissue is noted. 35. Ans1er: A" ;econd intention healing $ationale: 2hen !ounds dehisce, they !ill allo!ed to heal by secondary intention 36. Ans1er: :" #achycardia $ationale: 2ith an e/tracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. 37. Ans1er: A" 0.L> $ationale: #o determine the number of milliliters the client should receive, the nurse uses the fraction method in the follo!ing e&uation. L> mg6M ml Y 100 mg61 ml #o solve for M, cross-multiply* L> mg / 1 ml Y M ml / 100 mg L> Y 100M L>6100 Y M 0.L> ml or U ml" Y M 38. Ans1er: :" 't5s a measure of effect, not a standard measure of !eight or &uantity. $ationale: An insulin unit is a measure of effect, not a standard measure of !eight or &uantity. :ifferent drugs measured in units may have no relationship to one another in &uality or &uantity. 39. Ans1er: -" FH.9 OC $ationale: #o convert 3ahrenheit degreed to Centigrade, use this formula OC Y O3 N F2" Z 1.H OC Y 102 N F2" Z 1.H OC Y L0 Z 1.H OC Y FH.9 40. Ans1er: C" 3ailing eyesight, especially close vision. $ationale: 3ailing eyesight, especially close vision, is one of the first signs of aging in middle life ages EG to GE". 8ore fre&uent aches and pains begin in the early late years ages G> to L9". 'ncrease in loss of muscle tone occurs in later years age H0 and older". 41. Ans1er: A" Chec$ing and taping all connections $ationale: Air lea$s commonly occur if the system isn5t secure. Chec$ing all connections and taping them !ill prevent air lea$s. #he chest drainage system is $ept lo!er to promote drainage N not to prevent lea$s.
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42. Ans1er: A" Chec$ the client5s identification band. $ationale: Chec$ing the client5s identification band is the safest !ay to verify a client5s identity because the band is assigned on admission and isn5t be removed at any time. 'f it is removed, it must be replaced". As$ing the client5s name or having the client repeated his name !ould be appropriate only for a client !ho5s alert, oriented, and able to understand !hat is being said, but isn5t the safe standard of practice. Names on bed aren5t al!ays reliable 43. Ans1er: -" F2 drops6minute $ationale: <iving 1,000 ml over H hours is the same as giving 12> ml over 1 hour G0 minutes". 3ind the number of milliliters per minute as follo!s* 12>6G0 minutes Y M61 minute G0M Y 12> Y 2.1 ml6minute #o find the number of drops per minute* 2.1 ml6M gtt Y 1 ml6 1> gtt M Y F2 gtt6minute, or F2 drops6minute 44. Ans1er* A" Clamp the catheter $ationale* 'f a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. 'f a clamp isn5t available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub !ith alcohol or povidone-iodine solution, the nurse must replace the '.A. e/tension and restart the infusion. 45. Ans1er: :" Auscultation, percussion, and palpation. $ationale: #he correct order of assessment for e/amining the abdomen is inspection, auscultation, percussion, and palpation. #he reason for this approach is that the less intrusive techni&ues should be performed before the more intrusive techni&ues. 4ercussion and palpation can alter natural findings during auscultation. 46. Ans1er: :" )lnar surface of the hand $ationale: #he nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and vocal vibrations through the chest !all. #he fingertips and finger pads best distinguish te/ture and shape. #he dorsal surface best feels !armth. 47. Ans1er* C" 3ormative $ationale: 3ormative or concurrent" evaluation occurs continuously throughout the teaching and learning process. Bne benefit is that the nurse can ad1ust teaching strategies as necessary to enhance learning. ;ummative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. 'nformative is not a type of evaluation.
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48. Ans1er: -" Bnce per year $ationale: ,early mammograms should begin at age E0 and continue for as long as the !oman is in good health. 'f health ris$s, such as family history, genetic tendency, or past breast cancer, e/ist, more fre&uent e/aminations may be necessary. 49. Ans1er: A" 0espiratory acidosis $ationale: #he client has a belo!-normal acidic" blood p9 value and an above-normal partial pressure of arterial carbon dio/ide 4aco2" value, indicating respiratory acidosis. 'n respiratory al$alosis, the p9 value is above normal and in the 4aco2 value is belo! normal. 'n metabolic acidosis, the p9 and bicarbonate 9coF" values are belo! normal. 'n metabolic al$alosis, the p9 and 9coF values are above normal. 50. Ans1er: -" #o provide support for the client and family in coping !ith terminal illness. $ationale: 9ospices provide supportive care for terminally ill clients and their families. 9ospice care doesn5t focus on counseling regarding health care costs. 8ost client referred to hospices have been treated for their disease !ithout success and !ill receive only palliative care in the hospice. 51. Ans1er: C" )sing normal saline solution to clean the ulcer and applying a protective dressing as necessary. $ationale: 2ashing the area !ith normal saline solution and applying a protective dressing are !ithin the nurse5s realm of interventions and !ill protect the area. )sing a povidone-iodine !ash and an antibiotic cream re&uire a physician5s order. 8assaging !ith an astringent can further damage the s$in. 52. Ans1er: :" 3oot $ationale: An elastic bandage should be applied form the distal area to the pro/imal area. #his method promotes venous return. 'n this case, the nurse should begin applying the bandage at the client5s foot. -eginning at the an$le, lo!er thigh, or $nee does not promote venous return. 53. Ans1er: -" 9ypo$alemia $ationale: 'nsulin administration causes glucose and potassium to move into the cells, causing hypo$alemia. 54. Ans1er: A" #hrobbing headache or di((iness $ationale* 9eadache and di((iness often occur !hen nitroglycerin is ta$en at the beginning of therapy. 9o!ever, the client usually develops tolerance
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55. Ans1er: :" Chec$ the client5s level of consciousness $ationale: :etermining unresponsiveness is the first step assessment action to ta$e. 2hen a client is in ventricular tachycardia, there is a significant decrease in cardiac output. 9o!ever, chec$ing the unresponsiveness ensures !hether the client is affected by the decreased cardiac output. 56. Ans1er: -" Bn the affected side of the client. $ationale: 2hen !al$ing !ith clients, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the bac$. #he nurse should position the free hand at the shoulder area so that the client can be pulled to!ard the nurse in the event that there is a for!ard fall. #he client is instructed to loo$ up and out!ard rather than at his or her feet. 57. Ans1er* A" )rine output* E> ml6hr $ationale* Ade&uate perfusion must be maintained to all vital organs in order for the client to remain visible as an organ donor. A urine output of E> ml per hour indicates ade&uate renal perfusion. 7o! blood pressure and delayed capillary refill time are circulatory system indicators of inade&uate perfusion. A serum p9 of L.F2 is acidotic, !hich adversely affects all body tissues. 58. Ans1er: : " Bbtaining the specimen from the urinary drainage bag. $ationale* A urine specimen is not ta$en from the urinary drainage bag. )rine undergoes chemical changes !hile sitting in the bag and does not necessarily reflect the current client status. 'n addition, it may become contaminated !ith bacteria from opening the system. 59. Ans1er: -" Cover the client, place the call light !ithin reach, and ans!er the phone call. $ationale: -ecause telephone call is an emergency, the nurse may need to ans!er it. #he other appropriate action is to as$ another nurse to accept the call. 9o!ever, is not one of the options. #o maintain privacy and safety, the nurse covers the client and places the call light !ithin the client5s reach. Additionally, the client5s door should be closed or the room curtains pulled around the bathing area. 60. Ans1er: C" )se a sterile plastic container for obtaining the specimen. $ationale* ;putum specimens for culture and sensitivity testing need to be obtained using sterile techni&ues because the test is done to determine the presence of organisms. 'f the procedure for obtaining the specimen is not sterile, then the specimen is not sterile, then the specimen !ould be contaminated and the results of the test !ould be invalid.
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61. Ans1er: A" 4uts all the four points of the !al$er flat on the floor, puts !eight on the hand pieces, and then !al$s into it. $ationale* 2hen the client uses a !al$er, the nurse stands ad1acent to the affected side. #he client is instructed to put all four points of the !al$er 2 feet for!ard flat on the floor before putting !eight on hand pieces. #his !ill ensure client safety and prevent stress crac$s in the !al$er. #he client is then instructed to move the !al$er for!ard and !al$ into it. 62. Ans1er: C" :ra!s one line to cross out the incorrect information and then initials the change. $ationale: #o correct an error documented in a medical record, the nurse dra!s one line through the incorrect information and then initials the error. An error is never erased and correction fluid is never used in the medical record. 63. Ans1er: C" ;ecures the client safety belts after transferring to the stretcher. $ationale: :uring the transfer of the client after the surgical procedure is complete, the nurse should avoid e/posure of the client because of the ris$ for potential heat loss. 9urried movements and rapid changes in the position should be avoided because these predispose the client to hypotension. At the time of the transfer from the surgery table to the stretcher, the client is still affected by the effects of the anesthesiaI therefore, the client should not move self. ;afety belts can prevent the client from falling off the stretcher. 64. Ans1er: -" <o!n and gloves $ationale: Contact precautions re&uire the use of gloves and a go!n if direct client contact is anticipated. <oggles are not necessary unless the nurse anticipates the splashes of blood, body fluids, secretions, or e/cretions may occur. ;hoe protectors are not necessary. 65. Ans1er* C" Quad cane $ationale: Crutches and a !al$er can be difficult to maneuver for a client !ith !ea$ness on one side. A cane is better suited for client !ith !ea$ness of the arm and leg on one side. 9o!ever, the &uad cane !ould provide the most stability because of the structure of the cane and because a &uad cane has four legs. 66. Ans1er: :" 7eft side-lying !ith the head of the bed elevated E> degrees. $ationale* #o facilitate removal of fluid from the chest !all, the client is positioned sitting at the edge of the bed leaning over the bedside table !ith the feet supported on a stool. 'f the client is unable to sit up, the client is positioned lying in bed on the unaffected side !ith the head of the bed elevated F0 to E> degrees.
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67. Ans1er: :" 0eliability $ationale: 0eliability is consistency of the research instrument. 't refers to the repeatability of the instrument in e/tracting the same responses upon its repeated administration. 68. Ans1er* A" Jeep the identities of the sub1ect secret $ationale: Jeeping the identities of the research sub1ect secret !ill ensure anonymity because this !ill hinder providing lin$ bet!een the information given to !hoever is its source. 69. Ans1er: A" :escriptive- correlational $ationale: :escriptive- correlational study is the most appropriate for this study because it studies the variables that could be the antecedents of the increased incidence of nosocomial infection. 70. Ans1er: C" )se of laboratory data $ationale: 'ncidence of nosocomial infection is best collected through the use of biophysiologic measures, particularly in vitro measurements, hence laboratory data is essential. 71. Ans1er: -" Quasi-e/periment $ationale: Quasi-e/periment is done !hen randomi(ation and control of the variables are not possible. 72. Ans1er: 6C" 4rimary source $ationale: #his refers to a primary source !hich is a direct account of the investigation done by the investigator. 'n contrast to this is a secondary source, !hich is !ritten by someone other than the original researcher. 73. Ans1er: 6A" Non-maleficence $ationale: Non-maleficence means do not cause harm or do any action that !ill cause any harm to the patient6client. #o do good is referred as beneficence. 74. Ans1er: 6C" 0es ipsa lo&uitor $ationale* 0es ipsa lo&uitor literally means the thing spea$s for itself. #his means in operational terms that the in1ury caused is the proof that there !as a negligent act. 75. Ans1er* -" #he -oard can investigate violations of the nursing la! and code of ethics $ationale: Quasi-1udicial po!er means that the -oard of Nursing has the authority to investigate violations of the nursing la! and can issue summons, subpoena or subpoena duces tecum as needed.
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76. Ans1er: C" 8ay apply for re-issuance of his6her license based on certain conditions stipulated in 0A 91LF $ationale: 0A 91LF sec. 2E states that for e&uity and 1ustice, a revo$ed license maybe re-issued provided that the follo!ing conditions are met* a" the cause for revocation of license has already been corrected or removedI and, b" at least four years has elapsed since the license has been revo$ed. 77. Ans1er: -" 0evie! related literature $ationale: After formulating and delimiting the research problem, the researcher conducts a revie! of related literature to determine the e/tent of !hat has been done on the study by previous researchers. 78. Ans1er: -" 9a!thorne effect $ationale* 9a!thorne effect is based on the study of .lton 8ayo and company about the effect of an intervention done to improve the !or$ing conditions of the !or$ers on their productivity. 't resulted to an increased productivity but not due to the intervention but due to the psychological effects of being observed. #hey performed differently because they !ere under observation. 79. Ans1er: -" :etermines the different nationality of patients fre&uently admitted and decides to get representations samples from each. $ationale* Pudgment sampling involves including samples according to the $no!ledge of the investigator about the participants in the study. 80. Ans1er: -" 8adeleine 7eininger $ationale* 8adeleine 7eininger developed the theory on transcultural theory based on her observations on the behavior of selected people !ithin a culture. 81. Ans1er: 6A" 0andom $ationale* 0andom sampling gives e&ual chance for all the elements in the population to be pic$ed as part of the sample. 82. Ans1er: A" :egree of agreement and disagreement $ationale* 7i$ert scale is a >-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study 83. Ans1er: -" ;r. Callista 0oy $ationale: ;r. Callista 0oy developed the Adaptation 8odel !hich involves the physiologic mode, self-concept mode, role function mode and dependence mode. 84. Ans1er* A" ;pan of control
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$ationale* ;pan of control refers to the number of !or$ers !ho report directly to a manager. 85. Ans1er: -" Autonomy $ationale: 'nformed consent means that the patient fully understands about the surgery, including the ris$s involved and the alternative solutions. 'n giving consent it is done !ith full $no!ledge and is given freely. #he action of allo!ing the patient to decide !hether a surgery is to be done or not e/emplifies the bioethical principle of autonomy. 86. Ans1er: C" Avoid !earing canvas shoes. $ationale: #he client should be instructed to avoid !earing canvas shoes. Canvas shoes cause the feet to perspire, !hich may, in turn, cause s$in irritation and brea$do!n. -oth cotton and cornstarch absorb perspiration. #he client should be instructed to cut toenails straight across !ith nail clippers. 87. Ans1er: :" <round beef patties $ationale* 8eat is an e/cellent source of complete protein, !hich this client needs to repair the tissue brea$do!n caused by pressure ulcers. Branges and broccoli supply vitamin C but not protein. 'ce cream supplies only some incomplete protein, ma$ing it less helpful in tissue repair. 88. Ans1er: :" ;ims5 left lateral $ationale: #he ;ims+ left lateral position is the most common position used to administer a cleansing enema because it allo!s gravity to aid the flo! of fluid along the curve of the sigmoid colon. 'f the client can+t assume this position nor has poor sphincter control, the dorsal recumbent or right lateral position may be used. #he supine and prone positions are inappropriate and uncomfortable for the client. 89. Ans1er: A" Arrange for typing and cross matching of the client5s blood. $ationale: #he nurse first arranges for typing and cross matching of the client+s blood to ensure compatibility !ith donor blood. #he other options, although appropriate !hen preparing to administer a blood transfusion, come later. 90. Ans1er: A" 'ndependent $ationale* Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide !ith the client+s daily routine represents an independent intervention, !hereas consulting !ith the physician and pharmacist to change a client+s medication because of adverse reactions represents an interdependent intervention. Administering an already-prescribed drug on time is a dependent intervention. An intradependent nursing intervention doesn+t e/ist.
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91. Ans1er: :" .valuation $ationale: #he nursing actions described constitute evaluation of the e/pected outcomes. #he findings sho! that the e/pected outcomes have been achieved. Assessment consists of the client+s history, physical e/amination, and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. 'mplementation is the phase of the nursing process !here the nurse puts the plan of care into action. 92. Ans1er* -" #o observe the lo!er e/tremities $ationale: .lastic stoc$ings are used to promote venous return. #he nurse needs to remove them once per day to observe the condition of the s$in underneath the stoc$ings. Applying the stoc$ings increases blood flo! to the heart. 2hen the stoc$ings are in place, the leg muscles can still stretch and rela/, and the veins can fill !ith blood. 93. Ans1er: A" 'nstructing the client to report any itching, s!elling, or dyspnea. $ationale* -ecause administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. ;igns and symptoms of life-threatening allergic reactions include itching, s!elling, and dyspnea. Although the nurse should inform the client of the duration of the transfusion and should document its administration, these actions are less critical to the client+s immediate health. #he nurse should assess vital signs at least hourly during the transfusion. 94. Ans1er* -" :ecrease the rate of feedings and the concentration of the formula. $ationale* Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. :ecreasing the rate of the feeding and the concentration of the formula should decrease the client+s discomfort. 3eedings are normally given at room temperature to minimi(e abdominal cramping. #o prevent aspiration during feeding, the head of the client+s bed should be elevated at least F0 degrees. Also, to prevent bacterial gro!th, feeding containers should be routinely changed every H to 12 hours. 95. Ans1er: :" 0oll the vial gently bet!een the palms. $ationale: 0olling the vial gently bet!een the palms produces heat, !hich helps dissolve the medication. :oing nothing or inverting the vial !ouldn+t help dissolve the medication. ;ha$ing the vial vigorously could cause the medication to brea$ do!n, altering its action. 96. Ans1er: -" Assist the client to the semi-3o!ler position if possible.
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$ationale: -y assisting the client to the semi-3o!ler position, the nurse promotes easier chest e/pansion, breathing, and o/ygen inta$e. #he nurse should secure the elastic band so that the face mas$ fits comfortably and snugly rather than tightly, !hich could lead to irritation. #he nurse should apply the face mas$ from the client+s nose do!n to the chin [ not vice versa. #he nurse should chec$ the connectors bet!een the o/ygen e&uipment and humidifier to ensure that they+re airtightI loosened connectors can cause loss of o/ygen. 97. Ans1er: -" E hours $ationale: A unit of pac$ed 0-Cs may be given over a period of bet!een 1 and E hours. 't shouldn+t infuse for longer than E hours because the ris$ of contamination and sepsis increases after that time. :iscard or return to the blood ban$ any blood not given !ithin this time, according to facility policy. 98. Ans1er* -" 'mmediately before administering the ne/t dose. $ationale: 8easuring the blood drug concentration helps determine !hether the dosing has achieved the therapeutic goal. 3or measurement of the trough, or lo!est, blood level of a drug, the nurse dra!s a blood sample immediately before administering the ne/t dose. :epending on the drug+s duration of action and half-life, pea$ blood drug levels typically are dra!n after administering the ne/t dose. 99. Ans1er: A" #he nurse can implement medication orders &uic$ly. $ationale: A floor stoc$ system enables the nurse to implement medication orders &uic$ly. 't doesn+t allo! for pharmacist input, nor does it minimi(e transcription errors or reinforce accurate calculations. 100. Ans1er: C" ;hifting dullness over the abdomen. $ationale: ;hifting dullness over the abdomen indicates ascites, an abnormal finding. #he other options are normal abdominal findings.
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TEST II Ans1ers and $ationale 5 Comm(nity &ealth N(rsing and Care of the "other and Child 1. Ans1er: A" 'nevitable $ationale: An inevitable abortion is termination of pregnancy that cannot be prevented. 8oderate to severe bleeding !ith mild cramping and cervical dilation !ould be noted in this type of abortion. 2. Ans1er: -" 9istory of syphilis $ationale: 8aternal infections such as syphilis, to/oplasmosis, and rubella are causes of spontaneous abortion. 3. Ans1er* C" 8onitoring apical pulse $ationale: Nursing care for the client !ith a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shoc$ and controlling pain. An elevated pulse rate is an indicator of shoc$. 4. Ans1er* -" 'ncreased caloric inta$e $ationale: <lucose crosses the placenta, but insulin does not. 9igh fetal demands for glucose, combined !ith the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. #his increases the mother5s demand for insulin and is referred to as the diabetogenic effect of pregnancy. 5. Ans1er: A" ./cessive fetal activity. $ationale* #he most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even !ith sensitive instruments, e/cessive nausea and vomiting, and early development of pregnancy-induced hypertension. 3etal activity !ould not be noted. 6. Ans1er: -" Absent patellar refle/es $ationale: Absence of patellar refle/es is an indicator of hypermagnesemia, !hich re&uires administration of calcium gluconate. 7. Ans1er: C" 4resenting part in 2 cm belo! the plane of the ischial spines. $ationale: 3etus at station plus t!o indicates that the presenting part is 2 cm belo! the plane of the ischial spines. 8. Ans1er: A" Contractions every 1 R minutes lasting L0-H0 seconds. $ationale: Contractions every 1 R minutes lasting L0-H0 seconds, is indicative of hyperstimulation of the uterus, !hich could result in in1ury to the mother and the fetus if 4itocin is not discontinued.
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9. Ans1er: C" .J< tracings $ationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity .J<" throught administration of calcium gluconate is an essential part of care. 10. Ans1er* :" 3irst lo! transverse caesarean !as for breech position. 3etus in this pregnancy is in a verte/ presentation. $ationale* #his type of client has no obstetrical indication for a caesarean section as she did !ith her first caesarean delivery. 11. Ans1er* A" #al$ to the mother first and then to the toddler. $ationale: 2hen dealing !ith a crying toddler, the best approach is to tal$ to the mother and ignore the toddler first. #his approach helps the toddler get used to the nurse before she attempts any procedures. 't also gives the toddler an opportunity to see that the mother trusts the nurse. 12. Ans1er* :" 4lace the infant5s arms in soft elbo! restraints. $ationale* ;oft restraints from the upper arm to the !rist prevent the infant from touching her lip but allo! him to hold a favorite item such as a blan$et. -ecause they could damage the operative site, such as ob1ects as pacifiers, suction catheters, and small spoons shouldn5t be placed in a baby5s mouth after cleft repair. A baby in a prone position may rub her face on the sheets and traumati(e the operative site. #he suture line should be cleaned gently to prevent infection, !hich could interfere !ith healing and damage the cosmetic appearance of the repair. 13. Ans1er* -" Allo! the infant to rest before feeding. $ationale: -ecause feeding re&uires so much energy, an infant !ith heart failure should rest before feeding. 14. Ans1er: C" 'ron-rich formula only. $ationale: #he infants at age > months should receive iron-rich formula and that they shouldn5t receive solid food, even baby food until age G months. 15. Ans1er: :" 10 months $ationale* A 10 month old infant can sit alone and understands ob1ect permanence, so he !ould loo$ for the hidden toy. At age E to G months, infants can5t sit securely alone. At age H months, infants can sit securely alone but cannot understand the permanence of ob1ects. 16. Ans1er: :" 4ublic health nursing focuses on preventive, not curative, services. $ationale* #he catchments area in 49N consists of a residential
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community, many of !hom are !ell individuals !ho have greater need for preventive rather than curative services. 17. Ans1er: -" .fficiency $ationale: .fficiency is determining !hether the goals !ere attained at the least possible cost. 18. Ans1er: :" 0ural 9ealth )nit $ationale: 0.A. L1G0 devolved basic health services to local government units 7<)5s ". #he public health nurse is an employee of the 7<). 19. Ans1er* A" 8ayor $ationale: #he local e/ecutive serves as the chairman of the 8unicipal 9ealth -oard. 20. Ans1er: 6A" 1 $ationale* .ach rural health mid!ife is given a population assignment of about >,000. 21. Ans1er: -" 9ealth education and community organi(ing are necessary in providing community health services. $ationale: #he community health nurse develops the health capability of people through health education and community organi(ing activities. 22. Ans1er: -" 8easles $ationale* 4residential 4roclamation No. E is on the 7igtas #igdas 4rogram. 23. Ans1er: :" Core group formation $ationale* 'n core group formation, the nurse is able to transfer the technology of community organi(ing to the potential or informal community leaders through a training program. 24. Ans1er: :" #o ma/imi(e the community5s resources in dealing !ith health problems. $ationale: Community organi(ing is a developmental service, !ith the goal of developing the people5s self-reliance in dealing !ith community health problems. A, - and C are ob1ectives of contributory ob1ectives to this goal. 25. Ans1er: :" #erminal $ationale* #ertiary prevention involves rehabilitation, prevention of permanent disability and disability limitation appropriate for convalescents, the disabled, complicated cases and the terminally ill those in the terminal stage of a disease".
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26. Ans1er: 6A" 'ntrauterine fetal death. $ationale: 'ntrauterine fetal death, abruptio placentae, septic shoc$, and amniotic fluid embolism may trigger normal clotting mechanismsI if clotting factors are depleted, :'C may occur. 4lacenta accreta, dysfunctional labor, and premature rupture of the membranes aren+t associated !ith :'C. 27. Ans1er: C" 120 to 1G0 beats6minute $ationale* A rate of 120 to 1G0 beats6minute in the fetal heart appropriate for filling the heart !ith blood and pumping it out to the system. 28. Ans1er: A" Change the diaper more often. $ationale: :ecreasing the amount of time the s$in comes contact !ith !et soiled diapers !ill help heal the irritation. 29. Ans1er: :" .ndocardial cushion defect $ationale* .ndocardial cushion defects are seen most in children !ith :o!n syndrome, asplenia, or polysplenia. 30. Ans1er* -" :ecreased urine output $ationale* :ecreased urine output may occur in clients receiving '.A. magnesium and should be monitored closely to $eep urine output at greater than F0 ml6hour, because magnesium is e/creted through the $idneys and can easily accumulate to to/ic levels. 31. Ans1er: A" 8enorrhagia $ationale: 8enorrhagia is an e/cessive menstrual period. 32. Ans1er: C" -lood typing $ationale* -lood type !ould be a critical value to have because the ris$ of blood loss is al!ays a potential complication during the labor and delivery process. Appro/imately E0? of a !oman5s cardiac output is delivered to the uterus, therefore, blood loss can occur &uite rapidly in the event of uncontrolled bleeding. 33. Ans1er: :" 4hysiologic anemia $ationale: 9emoglobin values and hematocrit decrease during pregnancy as the increase in plasma volume e/ceeds the increase in red blood cell production. 34. Ans1er: :" A 2 year old infant !ith stridorous breath sounds, sitting up in his mother5s arms and drooling. $ationale* #he infant !ith the air!ay emergency should be treated first, because of the ris$ of epiglottitis. 35. Ans1er: A" 4lacenta previa
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$ationale: 4lacenta previa !ith painless vaginal bleeding. 36. Ans1er* :" .arly in the morning $ationale* -ased on the nurse5s $no!ledge of microbiology, the specimen should be collected early in the morning. #he rationale for this timing is that, because the female !orm lays eggs at night around the perineal area, the first bo!el movement of the day !ill yield the best results. #he specific type of stool specimen used in the diagnosis of pin!orms is called the tape test. 37. Ans1er: A" 'rritability and sei(ures $ationale* 7ead poisoning primarily affects the CN;, causing increased intracranial pressure. #his condition results in irritability and changes in level of consciousness, as !ell as sei(ure disorders, hyperactivity, and learning disabilities. 38. Ans1er: :" C' really need to use the diaphragm and 1elly most during the middle of my menstrual cycleD. $ationale: #he !oman must understand that, although the CfertileD period is appro/imately mid-cycle, hormonal variations do occur and can result in early or late ovulation. #o be effective, the diaphragm should be inserted before every intercourse. 39. Ans1er: C" 0estlessness $ationale* 'n a child, restlessness is the earliest sign of hypo/ia. 7ate signs of hypo/ia in a child are associated !ith a change in color, such as pallor or cyanosis. 40. Ans1er* -" 2al$ one step ahead, !ith the child5s hand on the nurse5s elbo!. $ationale* #his procedure is generally recommended to follo! in guiding a person !ho is blind. 41. Ans1er* A" 7oud, machinery-li$e murmur. $ationale* A loud, machinery-li$e murmur is a characteristic finding associated !ith patent ductus arteriosus. 42. Ans1er* C" 8ore o/ygen, and the ne!born5s metabolic rate increases. $ationale* 2hen cold, the infant re&uires more o/ygen and there is an increase in metabolic rate. Non-shievering thermogenesis is a comple/ process that increases the metabolic rate and rate of o/ygen consumption, therefore, the ne!born increase heat production. 43. Ans1er: :" Aoided $ationale: -efore administering potassium '.A. to any client, the nurse must first chec$ that the client5s $idneys are functioning and that the client
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is voiding. 'f the client is not voiding, the nurse should !ithhold the potassium and notify the physician. 44. Ans1er: c" 7aundry detergent $ationale* .c(ema or dermatitis is an allergic s$in reaction caused by an offending allergen. #he topical allergen that is the most common causative factor is laundry detergent. 45. Ans1er: A" G inches $ationale: #his distance allo!s for easy flo! of the formula by gravity, but the flo! !ill be slo! enough not to overload the stomach too rapidly. 46. Ans1er: A" #he older one gets, the more susceptible he becomes to the complications of chic$en po/. $ationale* Chic$en po/ is usually more severe in adults than in children. Complications, such as pneumonia, are higher in incidence in adults. 47. Ans1er: :" Consult a physician !ho may give them rubella immunoglobulin. $ationale* 0ubella vaccine is made up of attenuated <erman measles viruses. #his is contraindicated in pregnancy. 'mmune globulin, a specific prophylactic against <erman measles, may be given to pregnant !omen. 48. Ans1er* A" Contact tracing $ationale* Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections, such as se/ually transmitted diseases. 49. Ans1er* :" 7eptospirosis $ationale* 7eptospirosis is transmitted through contact !ith the s$in or mucous membrane !ith !ater or moist soil contaminated !ith urine of infected animals, li$e rats. 50. Ans1er* -" Cholera $ationale: 4assage of profuse !atery stools is the ma1or symptom of cholera. -oth amebic and bacillary dysentery are characteri(ed by the presence of blood and6or mucus in the stools. <iardiasis is characteri(ed by fat malabsorption and, therefore, steatorrhea. 51. Ans1er: A" 9emophilus influen(ae $ationale: 9emophilus meningitis is unusual over the age of > years. 'n developing countries, the pea$ incidence is in children less than G months of age. 8orbillivirus is the etiology of measles. ;treptococcus pneumoniae and Neisseria meningitidis may cause meningitis, but age distribution is not specific in young children.
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52. Ans1er: -" -uccal mucosa $ationale: Jopli$5s spot may be seen on the mucosa of the mouth or the throat. 53. Ans1er* A" F seconds $ationale: Ade&uate blood supply to the area allo!s the return of the color of the nailbed !ithin F seconds. 54. Ans1er: -" ;evere dehydration $ationale* #he order of priority in the management of severe dehydration is as follo!s* intravenous fluid therapy, referral to a facility !here 'A fluids can be initiated !ithin F0 minutes, Bresol or nasogastric tube. 2hen the foregoing measures are not possible or effective, then urgent referral to the hospital is done. 55. Ans1er: A" E> infants $ationale: #o estimate the number of infants, multiply total population by F?. 56. Ans1er* A" :4# $ationale* :4# is sensitive to free(ing. #he appropriate storage temperature of :4# is 2 to HO C only. B4A and measles vaccine are highly sensitive to heat and re&uire free(ing. 880 is not an immuni(ation in the ./panded 4rogram on 'mmuni(ation. 57. Ans1er: C" 4roper use of sanitary toilets $ationale: #he ova of the parasite get out of the human body together !ith feces. Cutting the cycle at this stage is the most effective !ay of preventing the spread of the disease to susceptible hosts. 58. Ans1er: :" > s$in lesions, positive slit s$in smear $ationale* A multibacillary leprosy case is one !ho has a positive slit s$in smear and at least > s$in lesions. 59. Ans1er: C" #hic$ened painful nerves $ationale: #he lesion of leprosy is not macular. 't is characteri(ed by a change in s$in color either reddish or !hitish" and loss of sensation, s!eating and hair gro!th over the lesion. 'nability to close the eyelids lagophthalmos" and sin$ing of the nosebridge are late symptoms. 60. Ans1er* -" As$ !here the family resides. $ationale: -ecause malaria is endemic, the first &uestion to determine malaria ris$ is !here the client5s family resides. 'f the area of residence is not a $no!n endemic area, as$ if the child had traveled !ithin the past G months, !here she !as brought and !hether she stayed overnight in that area.
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61. Ans1er* A" 'nability to drin$ $ationale: A sic$ child aged 2 months to > years must be referred urgently to a hospital if he6she has one or more of the follo!ing signs* not able to feed or drin$, vomits everything, convulsions, abnormally sleepy or difficult to a!a$en. 62. Ans1er* A" 0efer the child urgently to a hospital for confinement. $ationale: C-aggy pantsD is a sign of severe marasmus. #he best management is urgent referral to a hospital. 63. Ans1er* :" 7et the child rest for 10 minutes then continue giving Bresol more slo!ly. $ationale* 'f the child vomits persistently, that is, he vomits everything that he ta$es in, he has to be referred urgently to a hospital. Bther!ise, vomiting is managed by letting the child rest for 10 minutes and then continuing !ith Bresol administration. #each the mother to give Bresol more slo!ly. 64. Ans1er: -" ;ome dehydration $ationale* )sing the assessment guidelines of '8C', a child 2 months to > years old" !ith diarrhea is classified as having ;B8. :.9,:0A#'BN if he sho!s 2 or more of the follo!ing signs* restless or irritable, sun$en eyes, the s$in goes bac$ slo! after a s$in pinch. 65. Ans1er* C" Normal $ationale* 'n '8C', a respiratory rate of >06minute or more is fast breathing for an infant aged 2 to 12 months. 66. Ans1er* A" 1 year $ationale: #he baby !ill have passive natural immunity by placental transfer of antibodies. #he mother !ill have active artificial immunity lasting for about 10 years. > doses !ill give the mother lifetime protection. 67. Ans1er: -" E hours $ationale: 2hile the unused portion of other biologicals in .4' may be given until the end of the day, only -C< is discarded E hours after reconstitution. #his is !hy -C< immuni(ation is scheduled only in the morning. 68. Ans1er: -" G months $ationale: After G months, the baby5s nutrient needs, especially the baby5s iron re&uirement, can no longer be provided by mother5s mil$ alone. 69. Ans1er: C) 2E !ee$s
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$ationale: At appro/imately 2F to 2E !ee$s5 gestation, the lungs are developed enough to sometimes maintain e/trauterine life. #he lungs are the most immature system during the gestation period. 8edical care for premature labor begins much earlier aggressively at 21 !ee$s5 gestation" 70. Ans1er: -" ;udden infant death syndrome ;':;" $ationale* ;upine positioning is recommended to reduce the ris$ of ;':; in infancy. #he ris$ of aspiration is slightly increased !ith the supine position. ;uffocation !ould be less li$ely !ith an infant supine than prone and the position for <.0 re&uires the head of the bed to be elevated. 71. Ans1er: C" :ecreased temperature $ationale: #emperature instability, especially !hen it results in a lo! temperature in the neonate, may be a sign of infection. #he neonate5s color often changes !ith an infection process but generally becomes ashen or mottled. #he neonate !ith an infection !ill usually sho! a decrease in activity level or lethargy. 72. Ans1er: :" 4olycythemia probably due to chronic fetal hypo/ia $ationale* #he small-for-gestation neonate is at ris$ for developing polycythemia during the transitional period in an attempt to decrease hypo/ia. #he neonates are also at increased ris$ for developing hypoglycemia and hypothermia due to decreased glycogen stores. 73. Ans1er: C" :es&uamation of the epidermis $ationale: 4ostdate fetuses lose the verni/ caseosa, and the epidermis may become des&uamated. #hese neonates are usually very alert. 7anugo is missing in the postdate neonate. 74. Ans1er: C" 0espiratory depression $ationale* 8agnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and bradycardia. #he serum blood sugar isn5t affected by magnesium sulfate. #he neonate !ould be floppy, not 1ittery. 75. Ans1er: C" 0espiratory rate E0 to G0 breaths6minute $ationale: A respiratory rate E0 to G0 breaths6minute is normal for a neonate during the transitional period. Nasal flaring, respiratory rate more than G0 breaths6minute, and audible grunting are signs of respiratory distress. 76. Ans1er: C" Jeep the cord dry and open to air $ationale: Jeeping the cord dry and open to air helps reduce infection and hastens drying. 'nfants aren5t given tub bath but are sponged off until the cord falls off. 4etroleum 1elly prevents the cord from drying and encourages infection. 4ero/ide could be painful and isn5t recommended.
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77. Ans1er* -" Con1unctival hemorrhage $ationale* Con1unctival hemorrhages are commonly seen in neonates secondary to the cranial pressure applied during the birth process. -ulging fontanelles are a sign of intracranial pressure. ;imian creases are present in E0? of the neonates !ith trisomy 21. Cystic hygroma is a nec$ mass that can affect the air!ay. 78. Ans1er: -" #o assess for prolapsed cord $ationale: After a client has an amniotomy, the nurse should assure that the cord isn+t prolapsed and that the baby tolerated the procedure !ell. #he most effective !ay to do this is to chec$ the fetal heart rate. 3etal !ell-being is assessed via a nonstress test. 3etal position is determined by vaginal e/amination. Artificial rupture of membranes doesn+t indicate an imminent delivery. 79. Ans1er* :" #he parents5 interactions !ith each other. $ationale: 4arental interaction !ill provide the nurse !ith a good assessment of the stability of the family+s home life but it has no indication for parental bonding. 2illingness to touch and hold the ne!born, e/pressing interest about the ne!born+s si(e, and indicating a desire to see the ne!born are behaviors indicating parental bonding. 80. Ans1er: -" 'nstructing the client to use t!o or more peripads to cushion the area $ationale: )sing t!o or more peripads !ould do little to reduce the pain or promote perineal healing. Cold applications, sit( baths, and Jegel e/ercises are important measures !hen the client has a fourth-degree laceration. 81. Ans1er: C" C2hat is your e/pected due date@D $ationale: 2hen obtaining the history of a client !ho may be in labor, the nurse+s highest priority is to determine her current status, particularly her due date, gravidity, and parity. <ravidity and parity affect the duration of labor and the potential for labor complications. 7ater, the nurse should as$ about chronic illnesses, allergies, and support persons. 82. Ans1er: :" Aspirate the neonate5s nose and mouth !ith a bulb syringe. $ationale: #he nurse+s first action should be to clear the neonate+s air!ay !ith a bulb syringe. After the air!ay is clear and the neonate+s color improves, the nurse should comfort and calm the neonate. 'f the problem recurs or the neonate+s color doesn+t improve readily, the nurse should notify the physician. Administering o/ygen !hen the air!ay isn+t clear !ould be ineffective. 83. Ans1er* C" Conducting a bedside ultrasound for an amniotic fluid inde/.
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$ationale: 't isn+t !ithin a nurse+s scope of practice to perform and interpret a bedside ultrasound under these conditions and !ithout speciali(ed training. Bbserving for pooling of stra!-colored fluid, chec$ing vaginal discharge !ith nitra(ine paper, and observing for fla$es of verni/ are appropriate assessments for determining !hether a client has ruptured membranes. 84. Ans1er* C" 8onitor partial pressure of o/ygen 4ao2" levels. $ationale: 8onitoring 4aB2 levels and reducing the o/ygen concentration to $eep 4aB2 !ithin normal limits reduces the ris$ of retinopathy of prematurity in a premature infant receiving o/ygen. Covering the infant+s eyes and humidifying the o/ygen don+t reduce the ris$ of retinopathy of prematurity. -ecause cooling increases the ris$ of acidosis, the infant should be $ept !arm so that his respiratory distress isn+t aggravated. 85. Ans1er: A" 110 to 1F0 calories per $g. $ationale: Calories per $g is the accepted !ay of determined appropriate nutritional inta$e for a ne!born. #he recommended calorie re&uirement is 110 to 1F0 calories per $g of ne!born body !eight. #his level !ill maintain a consistent blood glucose level and provide enough calories for continued gro!th and development. 86. Ans1er: C" F0 to F2 !ee$s $ationale: 'ndividual t!ins usually gro! at the same rate as singletons until F0 to F2 !ee$s5 gestation, then t!ins don5t5 gain !eight as rapidly as singletons of the same gestational age. #he placenta can no longer $eep pace !ith the nutritional re&uirements of both fetuses after F2 !ee$s, so there5s some gro!th retardation in t!ins if they remain in utero at FH to E0 !ee$s. 87. Ans1er: A" con1oined t!ins $ationale: #he type of placenta that develops in mono(ygotic t!ins depends on the time at !hich cleavage of the ovum occurs. Cleavage in con1oined t!ins occurs more than 1F days after fertili(ation. Cleavage that occurs less than F day after fertili(ation results in diamniotic dicchorionic t!ins. Cleavage that occurs bet!een days F and H results in diamniotic monochorionic t!ins. Cleavage that occurs bet!een days H to 1F result in monoamniotic monochorionic t!ins. 88. Ans1er: :" )ltrasound $ationale: Bnce the mother and the fetus are stabili(ed, ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum e/amination shouldn5t be done as this may lead to severe
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bleeding or hemorrhage. ./ternal fetal monitoring !on5t detect a placenta previa, although it !ill detect fetal distress, !hich may result from blood loss or placenta separation. 89. Ans1er: A" 'ncreased tidal volume $ationale: A pregnant client breathes deeper, !hich increases the tidal volume of gas moved in and out of the respiratory tract !ith each breath. #he e/piratory volume and residual volume decrease as the pregnancy progresses. #he inspiratory capacity increases during pregnancy. #he increased o/ygen consumption in the pregnant client is 1>? to 20? greater than in the nonpregnant state. 90. Ans1er* A" :iet $ationale* Clients !ith gestational diabetes are usually managed by diet alone to control their glucose intolerance. Bral hypoglycemic drugs are contraindicated in pregnancy. 7ong-acting insulin usually isn5t needed for blood glucose control in the client !ith gestational diabetes. 91. Ans1er* :" ;ei(ure $ationale: #he anticonvulsant mechanism of magnesium is believes to depress sei(ure foci in the brain and peripheral neuromuscular bloc$ade. 9ypomagnesemia isn5t a complication of preeclampsia. Antihypertensive drug other than magnesium are preferred for sustained hypertension. 8agnesium doesn5t help prevent hemorrhage in preeclamptic clients. 92. Ans1er* C" '.A. fluids $ationale: A sic$le cell crisis during pregnancy is usually managed by e/change transfusion o/ygen, and 7.A. 3luids. #he client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis. Antihypertensive drugs usually aren5t necessary. :iuretic !ouldn5t be used unless fluid overload resulted. 93. Ans1er* A" Calcium gluconate Jalcinate" $ationale: Calcium gluconate is the antidote for magnesium to/icity. #en milliliters of 10? calcium gluconate is given 7.A. push over F to > minutes. 9ydrala(ine is given for sustained elevated blood pressure in preeclamptic clients. 0ho :" immune globulin is given to !omen !ith 0h-negative blood to prevent antibody formation from 09-positive conceptions. Nalo/one is used to correct narcotic to/icity. 94. Ans1er: -" An indurated !heal over 10 mm in diameter appears in EH to L2 hours. $ationale* A positive 44: result !ould be an indurated !heal over 10 mm in diameter that appears in EH to L2 hours. #he area must be a raised !heal, not a flat circumcised area to be considered positive.
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95. Ans1er: C" 4yelonephritis $ational: #he symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. )#' symptoms include dysuria, urgency, fre&uency, and suprapubic tenderness. Asymptomatic bacteriuria doesn5t cause symptoms. -acterial vaginosis causes mil$y !hite vaginal discharge but no systemic symptoms. 96. Ans1er: -" 0h-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. $ationale: 0h isoimmuni(ation occurs !hen 0h-positive fetal blood cells cross into the maternal circulation and stimulate maternal antibody production. 'n subse&uent pregnancies !ith 0h-positive fetuses, maternal antibodies may cross bac$ into the fetal circulation and destroy the fetal blood cells. 97. Ans1er: C" ;upine position $ationale: #he supine position causes compression of the client+s aorta and inferior vena cava by the fetus. #his, in turn, inhibits maternal circulation, leading to maternal hypotension and, ultimately, fetal hypo/ia. #he other positions promote comfort and aid labor progress. 3or instance, the lateral, or side-lying, position improves maternal and fetal circulation, enhances comfort, increases maternal rela/ation, reduces muscle tension, and eliminates pressure points. #he s&uatting position promotes comfort by ta$ing advantage of gravity. #he standing position also ta$es advantage of gravity and aligns the fetus !ith the pelvic angle. 98. Ans1er: -" 'rritability and poor suc$ing. $ationale: Neonates of heroin-addicted mothers are physically dependent on the drug and e/perience !ithdra!al !hen the drug is no longer supplied. ;igns of heroin !ithdra!al include irritability, poor suc$ing, and restlessness. 7ethargy isn+t associated !ith neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in infants !ith fetal alcohol syndrome. 9eroin use during pregnancy hasn+t been lin$ed to specific congenital anomalies. 99. Ans1er: A" Lth to 9th day postpartum $ationale: #he normal involutional process returns the uterus to the pelvic cavity in L to 9 days. A significant involutional complication is the failure of the uterus to return to the pelvic cavity !ithin the prescribed time period. #his is $no!n as subinvolution. 100. Ans1er: -" )terine atony $ationale: 8ultiple fetuses, e/tended labor stimulation !ith o/ytocin, and traumatic delivery commonly are associated !ith uterine atony, !hich may lead to postpartum hemorrhage. )terine inversion may precede or follo! delivery and commonly results from apparent e/cessive traction on the
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umbilical cord and attempts to deliver the placenta manually. )terine involution and some uterine discomfort are normal after delivery.
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TEST III Ans1ers and $ationale 5 Care of Clients 1ith #hysiologic and #sychosocial Alterations 1. Ans1er: C" 7oose, bloody $ationale* Normal bo!el function and soft-formed stool usually do not occur until around the seventh day follo!ing surgery. #he stool consistency is related to ho! much !ater is being absorbed. 2. Ans1er: A" Bn the client5s right side $ationale* #he client has left visual field blindness. #he client !ill see only from the right side. 3. Ans1er* C" Chec$ respirations, stabili(e spine, and chec$ circulation $ationale* Chec$ing the air!ay !ould be priority, and a nec$ in1ury should be suspected. 4. Ans1er: :" :ecreasing venous return through vasodilation. $ationale: The significant effect of nitroglycerin is -asodilation and decreased venous return, so the heart does not have to !or$ hard. 5. Ans1er: A" Call for help and note the time. $ationale* 9aving established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. #his may be done by dialing the operator from the client5s phone and giving the hospital code for cardiac arrest and the client5s room number to the operator, of if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure. 6. Ans1er* C" 8a$e sure that the client ta$es food and medications at prescribed intervals. $ationale* 3ood and drug therapy !ill prevent the accumulation of hydrochloric acid, or !ill neutrali(e and buffer the acid that does accumulate. 7. Ans1er: -" Continue treatment as ordered. $ationale* #he effects of heparin are monitored by the 4## is normally F0 to E> secondsI the therapeutic level is 1.> to 2 times the normal level. 8. Ans1er* -" 'n the operating room. $ationale: #he stoma drainage bag is applied in the operating room. :rainage from the ileostomy contains secretions that are rich in digestive en(ymes and highly irritating to the s$in. 4rotection of the s$in from the effects of these en(ymes is begun at once. ;$in e/posed to these
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en(ymes even for a short time becomes reddened, painful, and e/coriated. 9. Ans1er* -" 3lat on bac$. $ationale* #o avoid the complication of a painful spinal headache that can last for several days, the client is $ept in flat in a supine position for appro/imately E to 12 hours postoperatively. 9eadaches are believed to be causes by the seepage of cerebral spinal fluid from the puncture site. -y $eeping the client flat, cerebral spinal fluid pressures are e&uali(ed, !hich avoids trauma to the neurons. 10. Ans1er: C" #he client is oriented !hen aroused from sleep, and goes bac$ to sleep immediately. $ationale: #his finding suggest that the level of consciousness is decreasing. 11. Ans1er: 6A7 Altered mental status and dehydration $ationale: 3ever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but elderly clients may first appear !ith only an altered lentil status and dehydration due to a blunted immune response. 12. Ans1er: ($) Chills, fever, night s!eats, and hemoptysis $ationale: #ypical signs and symptoms are chills, fever, night s!eats, and hemoptysis. Chest pain may be present from coughing, but isn5t usual. Clients !ith #- typically have lo!-grade fevers, not higher than 102O3 FH.9OC". Nausea, headache, and photophobia aren5t usual #symptoms. 13. Ans1er:(A) Acute asthma $ationale* -ased on the client5s history and symptoms, acute asthma is the most li$ely diagnosis. 9e5s unli$ely to have bronchial pneumonia !ithout a productive cough and fever and he5s too young to have developed CB4:" and emphysema. 14. Ans1er: ($) 0espiratory arrest $ationale* Narcotics can cause respiratory arrest if given in large &uantities. 't5s unli$ely the client !ill have asthma attac$ or a sei(ure or !a$e up on his o!n. 15. Ans1er: (%) :ecreased vital capacity $ationale* 0eduction in vital capacity is a normal physiologic changes include decreased elastic recoil of the lungs, fe!er functional capillaries in the alveoli, and an increased in residual volume.
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16. Ans1er: C" 4resence of premature ventricular contractions 4ACs" on a cardiac monitor. $ationale: 7idocaine drips are commonly used to treat clients !hose arrhythmias haven5t been controlled !ith oral medication and !ho are having 4ACs that are visible on the cardiac monitor. ;aB2, blood pressure, and 'C4 are important factors but aren5t as significant as 4ACs in the situation. 17. Ans1er* -" Avoid foods high in vitamin J $ationale: #he client should avoid consuming large amounts of vitamin J because vitamin J can interfere !ith anticoagulation. #he client may need to report diarrhea, but isn5t effect of ta$ing an anticoagulant. An electric ra(or-not a straight ra(or-should be used to prevent cuts that cause bleeding. Aspirin may increase the ris$ of bleedingI acetaminophen should be used to pain relief. 18. Ans1er* C" Clipping the hair in the area $ationale* 9air can be a source of infection and should be removed by clipping. ;having the area can cause s$in abrasions and depilatories can irritate the s$in. 19. Ans1er* A" -one fracture $ationale* -one fracture is a ma1or complication of osteoporosis that results !hen loss of calcium and phosphate increased the fragility of bones. .strogen deficiencies result from menopause-not osteoporosis. Calcium and vitamin : supplements may be used to support normal bone metabolism, -ut a negative calcium balance isn5t a complication of osteoporosis. :o!ager5s hump results from bone fractures. 't develops !hen repeated vertebral fractures increase spinal curvature. 20. Ans1er* C" Changes from previous e/aminations. $ationale* 2omen are instructed to e/amine themselves to discover changes that have occurred in the breast. Bnly a physician can diagnose lumps that are cancerous, areas of thic$ness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant. 21. Ans1er: C" -alance the client5s periods of activity and rest. $ationale: A client !ith hyperthyroidism needs to be encouraged to balance periods of activity and rest. 8any clients !ith hyperthyroidism are hyperactive and complain of feeling very !arm. 22. Ans1er* -" 'ncrease his activity level. $ationale* #he client should be encouraged to increase his activity level. 8aintaining an ideal !eightI follo!ing a lo!-cholesterol, lo! sodium dietI
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and avoiding stress are all important factors in decreasing the ris$ of atherosclerosis. 23. Ans1er* A" 7aminectomy $ationale: #he client !ho has had spinal surgery, such as laminectomy, must be log rolled to $eep the spinal column straight !hen turning. #horacotomy and cystectomy may turn themselves or may be assisted into a comfortable position. )nder normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery. 24. Ans1er: :" Avoiding straining during bo!el movement or bending at the !aist. $ationale* #he client should avoid straining, lifting heavy ob1ects, and coughing harshly because these activities increase intraocular pressure. #ypically, the client is instructed to avoid lifting ob1ects !eighing more than 1> lb L$g" N not >lb. instruct the client !hen lying in bed to lie on either the side or bac$. #he client should avoid bright light by !earing sunglasses. 25. Ans1er: :" -efore age 20. $ationale: #esticular cancer commonly occurs in men bet!een ages 20 and F0. A male client should be taught ho! to perform testicular selfe/amination before age 20, preferably !hen he enters his teens. 26. Ans1er: -" 4lace a saline-soa$ed sterile dressing on the !ound. $ationale: #he nurse should first place saline-soa$ed sterile dressings on the open !ound to prevent tissue drying and possible infection. #hen the nurse should call the physician and ta$e the client5s vital signs. #he dehiscence needs to be surgically closed, so the nurse should never try to close it. 27. Ans1er: A" A progressively deeper breaths follo!ed by shallo!er breaths !ith apneic periods. $ationale: Cheyne-;tro$es respirations are breaths that become progressively deeper fallo!ed by shallo!er respirations !ith apneas periods. -iot5s respirations are rapid, deep breathing !ith abrupt pauses bet!een each breath, and e&ual depth bet!een each breath. Jussmaul5s respirationa are rapid, deep breathing !ithout pauses. #achypnea is shallo! breathing !ith increased respiratory rate. 28. Ans1er: -" 3ine crac$les $ationale* 3ine crac$les are caused by fluid in the alveoli and commonly occur in clients !ith heart failure. #racheal breath sounds are auscultated over the trachea. Coarse crac$les are caused by secretion accumulation in the air!ays. 3riction rubs occur !ith pleural inflammation.
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29. Ans1er: -" #he air!ays are so s!ollen that no air cannot get through $ationale* :uring an acute attac$, !hee(ing may stop and breath sounds become inaudible because the air!ays are so s!ollen that air can5t get through. 'f the attac$ is over and s!elling has decreased, there !ould be no more !hee(ing and less emergent concern. Crac$les do not replace !hee(es during an acute asthma attac$. 30. Ans1er: :" 4lace the client on his side, remove dangerous ob1ects, and protect his head. $ationale* :uring the active sei(ure phase, initiate precautions by placing the client on his side, removing dangerous ob1ects, and protecting his head from in1ury. A bite bloc$ should never be inserted during the active sei(ure phase. 'nsertion can brea$ the teeth and lead to aspiration. 31. Ans1er* -" Jin$ed or obstructed chest tube $ationales* Jin$ing and bloc$age of the chest tube is a common cause of a tension pneumothora/. 'nfection and e/cessive drainage !on5t cause a tension pneumothora/. ./cessive !ater !on5t affect the chest tube drainage. 32. Ans1er* :" ;tay !ith him but not intervene at this time. $ationale: 'f the client is coughing, he should be able to dislodge the ob1ect or cause a complete obstruction. 'f complete obstruction occurs, the nurse should perform the abdominal thrust maneuver !ith the client standing. 'f the client is unconscious, she should lay him do!n. A nurse should never leave a cho$ing client alone. 33. Ans1er: -" Current health promotion activities $ationale: 0ecogni(ing an individual5s positive health measures is very useful. <eneral health in the previous 10 years is important, ho!ever, the current activities of an HE year old client are most significant in planning care. 3amily history of disease for a client in later years is of minor significance. 8arital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem. 34. Ans1er* C" 4lace the client in a side lying position, !ith the head of the bed lo!ered. $ationale: #he client should be positioned in a side-lying position !ith the head of the bed lo!ered to prevent aspiration. A small amount of toothpaste should be used and the mouth s!abbed or suctioned to remove pooled secretions. 7emon glycerin can be drying if used for e/tended periods. -rushing the teeth !ith the client lying supine may lead to aspiration. 9ydrogen pero/ide is caustic to tissues and should not be used.
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35. Ans1er: C" 4neumonia $ationale* 3ever productive cough and pleuritic chest pain are common signs and symptoms of pneumonia. #he client !ith A0:; has dyspnea and hypo/ia !ith !orsening hypo/ia over time, if not treated aggressively. 4leuritic chest pain varies !ith respiration, unli$e the constant chest pain during an 8'I so this client most li$ely isn5t having an 8'. the client !ith #typically has a cough producing blood-tinged sputum. A sputum culture should be obtained to confirm the nurse5s suspicions. 36. Ans1er: 6C7 A EF-yesr-old homeless man !ith a history of alcoholism $ationale: Clients !ho are economically disadvantaged, malnourished, and have reduced immunity, such as a client !ith a history of alcoholism, are at e/tremely high ris$ for developing #-. A high school student, daycare !or$er, and businessman probably have a much lo! ris$ of contracting #-. 37. Ans1er: 6C 7 #o determine the e/tent of lesions $ationale* 'f the lesions are large enough, the chest M-ray !ill sho! their presence in the lungs. ;putum culture confirms the diagnosis. #here can be false-positive and false-negative s$in test results. A chest M-ray can5t determine if this is a primary or secondary infection. 38. Ans1er: 6*7 -ronchodilators $ationale: -ronchodilators are the first line of treatment for asthma because broncho-constriction is the cause of reduced airflo!. -etaadrenergic bloc$ers aren5t used to treat asthma and can cause bronchoconstriction. 'nhaled oral steroids may be given to reduce the inflammation but aren5t used for emergency relief. 39. Ans1er: 6C7 Chronic obstructive bronchitis $ationale: -ecause of this e/tensive smo$ing history and symptoms the client most li$ely has chronic obstructive bronchitis. Client !ith A0:; have acute symptoms of hypo/ia and typically need large amounts of o/ygen. Clients !ith asthma and emphysema tend not to have chronic cough or peripheral edema. 40. Ans1er: A" #he patient is under local anesthesia during the procedure $ationale* -efore the procedure, the patient is administered !ith drugs that !ould help to prevent infection and re1ection of the transplanted cells such as antibiotics, cytoto/ic, and corticosteroids. :uring the transplant, the patient is placed under general anesthesia. 41. Ans1er* :" 0aise the side rails
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$ationale* A patient !ho is disoriented is at ris$ of falling out of bed. #he initial action of the nurse should be raising the side rails to ensure patients safety. 42. Ans1er: A" Cro!d red blood cells $ationale* #he e/cessive production of !hite blood cells cro!d out red blood cells production !hich causes anemia to occur. 43. Ans1er* -" 7eu$ocytosis $ationale: Chronic 7ymphocytic leu$emia C77" is characteri(ed by increased production of leu$ocytes and lymphocytes resulting in leu$ocytosis, and proliferation of these cells !ithin the bone marro!, spleen and liver. 44. Ans1er: A" ./plain the ris$s of not having the surgery $ationale: #he best initial response is to e/plain the ris$s of not having the surgery. 'f the client understands the ris$s but still refuses the nurse should notify the physician and the nurse supervisor and then record the client5s refusal in the nurses5 notes. 45. Ans1er: :" #he L>-year-old client !ho !as admitted 1 hour ago !ith ne!-onset atrial fibrillation and is receiving 7.A. dilitia(em Cardi(em" $ationale* #he client !ith atrial fibrillation has the greatest potential to become unstable and is on 7.A. medication that re&uires close monitoring. After assessing this client, the nurse should assess the client !ith thrombophlebitis !ho is receiving a heparin infusion, and then the >Hyear-old client admitted 2 days ago !ith heart failure his signs and symptoms are resolving and don5t re&uire immediate attention". #he lo!est priority is the H9-year-old !ith end-stage right-sided heart failure, !ho re&uires time-consuming supportive measures. 46. Ans1er: C" Cocaine $ationale: -ecause of the client5s age and negative medical history, the nurse should &uestion her about cocaine use. Cocaine increases myocardial o/ygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and myocardial infarction. -arbiturate overdose may trigger respiratory depression and slo! pulse. Bpioids can cause mar$ed respiratory depression, !hile ben(odia(epines can cause dro!siness and confusion. 47. Ans1er* 6*7 Nonmobile mass !ith irregular edges $ationale: -reast cancer tumors are fi/ed, hard, and poorly delineated !ith irregular edges. A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst. A/illary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction [ not eversion [ may be a sign of cancer.
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48. Ans1er* C" 0adiation $ationale: #he usual treatment for vaginal cancer is e/ternal or intravaginal radiation therapy. 7ess often, surgery is performed. Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in an early stage, !hich is rare. 'mmunotherapy isn+t used to treat vaginal cancer. 49. Ans1er: -" Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis $ationale: #';, N0, 80 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as #0, N0, 80. 'f the tumor and regional lymph nodes can+t be assessed and no evidence of metastasis e/ists, the lesion is classified as #M, NM, 80. A progressive increase in tumor si(e, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as #1, #2, #F, or #EI N0I and 81, 82, or 8F. 50. Ans1er: :" %Jeep the stoma moist.% $ationale: #he nurse should instruct the client to $eep the stoma moist, such as by applying a thin layer of petroleum 1elly around the edges, because a dry stoma may become irritated. #he nurse should recommend placing a stoma bib over the stoma to filter and !arm air before it enters the stoma. #he client should begin performing stoma care !ithout assistance as soon as possible to gain independence in self-care activities. 51. Ans1er: -" 7ung cancer $ationale: 7ung cancer is the most deadly type of cancer in both !omen and men. -reast cancer ran$s second in !omen, follo!ed in descending order" by colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leu$emia, liver cancer, brain cancer, stomach cancer, and multiple myeloma. 52. Ans1er: A" miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. $ationale: 9orner+s syndrome, !hich occurs !hen a lung tumor invades the ribs and affects the sympathetic nerve ganglia, is characteri(ed by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Chest pain, dyspnea, cough, !eight loss, and fever are associated !ith pleural tumors. Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest 4ancoast+s tumor, a lung tumor involving the first thoracic and eighth cervical nerves !ithin the brachial ple/us. 9oarseness in a client !ith lung cancer suggests that the
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tumor has e/tended to the recurrent laryngeal nerveI dysphagia suggests that the lung tumor is compressing the esophagus. 53. Ans1er: A" prostate-specific antigen, !hich is used to screen for prostate cancer. $ationale: 4;A stands for prostate-specific antigen, !hich is used to screen for prostate cancer. #he other ans!ers are incorrect. 54. Ans1er: :" %0emain supine for the time specified by the physician.% $ationale: #he nurse should instruct the client to remain supine for the time specified by the physician. 7ocal anesthetics used in a subarachnoid bloc$ don+t alter the gag refle/. No interactions bet!een local anesthetics and food occur. 7ocal anesthetics don+t cause hematuria. 55. Ans1er: C" ;igmoidoscopy $ationale: )sed to visuali(e the lo!er <' tract, sigmoidoscopy and proctoscopy aid in the detection of t!o-thirds of all colorectal cancers. ;tool 9ematest detects blood, !hich is a sign of colorectal cancerI ho!ever, the test doesn+t confirm the diagnosis. C.A may be elevated in colorectal cancer but isn+t considered a confirming test. An abdominal C# scan is used to stage the presence of colorectal cancer. 56. Ans1er* -" A fi/ed nodular mass !ith dimpling of the overlying s$in $ationale: A fi/ed nodular mass !ith dimpling of the overlying s$in is common during late stages of breast cancer. 8any !omen have slightly asymmetrical breasts. -loody nipple discharge is a sign of intraductal papilloma, a benign condition. 8ultiple firm, round, freely movable masses that change !ith the menstrual cycle indicate fibrocystic breasts, a benign condition. 57. Ans1er* A" 7iver $ationale: #he liver is one of the five most common cancer metastasis sites. #he others are the lymph nodes, lung, bone, and brain. #he colon, reproductive tract, and 2-Cs are occasional metastasis sites. 58. Ans1er: :" #he client !ears a !atch and !edding band. $ationale: :uring an 80', the client should !ear no metal ob1ects, such as 1e!elry, because the strong magnetic field can pull on them, causing in1ury to the client and if they fly off" to others. #he client must lie still during the 80' but can tal$ to those performing the test by !ay of the microphone inside the scanner tunnel. #he client should hear thumping sounds, !hich are caused by the sound !aves thumping on the magnetic field. 59. Ans1er* C" #he recommended daily allo!ance of calcium may be found in a !ide variety of foods.
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$ationale: 4remenopausal !omen re&uire 1,000 mg of calcium per day. 4ostmenopausal !omen re&uire 1,>00 mg per day. 't+s often, though not al!ays, possible to get the recommended daily re&uirement in the foods !e eat. ;upplements are available but not al!ays necessary. Bsteoporosis doesn+t sho! up on ordinary M-rays until F0? of the bone loss has occurred. -one densitometry can detect bone loss of F? or less. #his test is sometimes recommended routinely for !omen over F> !ho are at ris$. ;trenuous e/ercise !on+t cause fractures. 60. Ans1er: C" Point fle/ion of less than >0? $ationale: Arthroscopy is contraindicated in clients !ith 1oint fle/ion of less than >0? because of technical problems in inserting the instrument into the 1oint to see it clearly. Bther contraindications for this procedure include s$in and !ound infections. Point pain may be an indication, not a contraindication, for arthroscopy. Point deformity and 1oint stiffness aren+t contraindications for this procedure. 61. Ans1er: :" <outy arthritis $ationale: <outy arthritis, a metabolic disease, is characteri(ed by urate deposits and pain in the 1oints, especially those in the feet and legs. )rate deposits don+t occur in septic or traumatic arthritis. ;eptic arthritis results from bacterial invasion of a 1oint and leads to inflammation of the synovial lining. #raumatic arthritis results from blunt trauma to a 1oint or ligament. 'ntermittent arthritis is a rare, benign condition mar$ed by regular, recurrent 1oint effusions, especially in the $nees. 62. Ans1er: -" F0 ml6hou $ationale: An infusion prepared !ith 2>,000 units of heparin in >00 ml of saline solution yields >0 units of heparin per milliliter of solution. #he e&uation is set up as >0 units times M the un$no!n &uantity" e&uals 1,>00 units6hour, M e&uals F0 ml6hour. 63. Ans1er: -" 7oss of muscle contraction decreasing venous return $ationale* 'n clients !ith hemiplegia or hemiparesis loss of muscle contraction decreases venous return and may cause s!elling of the affected e/tremity. Contractures, or bony calcifications may occur !ith a stro$e, but don5t appear !ith s!elling. :A# may develop in clients !ith a stro$e but is more li$ely to occur in the lo!er e/tremities. A stro$e isn5t lin$ed to protein loss. 64. Ans1er: -" 't appears on the distal interphalangeal 1oint $ationale: 9eberden5s nodes appear on the distal interphalageal 1oint on both men and !omen. -ouchard5s node appears on the dorsolateral aspect of the pro/imal interphalangeal 1oint.
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65. Ans1er: -" Bsteoarthritis is a locali(ed disease rheumatoid arthritis is systemic $ationale: Bsteoarthritis is a locali(ed disease, rheumatoid arthritis is systemic. Bsteoarthritis isn5t gender-specific, but rheumatoid arthritis is. Clients have dislocations and sublu/ations in both disorders. 66. Ans1er* C" #he cane should be used on the unaffected side $ationale: A cane should be used on the unaffected side. A client !ith osteoarthritis should be encouraged to ambulate !ith a cane, !al$er, or other assistive device as neededI their use ta$es !eight and stress off 1oints. 67. Ans1er: A" a. 9 ) regular insulin and 21 ) neutral protamine 9agedorn N49". $ationale: A L06F0 insulin preparation is L0? N49 and F0? regular insulin. #herefore, a correct substitution re&uires mi/ing 21 ) of N49 and 9 ) of regular insulin. #he other choices are incorrect dosages for the prescribed insulin. 68. Ans1er: C" colchicines $ationale: A disease characteri(ed by 1oint inflammation especially in the great toe", gout is caused by urate crystal deposits in the 1oints. #he physician prescribes colchicine to reduce these deposits and thus ease 1oint inflammation. Although aspirin is used to reduce 1oint inflammation and pain in clients !ith osteoarthritis and rheumatoid arthritis, it isn+t indicated for gout because it has no effect on urate crystal formation. 3urosemide, a diuretic, doesn+t relieve gout. Calcium gluconate is used to reverse a negative calcium balance and relieve muscle cramps, not to treat gout. 69. Ans1er* A" Adrenal corte/ $ationale: ./cessive secretion of aldosterone in the adrenal corte/ is responsible for the client+s hypertension. #his hormone acts on the renal tubule, !here it promotes reabsorption of sodium and e/cretion of potassium and hydrogen ions. #he pancreas mainly secretes hormones involved in fuel metabolism. #he adrenal medulla secretes the catecholamines [ epinephrine and norepinephrine. #he parathyroids secrete parathyroid hormone. 70. Ans1er* C" #hey debride the !ound and promote healing by secondary intention $ationale: 3or this client, !et-to-dry dressings are most appropriate because they clean the foot ulcer by debriding e/udate and necrotic tissue, thus promoting healing by secondary intention. 8oist, transparent dressings contain e/udate and provide a moist !ound environment. 9ydrocolloid dressings prevent the entrance of microorganisms and
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minimi(e !ound discomfort. :ry sterile dressings protect the !ound from mechanical trauma and promote healing. 71. Ans1er: A" 9yper$alemia $ationale: 'n adrenal insufficiency, the client has hyper$alemia due to reduced aldosterone secretion. -)N increases as the glomerular filtration rate is reduced. 9yponatremia is caused by reduced aldosterone secretion. 0educed cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia. 72. Ans1er: C" 0estricting fluids $ationale: #o reduce !ater retention in a client !ith the ;'A:9, the nurse should restrict fluids. Administering fluids by any route !ould further increase the client+s already heightened fluid load. 73. Ans1er: :" glycosylated hemoglobin level. $ationale: -ecause some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous F months. 3asting blood glucose and urine glucose levels only give information about glucose levels at the point in time !hen they !ere obtained. ;erum fructosamine levels provide information about blood glucose control over the past 2 to F !ee$s. 74. Ans1er: C" E*00 pm $ationale: N49 is an intermediate-acting insulin that pea$s H to 12 hours after administration. -ecause the nurse administered N49 insulin at L a.m., the client is at greatest ris$ for hypoglycemia from F p.m. to L p.m. 75. Ans1er* A" <lucocorticoids and androgens $ationale: #he adrenal glands have t!o divisions, the corte/ and medulla. #he corte/ produces three types of hormones* glucocorticoids, mineralocorticoids, and androgens. #he medulla produces catecholamines [ epinephrine and norepinephrine. 76. Ans1er: A" 9ypocalcemia $ationale: 9ypocalcemia may follo! thyroid surgery if the parathyroid glands !ere removed accidentally. ;igns and symptoms of hypocalcemia may be delayed for up to L days after surgery. #hyroid surgery doesn+t directly cause serum sodium, potassium, or magnesium abnormalities. 9yponatremia may occur if the client inadvertently received too much fluidI ho!ever, this can happen to any surgical client receiving '.A. fluid therapy, not 1ust one recovering from thyroid surgery. 9yper$alemia and
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hypermagnesemia usually are associated !ith reduced renal e/cretion of potassium and magnesium, not thyroid surgery. 77. Ans1er* :" Carcinoembryonic antigen level $ationale: 'n clients !ho smo$e, the level of carcinoembryonic antigen is elevated. #herefore, it can+t be used as a general indicator of cancer. 9o!ever, it is helpful in monitoring cancer treatment because the level usually falls to normal !ithin 1 month if treatment is successful. An elevated acid phosphatase level may indicate prostate cancer. An elevated al$aline phosphatase level may reflect bone metastasis. An elevated serum calcitonin level usually signals thyroid cancer. 78. Ans1er* -" :yspnea, tachycardia, and pallor $ationale: ;igns of iron-deficiency anemia include dyspnea, tachycardia, and pallor as !ell as fatigue, listlessness, irritability, and headache. Night s!eats, !eight loss, and diarrhea may signal ac&uired immunodeficiency syndrome A':;". Nausea, vomiting, and anore/ia may be signs of hepatitis -. 'tching, rash, and 1aundice may result from an allergic or hemolytic reaction. 79. Ans1er: :" %'+ll need to have a C-section if ' become pregnant and have a baby.% $ationale: #he human immunodeficiency virus 9'A" is transmitted from mother to child via the transplacental route, but a Cesarean section delivery isn+t necessary !hen the mother is 9'A-positive. #he use of birth control !ill prevent the conception of a child !ho might have 9'A. 't+s true that a mother !ho+s 9'A positive can give birth to a baby !ho+s 9'A negative. 80. Ans1er: C" %Avoid sharing such articles as toothbrushes and ra(ors.% $ationale: #he human immunodeficiency virus 9'A", !hich causes A':;, is most concentrated in the blood. 3or this reason, the client shouldn+t share personal articles that may be blood-contaminated, such as toothbrushes and ra(ors, !ith other family members. 9'A isn+t transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person !ith A':;. 81. Ans1er: -" 4allor, tachycardia, and a sore tongue $ationale: 4allor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Bther clinical manifestations include anore/iaI !eight lossI a smooth, beefy red tongueI a !ide pulse pressureI palpitationsI anginaI !ea$nessI fatigueI and paresthesia of the hands and feet. -radycardia, reduced pulse pressure, !eight gain, and double vision aren+t characteristic findings in pernicious anemia.
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82. Ans1er: -" Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. $ationale: #o reverse anaphylactic shoc$, the nurse first should administer epinephrine, a potent bronchodilator as prescribed. #he physician is li$ely to order additional medications, such as antihistamines and corticosteroidsI if these medications don+t relieve the respiratory compromise associated !ith anaphyla/is, the nurse should prepare to intubate the client. No antidote for penicillin e/istsI ho!ever, the nurse should continue to monitor the client+s vital signs. A client !ho remains hypotensive may need fluid resuscitation and fluid inta$e and output monitoringI ho!ever, administering epinephrine is the first priority. 83. Ans1er: :" bilateral hearing loss. $ationale: 4rolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of F0 to E0 decibels. )sually, this adverse effect resolves !ithin 2 !ee$s after the therapy is discontinued. Aspirin doesn+t lead to !eight gain or fine motor tremors. 7arge or to/ic salicylate doses may cause respiratory al$alosis, not respiratory acidosis. 84. Ans1er: :" 7ymphocyte $ationale: #he lymphocyte provides adaptive immunity [ recognition of a foreign antigen and formation of memory cells against the antigen. Adaptive immunity is mediated by - and # lymphocytes and can be ac&uired actively or passively. #he neutrophil is crucial to phagocytosis. #he basophil plays an important role in the release of inflammatory mediators. #he monocyte functions in phagocytosis and mono$ine production. 85. Ans1er: A" moisture replacement. $ationale: ;1ogren+s syndrome is an autoimmune disorder leading to progressive loss of lubrication of the s$in, <' tract, ears, nose, and vagina. 8oisture replacement is the mainstay of therapy. #hough malnutrition and electrolyte imbalance may occur as a result of ;1ogren+s syndrome+s effect on the <' tract, it isn+t the predominant problem. Arrhythmias aren+t a problem associated !ith ;1ogren+s syndrome. 86. Ans1er* C" stool for Clostridium difficile test. $ationale: 'mmunosuppressed clients [ for e/ample, clients receiving chemotherapy, [ are at ris$ for infection !ith C. difficile, !hich causes %horse barn% smelling diarrhea. ;uccessful treatment begins !ith an accurate diagnosis, !hich includes a stool test. #he .7';A test is diagnostic for human immunodeficiency virus 9'A" and isn+t indicated in this case. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren+t diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide useful information about bo!el function but isn+t indicated in the case of %horse barn% smelling diarrhea.
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87. Ans1er: :" 2estern blot test !ith .7';A. $ationale: 9'A infection is detected by analy(ing blood for antibodies to 9'A, !hich form appro/imately 2 to 12 !ee$s after e/posure to 9'A and denote infection. #he 2estern blot test [ electrophoresis of antibody proteins [ is more than 9H? accurate in detecting 9'A antibodies !hen used in con1unction !ith the .7';A. 't isn+t specific !hen used alone. .rosette immunofluorescence is used to detect viruses in generalI it doesn+t confirm 9'A infection. Quantification of #-lymphocytes is a useful monitoring test but isn+t diagnostic for 9'A. #he .7';A test detects 9'A antibody particles but may yield inaccurate resultsI a positive .7';A result must be confirmed by the 2estern blot test. 88. Ans1er: C" Abnormally lo! hematocrit 9C#" and hemoglobin 9b" levels $ationale: 7o! preoperative 9C# and 9b levels indicate the client may re&uire a blood transfusion before surgery. 'f the 9C# and 9b levels decrease during surgery because of blood loss, the potential need for a transfusion increases. 4ossible renal failure is indicated by elevated -)N or creatinine levels. )rine constituents aren+t found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes. 89. Ans1er: A" 4latelet count, prothrombin time, and partial thromboplastin time $ationale: #he diagnosis of :'C is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as !ell as client history and other assessment factors. -lood glucose levels, 2-C count, calcium levels, and potassium levels aren+t used to confirm a diagnosis of :'C. 90. Ans1er: :" ;tra!berries $ationale: Common food allergens include berries, peanuts, -ra(il nuts, cashe!s, shellfish, and eggs. -read, carrots, and oranges rarely cause allergic reactions. 91. Ans1er: -" A client !ith cast on the right leg !ho states, C' have a funny feeling in my right leg.D $ationale: 't may indicate neurovascular compromise, re&uires immediate assessment. 92. Ans1er* :" A G2-year-old !ho had an abdominal-perineal resection three days agoI client complaints of chills. $ationale* #he client is at ris$ for peritonitisI should be assessed for further symptoms and infection.
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93. Ans1er* C" #he client spontaneously fle/es his !rist !hen the blood pressure is obtained. $ationale: Carpal spasms indicate hypocalcemia. 94. Ans1er: :" )se comfort measures and pillo!s to position the client. $ationale: )sing comfort measures and pillo!s to position the client is a non-pharmacological methods of pain relief. 95. Ans1er: -" 2arm the dialysate solution. $ationale: Cold dialysate increases discomfort. #he solution should be !armed to body temperature in !armer or heating padI don5t use micro!ave oven. 96. Ans1er: C" #he client holds the cane !ith his left hand, moves the cane for!ard follo!ed by the right leg, and then moves the left leg. $ationale: #he cane acts as a support and aids in !eight bearing for the !ea$er right leg. 97. Ans1er: A" As$ the !oman5s family to provide personal items such as photos or mementos. $ationale: 4hotos and mementos provide visual stimulation to reduce sensory deprivation. 98. Ans1er: -" #he client lifts the !al$er, moves it for!ard 10 inches, and then ta$es several small steps for!ard. $ationale: A !al$er needs to be pic$ed up, placed do!n on all legs. 99. Ans1er: C" 'solation from their families and familiar surroundings. $ationale: <radual loss of sight, hearing, and taste interferes !ith normal functioning. 100. Ans1er: A" .ncourage the client to perform pursed lip breathing. $ationale: 4urse lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing.
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TEST I. Ans1ers and $ationale 5 Care of Clients 1ith #hysiologic and #sychosocial Alterations 1. Ans1er: C" 9ypertension $ationale: 9ypertension, along !ith fever, and tenderness over the grafted $idney, reflects acute re1ection. 2. Ans1er: A" 4ain $ationale* ;harp, severe pain renal colic" radiating to!ard the genitalia and thigh is caused by uretheral distention and smooth muscle spasmI relief form pain is the priority. 3. Ans1er: :" :ecrease the si(e and vascularity of the thyroid gland. $ationale: 7ugol5s solution provides iodine, !hich aids in decreasing the vascularity of the thyroid gland, !hich limits the ris$ of hemorrhage !hen surgery is performed. 4. Ans1er: A" 7iver :isease $ationale: #he client !ith liver disease has a decreased ability to metaboli(e carbohydrates because of a decreased ability to form glycogen glycogenesis" and to form glucose from glycogen. 5. Ans1er: C" 7eu$openia $ationale* 7eu$openia, a reduction in 2-Cs, is a systemic effect of chemotherapy as a result of myelosuppression. 6. Ans1er: C" Avoid foods that in the past caused flatus. $ationale* 3oods that bothered a person preoperatively !ill continue to do so after a colostomy. 7. Ans1er: -" Jeep the irrigating container less than 1H inches above the stoma.D $ationale: #his height permits the solution to flo! slo!ly !ith little force so that e/cessive peristalsis is not immediately precipitated. 8. Ans1er: A" Administer Jaye/alate $ationale: Jaye/alate,a potassium e/change resin, permits sodium to be e/changed for potassium in the intestine, reducing the serum potassium level. 9. Ans1er: -" 2H gtt6min $ationale: #his is the correct flo! rateI multiply the amount to be infused 2000 ml" by the drop factor 10" and divide the result by the amount of time in minutes 12 hours / G0 minutes"
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10. Ans1er: :" )pper trun$ $ationale: #he percentage designated for each burned part of the body using the rule of nines* 9ead and nec$ 9?I 0ight upper e/tremity 9?I 7eft upper e/tremity 9?I Anterior trun$ 1H?I 4osterior trun$ 1H?I 0ight lo!er e/tremity 1H?I 7eft lo!er e/tremity 1H?I 4erineum 1?. 11. Ans1er: C" -leeding from ears $ationale: #he nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. -leeding from the ears occurs only !ith basal s$ull fractures that can easily contribute to increased intracranial pressure and brain herniation. 12. Ans1er: :" may engage in contact sports $ationale: #he client should be advised by the nurse to avoid contact sports. #his !ill prevent trauma to the area of the pacema$er generator. 13. Ans1er* A" B/ygen at 1-276min is given to maintain the hypo/ic stimulus for breathing. $ationale: CB4: causes a chronic CB2 retention that renders the medulla insensitive to the CB2 stimulation for breathing. #he hypo/ic state of the client then becomes the stimulus for breathing. <iving the client o/ygen in lo! concentrations !ill maintain the client5s hypo/ic drive. 14. Ans1er: -" 3acilitate ventilation of the left lung. $ationale: ;ince only a partial pneumonectomy is done, there is a need to promote e/pansion of this remaining 7eft lung by positioning the client on the opposite unoperated side. 15. Ans1er: A" 3ood and fluids !ill be !ithheld for at least 2 hours. $ationale: 4rior to bronchoscopy, the doctors sprays the bac$ of the throat !ith anesthetic to minimi(e the gag refle/ and thus facilitate the insertion of the bronchoscope. <iving the client food and drin$ after the procedure !ithout chec$ing on the return of the gag refle/ can cause the client to aspirate. #he gag refle/ usually returns after t!o hours. 16. Ans1er: C" hyper$alemia. $ationale: 9yper$alemia is a common complication of acute renal failure. 't+s life-threatening if immediate action isn+t ta$en to reverse it. #he administration of glucose and regular insulin, !ith sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. 9ypernatremia, hypo$alemia, and hypercalcemia don+t usually occur !ith acute renal failure and aren+t treated !ith glucose, insulin, or sodium bicarbonate.
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17. Ans1er: A" #his condition puts her at a higher ris$ for cervical cancerI therefore, she should have a 4apanicolaou 4ap" smear annually. $ationale: 2omen !ith condylomata acuminata are at ris$ for cancer of the cervi/ and vulva. ,early 4ap smears are very important for early detection. -ecause condylomata acuminata is a virus, there is no permanent cure. -ecause condylomata acuminata can occur on the vulva, a condom !on+t protect se/ual partners. 94A can be transmitted to other parts of the body, such as the mouth, oropharyn/, and laryn/. 18. Ans1er: A" #he left $idney usually is slightly higher than the right one. $ationale: #he left $idney usually is slightly higher than the right one. An adrenal gland lies atop each $idney. #he average $idney measures appro/imately 11 cm E-F6H%" long, > to >.H cm 2% to 2\%" !ide, and 2.> cm 1%" thic$. #he $idneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. #hey lie bet!een the 12th thoracic and Frd lumbar vertebrae. 19. Ans1er: C" -lood urea nitrogen -)N" 100 mg6dl and serum creatinine G.> mg6dl. $ationale: #he normal -)N level ranges H to 2F mg6dlI the normal serum creatinine level ranges from 0.L to 1.> mg6dl. #he test results in option C are abnormally elevated, reflecting C03 and the $idneys+ decreased ability to remove nonprotein nitrogen !aste from the blood. C03 causes decreased p9 and increased hydrogen ions [ not vice versa. C03 also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of F.> mg6dl falls !ithin the normal range of 2.L to L.L mg6dlI 4;4 e/cretion of L>? also falls !ith the normal range of G0? to L>?. 20. Ans1er: :" Alteration in the si(e, shape, and organi(ation of differentiated cells $ationale: Dysplasia refers to an alteration in the si(e, shape, and organi(ation of differentiated cells. #he presence of completely undifferentiated tumor cells that don+t resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. 0eplacement of one type of fully differentiated cell by another in tissues !here the second type normally isn+t found is called metaplasia. 21. Ans1er: :" Japosi+s sarcoma $ationale: Japosi+s sarcoma is the most common cancer associated !ith A':;. ;&uamous cell carcinoma, multiple myeloma, and leu$emia may occur in anyone and aren+t associated specifically !ith A':;. 22. Ans1er: C" #o prevent cerebrospinal fluid C;3" lea$age
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$ationale: #he client receiving a subarachnoid bloc$ re&uires special positioning to prevent C;3 lea$age and headache and to ensure proper anesthetic distribution. 4roper positioning doesn+t help prevent confusion, sei(ures, or cardiac arrhythmias. 23. Ans1er: A" Auscultate bo!el sounds. $ationale: 'f abdominal distention is accompanied by nausea, the nurse must first auscultate bo!el sounds. 'f bo!el sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. 4alpation should be avoided postoperatively !ith abdominal distention. 'f peristalsis is absent, changing positions and inserting a rectal tube !on+t relieve the client+s discomfort. 24. Ans1er: -" 7ying on the left side !ith $nees bent $ationale: 3or a colonoscopy, the nurse initially should position the client on the left side !ith $nees bent. 4lacing the client on the right side !ith legs straight, prone !ith the torso elevated, or bent over !ith hands touching the floor !ouldn+t allo! proper visuali(ation of the large intestine. 25. Ans1er: A" -lood supply to the stoma has been interrupted $ationale: An ileostomy stoma forms as the ileum is brought through the abdominal !all to the surface s$in, creating an artificial opening for !aste elimination. #he stoma should appear cherry red, indicating ade&uate arterial perfusion. A dus$y stoma suggests decreased perfusion, !hich may result from interruption of the stoma+s blood supply and may lead to tissue damage or necrosis. A dus$y stoma isn+t a normal finding. Ad1usting the ostomy bag !ouldn+t affect stoma color, !hich depends on blood supply to the area. An intestinal obstruction also !ouldn+t change stoma color. 26. Ans1er: A" Applying $nee splints $ationale: Applying $nee splints prevents leg contractures by holding the 1oints in a position of function. .levating the foot of the bed can+t prevent contractures because this action doesn+t hold the 1oints in a position of function. 9ypere/tending a body part for an e/tended time is inappropriate because it can cause contractures. 4erforming shoulder range-of-motion e/ercises can prevent contractures in the shoulders, but not in the legs. 27. Ans1er: -" )rine output of 20 ml6hour. $ationale: A urine output of less than E0 ml6hour in a client !ith burns indicates a fluid volume deficit. #his client+s 4aB2 value falls !ithin the normal range H0 to 100 mm 9g". 2hite pulmonary secretions also are normal. #he client+s rectal temperature isn+t significantly elevated and probably results from the fluid volume deficit. 28. Ans1er: A" #urn him fre&uently.
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$ationale: #he most important intervention to prevent pressure ulcers is fre&uent position changes, !hich relieve pressure on the s$in and underlying tissues. 'f pressure isn+t relieved, capillaries become occluded, reducing circulation and o/ygenation of the tissues and resulting in cell death and ulcer formation. :uring passive 0B8 e/ercises, the nurse moves each 1oint through its range of movement, !hich improves 1oint mobility and circulation to the affected area but doesn+t prevent pressure ulcers. Ade&uate hydration is necessary to maintain healthy s$in and ensure tissue repair. A footboard prevents plantar fle/ion and footdrop by maintaining the foot in a dorsifle/ed position. 29. Ans1er: C" 'n long, even, out!ard, and do!n!ard stro$es in the direction of hair gro!th $ationale: 2hen applying a topical agent, the nurse should begin at the midline and use long, even, out!ard, and do!n!ard stro$es in the direction of hair gro!th. #his application pattern reduces the ris$ of follicle irritation and s$in inflammation. 30. Ans1er: A" -eta -adrenergic bloc$ers $ationale: -eta-adrenergic bloc$ers !or$ by bloc$ing beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. #hey protect the myocardium, helping to reduce the ris$ of another infraction by decreasing myocardial o/ygen demand. Calcium channel bloc$ers reduce the !or$load of the heart by decreasing the heart rate. Narcotics reduce myocardial o/ygen demand, promote vasodilation, and decrease an/iety. Nitrates reduce myocardial o/ygen consumption bt decreasing left ventricular end diastolic pressure preload" and systemic vascular resistance afterload". 31. Ans1er: C" 0aised F0 degrees $ationale: Pugular venous pressure is measured !ith a centimeter ruler to obtain the vertical distance bet!een the sternal angle and the point of highest pulsation !ith the head of the bed inclined bet!een 1> to F0 degrees. 'ncreased pressure can5t be seen !hen the client is supine or !hen the head of the bed is raised 10 degrees because the point that mar$s the pressure level is above the 1a! therefore, not visible". 'n high 3o!ler5s position, the veins !ould be barely discernible above the clavicle. 32. Ans1er: :" 'notropic agents $ationale: 'notropic agents are administered to increase the force of the heart5s contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. -eta-adrenergic bloc$ers and calcium channel bloc$ers decrease the heart rate and ultimately decreased the !or$load of the heart. :iuretics are administered to decrease the overall vascular volume, also decreasing the !or$load of the heart.
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33. Ans1er: -" 7ess than F0? of calories form fat $ationale: A client !ith lo! serum 9:7 and high serum 7:7 levels should get less than F0? of daily calories from fat. #he other modifications are appropriate for this client. 34. Ans1er: C" #he emergency department nurse calls up the latest electrocardiogram results to chec$ the client5s progress $ationale: #he emergency department nurse is no longer directly involved !ith the client5s care and thus has no legal right to information about his present condition. Anyone directly involved in his care such as the telemetry nurse and the on-call physician" has the right to information about his condition. -ecause the client re&uested that the nurse update his !ife on his condition, doing so doesn5t breach confidentiality. 35. Ans1er: -" Chec$ endotracheal tube placement. $ationale: .# tube placement should be confirmed as soon as the client arrives in the emergency department. Bnce the air!ays is secured, o/ygenation and ventilation should be confirmed using an end-tidal carbon dio/ide monitor and pulse o/imetry. Ne/t, the nurse should ma$e sure 7.A. access is established. 'f the client e/periences symptomatic bradycardia, atropine is administered as ordered 0.> to 1 mg every F to > minutes to a total of F mg. #hen the nurse should try to find the cause of the client5s arrest by obtaining an A-< sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation and atrial flutter N not symptomatic bradycardia. 36. Ans1er: C" 9> mm 9g $ationale: )se the follo!ing formula to calculate 8A4 8A4 Y systolic ] 2 diastolic" F 8A4Y12G mm 9g ] 2 H0 mm 9g" F 8A4Y2HG mm 9< F 8A4Y9> mm 9g 37. Ans1er: C" .lectrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel. $ationale: An electrocardiogram evaluates the complaints of chest pain, laboratory tests determines anemia, and the stool test for occult blood determines blood in the stool. Cardiac monitoring, o/ygen, and creatine $inase and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and al$aline phosphatase and aspartate aminotransferase levels assess liver function. 4rothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are
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measured to verify bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity. 38. Ans1er: :" 9eparin-associated thrombosis and thrombocytopenia 9A##" $ationale: 9A## may occur after CA-< surgery due to heparin use during surgery. Although :'C and '#4 cause platelet aggregation and bleeding, neither is common in a client after revasculari(ation surgery. 4ancytopenia is a reduction in all blood cells. 39. Ans1er: -" Corticosteroids $ationale: Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets. 8ethotre/ate can cause thrombocytopenia. Aitamin J is used to treat an e/cessive anticoagulate state from !arfarin overload, and A;A decreases platelet aggregation. 40. Ans1er: :" Menogeneic $ationale: An /enogeneic transplant is bet!een is bet!een human and another species. A syngeneic transplant is bet!een identical t!ins, allogeneic transplant is bet!een t!o humans, and autologous is a transplant from the same individual. 41. Ans1er: -" $ationale: #issue thromboplastin is released !hen damaged tissue comes in contact !ith clotting factors. Calcium is released to assist the conversion of factors M to Ma. Conversion of factors M'' to M''a and A''' to A'''a are part of the intrinsic path!ay. 42. Ans1er: C" .ssential thrombocytopenia $ationale: .ssential thrombocytopenia is lin$ed to immunologic disorders, such as ;7. and human immunodeficiency vitus. #he disorder $no!n as von 2illebrand5s disease is a type of hemophilia and isn5t lin$ed to ;7.. 8oderate to severe anemia is associated !ith ;7., not polycythermia. :ressler5s syndrome is pericarditis that occurs after a myocardial infarction and isn5t lin$ed to ;7.. 43. Ans1er: -" Night s!eat $ationale: 'n stage 1, symptoms include a single enlarged lymph node usually", une/plained fever, night s!eats, malaise, and generali(ed pruritis. Although splenomegaly may be present in some clients, night s!eats are generally more prevalent. 4ericarditis isn5t associated !ith 9odg$in5s disease, nor is hypothermia. 8oreover, splenomegaly and pericarditis aren5t symptoms. 4ersistent hypothermia is associated !ith 9odg$in5s but isn5t an early sign of the disease.
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44. Ans1er: :" -reath sounds $ationale: 4neumonia, both viral and fungal, is a common cause of death in clients !ith neutropenia, so fre&uent assessment of respiratory rate and breath sounds is re&uired. Although assessing blood pressure, bo!el sounds, and heart sounds is important, it !on5t help detect pneumonia. 45. Ans1er: -" 8uscle spasm $ationale: -ac$ pain or paresthesia in the lo!er e/tremities may indicate impending spinal cord compression from a spinal tumor. #his should be recogni(ed and treated promptly as progression of the tumor may result in paraplegia. #he other options, !hich reflect parts of the nervous system, aren5t usually affected by 88. 46. Ans1er: C"10 years $ationale: .pidermiologic studies sho! the average time from initial contact !ith 9'A to the development of A':; is 10 years. 47. Ans1er: A" 7o! platelet count $ationale: 'n :'C, platelets and clotting factors are consumed, resulting in microthrombi and e/cessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. 3ibrin degeneration products increase as fibrinolysis ta$es places. 48. Ans1er: :" 9odg$in5s disease $ationale: 9odg$in5s disease typically causes fever night s!eats, !eight loss, and lymph mode enlargement. 'nfluen(a doesn5t last for months. Clients !ith sic$le cell anemia manifest signs and symptoms of chronic anemia !ith pallor of the mucous membrane, fatigue, and decreased tolerance for e/erciseI they don5t sho! fever, night s!eats, !eight loss or lymph node enlargement. 7eu$emia doesn5t cause lymph node enlargement. 49. Ans1er: C" A 0h-negative $ationale: 9uman blood can sometimes contain an inherited : antigen. 4ersons !ith the : antigen have 0h-positive blood typeI those lac$ing the antigen have 0h-negative blood. 't5s important that a person !ith 0hnegative blood receives 0h-negative blood. 'f 0h-positive blood is administered to an 0h-negative person, the recipient develops anti-0h agglutinins, and sub se&uent transfusions !ith 0h-positive blood may cause serious reactions !ith clumping and hemolysis of red blood cells. 50. Ans1er: -" C' !ill call my doctor if ;tacy has persistent vomiting and diarrheaD. $ationale: 4ersistent more than 2E hours" vomiting, anore/ia, and diarrhea are signs of to/icity and the patient should stop the medication
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and notify the health care provider. #he other manifestations are e/pected side effects of chemotherapy. 51. Ans1er: :" C#his is only temporaryI ;tacy !ill re-gro! ne! hair in F-G months, but may be different in te/tureD. $ationale: #his is the appropriate response. #he nurse should help the mother ho! to cope !ith her o!n feelings regarding the child5s disease so as not to affect the child negatively. 2hen the hair gro!s bac$, it is still of the same color and te/ture. 52. Ans1er: -" Apply viscous 7idocaine to oral ulcers as needed. $ationale: ;tomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. 2hen the patient is already comfortable, the nurse can proceed !ith providing the patient !ith oral rinses of saline solution mi/ed !ith e&ual part of !ater or hydrogen pero/ide mi/ed !ater in 1*F concentrations to promote oral hygiene. .very 2-E hours. 53. Ans1er* C" 'mmediately discontinue the infusion $ationale: .dema or s!elling at the 'A site is a sign that the needle has been dislodged and the 'A solution is lea$ing into the tissues causing the edema. #he patient feels pain as the nerves are irritated by pressure and the 'A solution. #he first action of the nurse !ould be to discontinue the infusion right a!ay to prevent further edema and other complication. 54. Ans1er: C" Chronic obstructive bronchitis $ationale: Clients !ith chronic obstructive bronchitis appear bloatedI they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis. Clients !ith A0:; are acutely short of breath and fre&uently need intubation for mechanical ventilation and large amount of o/ygen. Clients !ith asthma don5t e/hibit characteristics of chronic disease, and clients !ith emphysema appear pin$ and cachectic. 55. Ans1er: :" .mphysema $ationale: -ecause of the large amount of energy it ta$es to breathe, clients !ith emphysema are usually cachectic. #hey5re pin$ and usually breathe through pursed lips, hence the term Cpuffer.D Clients !ith A0:; are usually acutely short of breath. Clients !ith asthma don5t have any particular characteristics, and clients !ith chronic obstructive bronchitis are bloated and cyanotic in appearance. 56. Ans1er: % H0 mm 9g $ationale: A client about to go into respiratory arrest !ill have inefficient ventilation and !ill be retaining carbon dio/ide. #he value e/pected !ould be around H0 mm 9g. All other values are lo!er than e/pected.
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57. Ans1er* C" 0espiratory acidosis $ationale: -ecause 4aco2 is high at H0 mm 9g and the metabolic measure, 9CBF- is normal, the client has respiratory acidosis. #he p9 is less than L.F>, academic, !hich eliminates metabolic and respiratory al$alosis as possibilities. 'f the 9CBF- !as belo! 22 m.&67 the client !ould have metabolic acidosis. 58. Ans1er* C" 0espiratory failure $ationale: #he client !as reacting to the drug !ith respiratory signs of impending anaphyla/is, !hich could lead to eventually respiratory failure. Although the signs are also related to an asthma attac$ or a pulmonary embolism, consider the ne! drug first. 0heumatoid arthritis doesn5t manifest these signs. 59. Ans1er: :" .levated serum aminotransferase $ationale: 9epatic cell death causes release of liver en(ymes alanine aminotransferase A7#", aspartate aminotransferase A;#" and lactate dehydrogenase 7:9" into the circulation. 7iver cirrhosis is a chronic and irreversible disease of the liver characteri(ed by generali(ed inflammation and fibrosis of the liver tissues. 60. Ans1er: A" 'mpaired clotting mechanism $ationale: Cirrhosis of the liver results in decreased Aitamin J absorption and formation of clotting factors resulting in impaired clotting mechanism. 61. Ans1er: -" Altered level of consciousness $ationale: Changes in behavior and level of consciousness are the first sins of hepatic encephalopathy. 9epatic encephalopathy is caused by liver failure and develops !hen the liver is unable to convert protein metabolic product ammonia to urea. #his results in accumulation of ammonia and other to/ic in the blood that damages the cells. 62. Ans1er: C" C'5ll lo!er the dosage as ordered so the drug causes only 2 to E stools a dayD. $ationale: 7actulose is given to a patients !ith hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding !ith ammonia and promoting more fre&uent bo!el movements. 'f the patient e/perience diarrhea, it indicates over dosage and the nurse must reduce the amount of medication given to the patient. #he stool !ill be mashy or soft. 7actulose is also very s!eet and may cause cramping and bloating. 63. Ans1er: -" ;evere lo!er bac$ pain, decreased blood pressure, decreased 0-C count, increased 2-C count. $ationale: ;evere lo!er bac$ pain indicates an aneurysm rupture, secondary to pressure being applied !ithin the abdominal cavity. 2hen ruptured occurs, the pain is constant because it can5t be alleviated until
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the aneurysm is repaired. -lood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure !ouldn5t increase. 3or the same reason, the 0-C count is decreased N not increased. #he 2-C count increases as cell migrate to the site of in1ury. 64. Ans1er: :" Apply gloves and assess the groin site $ationale: Bbserving standard precautions is the first priority !hen dealing !ith any blood fluid. Assessment of the groin site is the second priority. #his establishes !here the blood is coming from and determines ho! much blood has been lost. #he goal in this situation is to stop the bleeding. #he nurse !ould call for help if it !ere !arranted after the assessment of the situation. After determining the e/tent of the bleeding, vital signs assessment is important. #he nurse should never move the client, in case a clot has formed. 8oving can disturb the clot and cause rebleeding. 65. Ans1er: :" 4ercutaneous transluminal coronary angioplasty 4#CA" $ationale: 4#CA can alleviate the bloc$age and restore blood flo! and o/ygenation. An echocardiogram is a noninvasive diagnosis test. Nitroglycerin is an oral sublingual medication. Cardiac catheteri(ation is a diagnostic tool N not a treatment. 66. Ans1er: -" Cardiogenic shoc$ $ationale: Cardiogenic shoc$ is shoc$ related to ineffective pumping of the heart. Anaphylactic shoc$ results from an allergic reaction. :istributive shoc$ results from changes in the intravascular volume distribution and is usually associated !ith increased cardiac output. 8' isn5t a shoc$ state, though a severe 8' can lead to shoc$. 67. Ans1er: 6C" Jidneys5 e/cretion of sodium and !ater $ationale: #he $idneys respond to rise in blood pressure by e/creting sodium and e/cess !ater. #his response ultimately affects sysmolic blood pressure by regulating blood volume. ;odium or !ater retention !ould only further increase blood pressure. ;odium and !ater travel together across the membrane in the $idneysI one can5t travel !ithout the other. 68. Ans1er: :" 't inhibits reabsorption of sodium and !ater in the loop of 9enle. $ationale: 3urosemide is a loop diuretic that inhibits sodium and !ater reabsorption in the loop 9enle, thereby causing a decrease in blood pressure. Aasodilators cause dilation of peripheral blood vessels, directly rela/ing vascular smooth muscle and decreasing blood pressure. Adrenergic bloc$ers decrease sympathetic cardioacceleration and decrease blood pressure. Angiotensin-converting en(yme inhibitors decrease blood pressure due to their action on angiotensin.
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69. Ans1er: C" 4ancytopenia, elevated antinuclear antibody ANA" titer $ationale: 7aboratory findings for clients !ith ;7. usually sho! pancytopenia, elevated ANA titer, and decreased serum complement levels. Clients may have elevated -)N and creatinine levels from nephritis, but the increase does not indicate ;7.. 70. Ans1er* C" Narcotics are avoided after a head in1ury because they may hide a !orsening condition. $ationale: Narcotics may mas$ changes in the level of consciousness that indicate increased 'C4 and shouldn5t acetaminophen is strong enough ignores the mother5s &uestion and therefore isn5t appropriate. Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young adults !ith viral illnesses due to the danger of 0eye5s syndrome. ;tronger medications may not necessarily lead to vomiting but !ill sedate the client, thereby mas$ing changes in his level of consciousness. 71. Ans1er* A" AppropriateI lo!ering carbon dio/ide CB2" reduces intracranial pressure 'C4" $ationale: A normal 4aco2 value is F> to E> mm 9g CB2 has vasodilating propertiesI therefore, lo!ering 4aco2 through hyperventilation !ill lo!er 'C4 caused by dilated cerebral vessels. B/ygenation is evaluated through 4ao2 and o/ygen saturation. Alveolar hypoventilation !ould be reflected in an increased 4aco2. 72. Ans1er* -" A FF-year-old client !ith a recent diagnosis of <uillain--arre syndrome $ationale: <uillain--arre syndrome is characteri(ed by ascending paralysis and potential respiratory failure. #he order of client assessment should follo! client priorities, !ith disorder of air!ays, breathing, and then circulation. #here5s no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. #here5s no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care. 73. Ans1er* C" :ecreases inflammation $ationale: #hen action of colchicines is to decrease inflammation by reducing the migration of leu$ocytes to synovial fluid. Colchicine doesn5t replace estrogen, decrease infection, or decrease bone deminerali(ation. 74. Ans1er* C" Bsteoarthritis is the most common form of arthritis $ationale: Bsteoarthritis is the most common form of arthritis and can be e/tremely debilitating. 't can afflict people of any age, although most are elderly. 75. Ans1er* C" 8y/edema coma
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$ationale: 8y/edema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn+t ta$en. ./ophthalmos, protrusion of the eyeballs, is seen !ith hyperthyroidism. #hyroid storm is life-threatening but is caused by severe hyperthyroidism. #ibial my/edema, peripheral mucinous edema involving the lo!er leg, is associated !ith hypothyroidism but isn+t life-threatening. 76. Ans1er: -" An irregular apical pulse $ationale: -ecause Cushing+s syndrome causes aldosterone overproduction, !hich increases urinary potassium loss, the disorder may lead to hypo$alemia. #herefore, the nurse should immediately report signs and symptoms of hypo$alemia, such as an irregular apical pulse, to the physician. .dema is an e/pected finding because aldosterone overproduction causes sodium and fluid retention. :ry mucous membranes and fre&uent urination signal dehydration, !hich isn+t associated !ith Cushing+s syndrome. 77. Ans1er: :" -elo!-normal urine osmolality level, above-normal serum osmolality level $ationale: 'n diabetes insipidus, e/cessive polyuria causes dilute urine, resulting in a belo!-normal urine osmolality level. At the same time, polyuria depletes the body of !ater, causing dehydration that leads to an above-normal serum osmolality level. 3or the same reasons, diabetes insipidus doesn+t cause above-normal urine osmolality or belo!-normal serum osmolality levels. 78. Ans1er: A" %' can avoid getting sic$ by not becoming dehydrated and by paying attention to my need to urinate, drin$, or eat more than usual.% $ationale: 'nade&uate fluid inta$e during hyperglycemic episodes often leads to 99N;. -y recogni(ing the signs of hyperglycemia polyuria, polydipsia, and polyphagia" and increasing fluid inta$e, the client may prevent 99N;. :rin$ing a glass of nondiet soda !ould be appropriate for hypoglycemia. A client !hose diabetes is controlled !ith oral antidiabetic agents usually doesn+t need to monitor blood glucose levels. A highcarbohydrate diet !ould e/acerbate the client+s condition, particularly if fluid inta$e is lo!. 79. Ans1er: :" 9yperparathyroidism $ationale: 9yperparathyroidism is most common in older !omen and is characteri(ed by bone pain and !ea$ness from e/cess parathyroid hormone 4#9". Clients also e/hibit hypercaliuria-causing polyuria. 2hile clients !ith diabetes mellitus and diabetes insipidus also have polyuria, they don+t have bone pain and increased sleeping. 9ypoparathyroidism is characteri(ed by urinary fre&uency rather than polyuria.
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80. Ans1er: C" %'+ll ta$e t!o-thirds of the dose !hen ' !a$e up and one-third in the late afternoon.% $ationale: 9ydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body+s o!n secretion of this hormoneI therefore, t!o-thirds of the dose of hydrocortisone should be ta$en in the morning and one-third in the late afternoon. #his dosage schedule reduces adverse effects. 81. Ans1er: C" 9igh corticotropin and high cortisol levels $ationale: A corticotropin-secreting pituitary tumor !ould cause high corticotropin and high cortisol levels. A high corticotropin level !ith a lo! cortisol level and a lo! corticotropin level !ith a lo! cortisol level !ould be associated !ith hypocortisolism. 7o! corticotropin and high cortisol levels !ould be seen if there !as a primary defect in the adrenal glands. 82. Ans1er: :" 4erforming capillary glucose testing every E hours $ationale: #he nurse should perform capillary glucose testing every E hours because e/cess cortisol may cause insulin resistance, placing the client at ris$ for hyperglycemia. )rine $etone testing isn+t indicated because the client does secrete insulin and, therefore, isn+t at ris$ for $etosis. )rine specific gravity isn+t indicated because although fluid balance can be compromised, it usually isn+t dangerously imbalanced. #emperature regulation may be affected by e/cess cortisol and isn+t an accurate indicator of infection. 83. Ans1er: C" onset to be at 2*F0 p.m. and its pea$ to be at E p.m. $ationale: 0egular insulin, !hich is a short-acting insulin, has an onset of 1> to F0 minutes and a pea$ of 2 to E hours. -ecause the nurse gave the insulin at 2 p.m., the e/pected onset !ould be from 2*1> p.m. to 2*F0 p.m. and the pea$ from E p.m. to G p.m. 84. Ans1er: A" No increase in the thyroid-stimulating hormone #;9" level after F0 minutes during the #;9 stimulation test $ationale: 'n the #;9 test, failure of the #;9 level to rise after F0 minutes confirms hyperthyroidism. A decreased #;9 level indicates a pituitary deficiency of this hormone. -elo!-normal levels of #F and #E, as detected by radioimmunoassay, signal hypothyroidism. A belo!-normal #E level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs. 85. Ans1er: -" %0otate in1ection sites !ithin the same anatomic region, not among different regions.% $ationale: #he nurse should instruct the client to rotate in1ection sites !ithin the same anatomic region. 0otating sites among different regions may cause e/cessive day-to-day variations in the blood glucose levelI also, insulin absorption differs from one region to the ne/t. 'nsulin should
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be in1ected only into healthy tissue lac$ing large blood vessels, nerves, or scar tissue or other deviations. 'n1ecting insulin into areas of hypertrophy may delay absorption. #he client shouldn+t in1ect insulin into areas of lipodystrophy such as hypertrophy or atrophy"I to prevent lipodystrophy, the client should rotate in1ection sites systematically. ./ercise speeds drug absorption, so the client shouldn+t in1ect insulin into sites above muscles that !ill be e/ercised heavily. 86. Ans1er: :" -elo!-normal serum potassium level $ationale: A client !ith 99N; has an overall body deficit of potassium resulting from diuresis, !hich occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum $etone bodies are characteristic of diabetic $etoacidosis. 8etabolic acidosis, not serum al$alosis, may occur in 99N;. 87. Ans1er: :" 8aintaining room temperature in the lo!-normal range $ationale: <raves+ disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, e/cessive thirst and appetite, and !eight loss. #o reduce heat intolerance and diaphoresis, the nurse should $eep the client+s room temperature in the lo!-normal range. #o replace fluids lost via diaphoresis, the nurse should encourage, not restrict, inta$e of oral fluids. 4lacing e/tra blan$ets on the bed of a client !ith heat intolerance !ould cause discomfort. #o provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods. 88. Ans1er: A" 3racture of the distal radius $ationale: Colles+ fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. 't+s most common in !omen. Colles+ fracture doesn+t refer to a fracture of the olecranon, humerus, or carpal scaphoid. 89. Ans1er: -" Calcium and phosphorous $ationale: 'n osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. ;odium and potassium aren+t involved in the development of osteoporosis. 90. Ans1er: A" Adult respiratory distress syndrome A0:;" $ationale: ;evere hypo/ia after smo$e inhalation is typically related to A0:;. #he other conditions listed aren5t typically associated !ith smo$e inhalation and severe hypo/ia. 91. Ans1er: :" 3at embolism $ationale: 7ong bone fractures are correlated !ith fat emboli, !hich cause shortness of breath and hypo/ia. 't5s unli$ely the client has
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developed asthma or bronchitis !ithout a previous history. 9e could develop atelectasis but it typically doesn5t produce progressive hypo/ia. 92. Ans1er: :" ;pontaneous pneumothora/ $ationale: A spontaneous pneumothora/ occurs !hen the client5s lung collapses, causing an acute decreased in the amount of functional lung used in o/ygenation. #he sudden collapse !as the cause of his chest pain and shortness of breath. An asthma attac$ !ould sho! !hee(ing breath sounds, and bronchitis !ould have rhonchi. 4neumonia !ould have bronchial breath sounds over the area of consolidation. 93. Ans1er: C" 4neumothora/ $ationale: 3rom the trauma the client e/perienced, it5s unli$ely he has bronchitis, pneumonia, or #-I rhonchi !ith bronchitis, bronchial breath sounds !ith #- !ould be heard. 94. Ans1er* C" ;erous fluids fills the space and consolidates the region $ationale: ;erous fluid fills the space and eventually consolidates, preventing e/tensive mediastinal shift of the heart and remaining lung. Air can5t be left in the space. #here5s no gel that can be placed in the pleural space. #he tissue from the other lung can5t cross the mediastinum, although a temporary mediastinal shift e/its until the space is filled. 95. Ans1er* A" Alveolar damage in the infracted area $ationale: #he infracted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts. Clot formation usually occurs in the legs. #here5s a loss of lung parenchyma and subse&uent scar tissue formation. 96. Ans1er* :" 0espiratory al$alosis $ationale: A client !ith massive pulmonary embolism !ill have a large region and blo! off large amount of carbon dio/ide, !hich crosses the unaffected alveolar-capillary membrane more readily than does o/ygen and results in respiratory al$alosis. 97. Ans1er* A" Air lea$ $ationale: -ubbling in the !ater seal chamber of a chest drainage system stems from an air lea$. 'n pneumothora/ an air lea$ can occur as air is pulled from the pleural space. -ubbling doesn5t normally occur !ith either ade&uate or inade&uate suction or any pree/isting bubbling in the !ater seal chamber. 98. Ans1er* -" 21 $ationale: F000 / 10 divided by 2E / G0. 99. Ans1er: -" 2.E ml
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$ationale: .0> mg6 1 ml Y .12mg6 / ml, .0>/ Y .12, / Y 2.E ml. 100. Ans1er: :" C' should put on the stoc$ings before getting out of bed in the morning. $ationale: 4romote venous return by applying e/ternal pressure on veins.
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TEST . Ans1ers and $ationale 5 Care of Clients 1ith #hysiologic and #sychosocial Alterations 1. Ans1er* :" 3ocusing $ationale* #he nurse is using focusing by suggesting that the client discuss a specific issue. #he nurse didn5t restate the &uestion, ma$e observation, or as$ further &uestion e/ploring". 2. Ans1er* :" 0emove all other clients from the dayroom. $ationale* #he nurse5s first priority is to consider the safety of the clients in the therapeutic setting. #he other actions are appropriate responses after ensuring the safety of other clients. 3. Ans1er* A" #he client is disruptive. $ationale* <roup activity provides too much stimulation, !hich the client !ill not be able to handle harmful to self" and as a result !ill be disruptive to others. 4. Ans1er* C" Agree to tal$ !ith the mother and the father together. $ationale* -y agreeing to tal$ !ith both parents, the nurse can provide emotional support and further assess and validate the family5s needs. 5. Ans1er* A" 4erceptual disorders. $ationale* 3rightening visual hallucinations are especially common in clients e/periencing alcohol !ithdra!al. 6. Ans1er* :" ;uggest that it ta$es a!hile before seeing the results. $ationale* #he client needs a specific responseI that it ta$es 2 to F !ee$s a delayed effect" until the therapeutic blood level is reached. 7. Ans1er* C" ;uperego $ationale* #his behavior sho!s a !ea$ sense of moral consciousness. According to 3reudian theory, personality disorders stem from a !ea$ superego. 8. Ans1er* C" ;$eletal muscle paralysis. $ationale* Anectine is a depolari(ing muscle rela/ant causing paralysis. 't is used to reduce the intensity of muscle contractions during the convulsive stage, thereby reducing the ris$ of bone fractures or dislocation. 9. Ans1er* :" 'ncrease calories, carbohydrates, and protein. $ationale* #his client increased protein for tissue building and increased calories to replace !hat is burned up usually via carbohydrates".
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10. Ans1er* C" Acting overly solicitous to!ard the child. $ationale* #his behavior is an e/ample of reaction formation, a coping mechanism. 11. Ans1er* A" -y designating times during !hich the client can focus on the behavior. $ationale* #he nurse should designate times during !hich the client can focus on the compulsive behavior or obsessive thoughts. #he nurse should urge the client to reduce the fre&uency of the compulsive behavior gradually, not rapidly. ;he shouldn+t call attention to or try to prevent the behavior. #rying to prevent the behavior may cause pain and terror in the client. #he nurse should encourage the client to verbali(e an/ieties to help distract attention from the compulsive behavior. 12. Ans1er* :" ./ploring the meaning of the traumatic event !ith the client. $ationale* #he client !ith 4#;: needs encouragement to e/amine and understand the meaning of the traumatic event and conse&uent losses. Bther!ise, symptoms may !orsen and the client may become depressed or engage in self-destructive behavior such as substance abuse. #he client must e/plore the meaning of the event and !on+t heal !ithout this, no matter ho! much time passes. -ehavioral techni&ues, such as rela/ation therapy, may help decrease the client+s an/iety and induce sleep. #he physician may prescribe antian/iety agents or antidepressants cautiously to avoid dependenceI sleep medication is rarely appropriate. A special diet isn+t indicated unless the client also has an eating disorder or a nutritional problem. 13. Ans1er* C" %,our problem is real but there is no physical basis for it. 2e+ll !or$ on !hat is going on in your life to find out !hy it+s happened.% $ationale* #he nurse must be honest !ith the client by telling her that the paralysis has no physiologic cause !hile also conveying empathy and ac$no!ledging that her symptoms are real. #he client !ill benefit from psychiatric treatment, !hich !ill help her understand the underlying cause of her symptoms. After the psychological conflict is resolved, her symptoms !ill disappear. ;aying that it must be a!ful not to be able to move her legs !ouldn+t ans!er the client+s &uestionI $no!ing that the cause is psychological !ouldn+t necessarily ma$e her feel better. #elling her that she has developed paralysis to avoid leaving her parents or that her personality caused her disorder !ouldn+t help her understand and resolve the underlying conflict. 14. Ans1er* C" fluvo/amine 7uvo/" and clomipramine Anafranil" $ationale* #he antidepressants fluvo/amine and clomipramine have been effective in the treatment of BC:. 7ibrium and Aalium may be helpful in treating an/iety related to BC: but aren+t drugs of choice to treat the
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illness. #he other medications mentioned aren+t effective in the treatment of BC:. 15. Ans1er* A" A !arning about the drugs delayed therapeutic effect, !hich is from 1E to F0 days. $ationale* #he client should be informed that the drug+s therapeutic effect might not be reached for 1E to F0 days. #he client must be instructed to continue ta$ing the drug as directed. -lood level chec$s aren+t necessary. N8; hasn+t been reported !ith this drug, but tachycardia is fre&uently reported. 16. Ans1er* -" ;evere an/iety and fear. $ationale* 4hobias cause severe an/iety such as a panic attac$" that is out of proportion to the threat of the feared ob1ect or situation. 4hysical signs and symptoms of phobias include profuse s!eating, poor motor control, tachycardia, and elevated blood pressure. 'nsomnia, an inability to concentrate, and !eight loss are common in depression. 2ithdra!al and failure to distinguish reality from fantasy occur in schi(ophrenia. 17. Ans1er* A" Antidepressants $ationale* #ricyclic and monoamine o/idase 8AB" inhibitor antidepressants have been found to be effective in treating clients !ith panic attac$s. 2hy these drugs help control panic attac$s isn+t clearly understood. Anticholinergic agents, !hich are smooth-muscle rela/ants, relieve physical symptoms of an/iety but don+t relieve the an/iety itself. Antipsychotic drugs are inappropriate because clients !ho e/perience panic attac$s aren+t psychotic. 8ood stabili(ers aren+t indicated because panic attac$s are rarely associated !ith mood changes. 18. Ans1er* -" F to > days $ationale* 8onoamine o/idase inhibitors, such as tranylcypromine, have an onset of action of appro/imately F to > days. A full clinical response may be delayed for F to E !ee$s. #he therapeutic effects may continue for 1 to 2 !ee$s after discontinuation. 19. Ans1er* -" 4roviding emotional support and individual counseling. $ationale* Clients in the first stage of Al(heimer+s disease are a!are that something is happening to them and may become over!helmed and frightened. #herefore, nursing care typically focuses on providing emotional support and individual counseling. #he other options are appropriate during the second stage of Al(heimer+s disease, !hen the client needs continuous monitoring to prevent minor illnesses from progressing into ma1or problems and !hen maintaining ade&uate nutrition may become a challenge. :uring this stage, offering nourishing finger foods helps clients to feed themselves and maintain ade&uate nutrition.
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20. Ans1er* C" .motional lability, euphoria, and impaired memory $ationale* ;igns of antian/iety agent overdose include emotional lability, euphoria, and impaired memory. 4hencyclidine overdose can cause combativeness, s!eating, and confusion. Amphetamine overdose can result in agitation, hyperactivity, and grandiose ideation. 9allucinogen overdose can produce suspiciousness, dilated pupils, and increased blood pressure. 21. Ans1er* :" A lo! tolerance for frustration $ationale* Clients !ith an antisocial personality disorder e/hibit a lo! tolerance for frustration, emotional immaturity, and a lac$ of impulse control. #hey commonly have a history of unemployment, miss !or$ repeatedly, and &uit !or$ !ithout other plans for employment. #hey don+t feel guilt about their behavior and commonly perceive themselves as victims. #hey also display a lac$ of responsibility for the outcome of their actions. -ecause of a lac$ of trust in others, clients !ith antisocial personality disorder commonly have difficulty developing stable, close relationships. 22. Ans1er* C" 8ethadone $ationale* 8ethadone is used to deto/ify opiate users because it binds !ith opioid receptors at many sites in the central nervous system but doesn5t have the same deterious effects as other opiates, such as cocaine, heroin, and morphine. -arbiturates, amphetamines, and ben(odia(epines are highly addictive and !ould re&uire deto/ification treatment. 23. Ans1er* -" 9allucinations $ationale* 9allucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. :elusions are false beliefs, rather than perceptions, that the client accepts as real. 7oose associations are rapid shifts among unrelated ideas. Neologisms are bi(arre !ords that have meaning only to the client. 24. Ans1er* C" ;et up a strict eating plan for the client. $ationale* .stablishing a consistent eating plan and monitoring the client5s !eight are very important in this disorder. #he family and friends should be included in the client5s care. #he client should be monitored during meals-not given privacy. ./ercise must be limited and supervised. 25. Ans1er* A" 9ighly important or famous. $ationale* A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the !orld.
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26. Ans1er* :" 7istening attentively !ith a neutral attitude and avoiding po!er struggles. $ationale* #he nurse should listen to the client5s re&uests, e/press !illingness to seriously consider the re&uest, and respond later. #he nurse should encourage the client to ta$e short daytime naps because he e/pends so much energy. #he nurse shouldn5t try to restrain the client !hen he feels the need to move around as long as his activity isn5t harmful. 9igh calorie finger foods should be offered to supplement the client5s diet, if he can5t remain seated long enough to eat a complete meal. #he nurse shouldn5t be forced to stay seated at the table to finidYsh a meal. #he nurse should set limits in a calm, clear, and self-confident tone of voice. 27. Ans1er* :" :enial $ationale* :enial is unconscious defense mechanism in !hich emotional conflict and an/iety is avoided by refusing to ac$no!ledge feelings, desires, impulses, or e/ternal facts that are consciously intolerable. 2ithdra!al is a common response to stress, characteri(ed by apathy. 7ogical thin$ing is the ability to thin$ rationally and ma$e responsible decisions, !hich !ould lead the client admitting the problem and see$ing help. 0epression is suppressing past events from the consciousness because of guilty association. 28. Ans1er* -" 4aranoid thoughts $ationale* Clients !ith schi(otypal personality disorder e/perience e/cessive social an/iety that can lead to paranoid thoughts. Aggressive behavior is uncommon, although these clients may e/perience agitation !ith an/iety. #heir behavior is emotionally cold !ith a flattened affect, regardless of the situation. #hese clients demonstrate a reduced capacity for close or dependent relationships. 29. Ans1er* C" 'dentify an/iety-causing situations $ationale* -ulimic behavior is generally a maladaptive coping response to stress and underlying issues. #he client must identify an/iety-causing situations that stimulate the bulimic behavior and then learn ne! !ays of coping !ith the an/iety. 30. Ans1er* A" #ension and irritability $ationale* An amphetamine is a nervous system stimulant that is sub1ect to abuse because of its ability to produce !a$efulness and euphoria. An overdose increases tension and irritability. Bptions - and C are incorrect because amphetamines stimulate norepinephrine, !hich increase the heart rate and blood flo!. :iarrhea is a common adverse effect so option : in is incorrect.
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31. Ans1er* -" CNo, ' do not hear your voices, but ' believe you can hear themD. $ationale* #he nurse, demonstrating $no!ledge and understanding, accepts the client5s perceptions even though they are hallucinatory. 32. Ans1er* C" Confusion for a time after treatment $ationale* #he electrical energy passing through the cerebral corte/ during .C# results in a temporary state of confusion after treatment. 33. Ans1er* :" Acceptance stage $ationale* Communication and intervention during this stage are mainly nonverbal, as !hen the client gestures to hold the nurse5s hand. 34. Ans1er* :" A higher level of an/iety continuing for more than F months. $ationale* #his is not an e/pected outcome of a crisis because by definition a crisis !ould be resolved in G !ee$s. 35. Ans1er* -" ;taying in the sun $ationale* 9aldol causes photosensitivity. ;evere sunburn can occur on e/posure to the sun. 36. Ans1er* :" 8oderate-level an/iety $ationale* A moderately an/ious person can ignore peripheral events and focuses on central concerns. 37. Ans1er* C" :iverse interest $ationale* -efore onset of depression, these clients usually have very narro!, limited interest. 38. Ans1er* A" As their depression begins to improve $ationale* At this point the client may have enough energy to plan and e/ecute an attempt. 39. Ans1er* :" :isturbance in recalling recent events related to cerebral hypo/ia. $ationale* Cell damage seems to interfere !ith registering input stimuli, !hich affects the ability to register and recall recent eventsI vascular dementia is related to multiple vascular lesions of the cerebral corte/ and subcortical structure. 40. Ans1er* :" .ncouraging the client to have blood levels chec$ed as ordered. $ationale* -lood levels must be chec$ed monthly or bimonthly !hen the client is on maintenance therapy because there is only a small range bet!een therapeutic and to/ic levels.
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41. Ans1er* -" 3ine hand tremors or slurred speech $ationale* #hese are common side effects of lithium carbonate. 42. Ans1er* :" 4resence $ationale* #he constant presence of a nurse provides emotional support because the client $no!s that someone is attentive and available in case of an emergency. 43. Ans1er* A" Client5s perception of the presenting problem. $ationale* #he nurse can be most therapeutic by starting !here the client is, because it is the client5s concept of the problem that serves as the starting point of the relationship. 44. Ans1er* -" Chocolate mil$, aged cheese, and yogurt5D $ationale* #hese high-tyramine foods, !hen ingested in the presence of an 8AB inhibitor, cause a severe hypertensive response. 45. Ans1er* -" E to G !ee$s $ationale* Crisis is self-limiting and lasts from E to G !ee$s. 46. Ans1er* :" 8ales are more li$ely to use lethal methods than are females $ationale* #his finding is supported by researchI females account for 90? of suicide attempts but males are three times more successful because of methods used. 47. Ans1er* C" %,our cursing is interrupting the activity. #a$e time out in your room for 10 minutes.% $ationale* #he nurse should set limits on client behavior to ensure a comfortable environment for all clients. #he nurse should accept hostile or &uarrelsome client outbursts !ithin limits !ithout becoming personally offended, as in option A. Bption - is incorrect because it implies that the client+s actions reflect feelings to!ard the staff instead of the client+s o!n misery. Pudgmental remar$s, such as option :, may decrease the client+s self-esteem. 48. Ans1er* C" lithium carbonate 7ithane" $ationale* 7ithium carbonate, an antimania drug, is used to treat clients !ith cyclical schi(oaffective disorder, a psychotic disorder once classified under schi(ophrenia that causes affective symptoms, including manicli$e activity. 7ithium helps control the affective component of this disorder. 4henel(ine is a monoamine o/idase inhibitor prescribed for clients !ho don+t respond to other antidepressant drugs such as imipramine. Chlordia(epo/ide, an antian/iety agent, generally is contraindicated in psychotic clients. 'mipramine, primarily considered an antidepressant agent, is also used to treat clients !ith agoraphobia and that undergoing cocaine deto/ification.
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49. Ans1er* -" 0eport a sore throat or fever to the physician immediately. $ationale* A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clo(apine. -ecause of the ris$ of agranulocytosis, !hite blood cell 2-C" counts are necessary !ee$ly, not monthly. 'f the 2-C count drops belo! F,0006=l, the medication must be stopped. 9ypotension may occur in clients ta$ing this medication. 2arn the client to stand up slo!ly to avoid di((iness from orthostatic hypotension. #he medication should be continued, even !hen symptoms have been controlled. 'f the medication must be stopped, it should be slo!ly tapered over 1 to 2 !ee$s and only under the supervision of a physician. 50. Ans1er* C" Neuroleptic malignant syndrome. $ationale* #he client+s signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that re&uires immediate treatment. #ardive dys$inesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. :ystonia is characteri(ed by cramps and rigidity of the tongue, face, nec$, and bac$ muscles. A$athisia causes restlessness, an/iety, and 1itteriness. 51. Ans1er* -" Advising the client to sit up for 1 minute before getting out of bed. $ationale* #o minimi(e the effects of amitriptyline-induced orthostatic hypotension, the nurse should advise the client to sit up for 1 minute before getting out of bed. Brthostatic hypotension commonly occurs !ith tricyclic antidepressant therapy. 'n these cases, the dosage may be reduced or the physician may prescribe nortriptyline, another tricyclic antidepressant. Brthostatic hypotension disappears only !hen the drug is discontinued. 52. Ans1er* :" :ysthymic disorder. $ationale* :ysthymic disorder is mar$ed by feelings of depression lasting at least 2 years, accompanied by at least t!o of the follo!ing symptoms* sleep disturbance, appetite disturbance, lo! energy or fatigue, lo! selfesteem, poor concentration, difficulty ma$ing decisions, and hopelessness. #hese symptoms may be relatively continuous or separated by intervening periods of normal mood that last a fe! days to a fe! !ee$s. Cyclothymic disorder is a chronic mood disturbance of at least 2 years+ duration mar$ed by numerous periods of depression and hypomania. Atypical affective disorder is characteri(ed by manic signs and symptoms. 8a1or depression is a recurring, persistent sadness or loss of interest or pleasure in almost all activities, !ith signs and symptoms recurring for at least 2 !ee$s. 53. Ans1er* C" F0 g mi/ed in 2>0 ml of !ater
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$ationale* #he usual adult dosage of activated charcoal is > to 10 times the estimated !eight of the drug or chemical ingested, or a minimum dose of F0 g, mi/ed in 2>0 ml of !ater. :oses less than this !ill be ineffectiveI doses greater than this can increase the ris$ of adverse reactions, although to/icity doesn+t occur !ith activated charcoal, even at the ma/imum dose. 54. Ans1er* C" ;t. Pohn+s !ort $ationale* ;t. Pohn+s !ort has been found to have serotonin-elevating properties, similar to prescription antidepressants. <in$go biloba is prescribed to enhance mental acuity. .chinacea has immune-stimulating properties. .phedra is a naturally occurring stimulant that is similar to ephedrine. 55. Ans1er* -" ;odium $ationale* 7ithium is chemically similar to sodium. 'f sodium levels are reduced, such as from s!eating or diuresis, lithium !ill be reabsorbed by the $idneys, increasing the ris$ of to/icity. Clients ta$ing lithium shouldn+t restrict their inta$e of sodium and should drin$ ade&uate amounts of fluid each day. #he other electrolytes are important for normal body functions but sodium is most important to the absorption of lithium. 56. Ans1er* :" 't+s characteri(ed by an acute onset and lasts hours to a number of days $ationale* :elirium has an acute onset and typically can last from several hours to several days. 57. Ans1er* -" 'mpaired communication. $ationale* 'nitially, memory impairment may be the only cognitive deficit in a client !ith Al(heimer+s disease. :uring the early stage of this disease, subtle personality changes may also be present. 9o!ever, other than occasional irritable outbursts and lac$ of spontaneity, the client is usually cooperative and e/hibits socially appropriate behavior. ;igns of advancement to the middle stage of Al(heimer+s disease include e/acerbated cognitive impairment !ith obvious personality changes and impaired communication, such as inappropriate conversation, actions, and responses. :uring the late stage, the client can+t perform self-care activities and may become mute. 58. Ans1er* :" #his medication may initially cause tiredness, !hich should become less bothersome over time. $ationale* ;edation is a common early adverse effect of imipramine, a tricyclic antidepressant, and usually decreases as tolerance develops. Antidepressants aren+t habit forming and don+t cause physical or psychological dependence. 9o!ever, after a long course of high-dose therapy, the dosage should be decreased gradually to avoid mild
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!ithdra!al symptoms. ;erious adverse effects, although rare, include myocardial infarction, heart failure, and tachycardia. :ietary restrictions, such as avoiding aged cheeses, yogurt, and chic$en livers, are necessary for a client ta$ing a monoamine o/idase inhibitor, not a tricyclic antidepressant. 59. Ans1er* C" 8onitor vital signs, serum electrolyte levels, and acid-base balance. $ationale* An anore/ic client !ho re&uires hospitali(ation is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. #herefore, monitoring the client+s vital signs, serum electrolyte level, and acid base balance is crucial. Bption A may !orsen an/iety. Bption - is incorrect because a !eight obtained after brea$fast is more accurate than one obtained after the evening meal. Bption : !ould re!ard the client !ith attention for not eating and reinforce the control issues that are central to the underlying psychological problemI also, the client may record food and fluid inta$e inaccurately. 60. Ans1er* :" Bpioid !ithdra!al $ationale* #he symptoms listed are specific to opioid !ithdra!al. Alcohol !ithdra!al !ould sho! elevated vital signs. #here is no real !ithdra!al from cannibis. ;ymptoms of cocaine !ithdra!al include depression, an/iety, and agitation. 61. Ans1er* A" 0egression $ationale* An adult !ho thro!s temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. 'n pro1ection, the client blames someone or something other than the source. 'n reaction formation, the client acts in opposition to his feelings. 'n intellectuali(ation, the client overuses rational e/planations or abstract thin$ing to decrease the significance of a feeling or event. 62. Ans1er* A" Abnormal movements and involuntary movements of the mouth, tongue, and face. $ationale* #ardive dys$inesia is a severe reaction associated !ith long term use of antipsychotic medication. #he clinical manifestations include abnormal movements dys$inesia" and involuntary movements of the mouth, tongue fly catcher tongue", and face. 63. Ans1er* C" -lurred vision $ationale* At lithium levels of 2 to 2.> m.&67 the client !ill e/perienced blurred vision, muscle t!itching, severe hypotension, and persistent nausea and vomiting. 2ith levels bet!een 1.> and 2 m.&67 the client e/periencing vomiting, diarrhea, muscle !ea$ness, ata/ia, di((iness, slurred speech, and confusion. At lithium levels of 2.> to F m.&67 or
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higher, urinary and fecal incontinence occurs, as !ell as sei(ures, cardiac dysrythmias, peripheral vascular collapse, and death. 64. Ans1er* C" No acts of aggression have been observed !ithin 1 hour after the release of t!o of the e/tremity restraints. $ationale* #he best indicator that the behavior is controlled, if the client e/hibits no signs of aggression after partial release of restraints. Bptions A, -, and : do not ensure that the client has controlled the behavior. 65. Ans1er: A" increased attention span and concentration $ationale* #he medication has a parado/ic effect that decrease hyperactivity and impulsivity among children !ith A:9:. -, C, :. ;ide effects of 0italin include anore/ia, insomnia, diarrhea and irritability. 66. Ans1er: C" 8oderate $ationale* #he child !ith moderate mental retardation has an '.Q. of F>>0 4rofound 8ental retardation has an '.Q. of belo! 20I 8ild mental retardation >0-L0 and ;evere mental retardation has an '.Q. of 20-F>. 67. Ans1er: :" 0earrange the environment to activate the child $ationale* #he child !ith autistic disorder does not !ant change. 8aintaining a consistent environment is therapeutic. A. Angry outburst can be re-channeling through safe activities. -. Acceptance enhances a trusting relationship. C. .nsure safety from self-destructive behaviors li$e head banging and hair pulling. 68. Ans1er: -" cocaine $ationale* #he manifestations indicate into/ication !ith cocaine, a CN; stimulant. A. 'nto/ication !ith heroine is manifested by euphoria then impairment in 1udgment, attention and the presence of papillary constriction. C. 'nto/ication !ith hallucinogen li$e 7;: is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs :. 'nto/ication !ith 8ari1uana, a cannabinoid is manifested by sensation of slo!ed time, con1unctival redness, social !ithdra!al, impaired 1udgment and hallucinations. 69. Ans1er* -" insidious onset $ationale* :ementia has a gradual onset and progressive deterioration. 't causes pronounced memory and cognitive disturbances. A,C and : are all characteristics of delirium. 70. Ans1er: C" Claustrophobia $ationale* Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation !here escape is difficult. -. ;ocial phobia is fear of performing in the presence of others in a !ay that !ill be humiliating or embarrassing. :. Menophobia is fear of strangers.
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71. Ans1er: A" 0evealing personal information to the client $ationale* Counter-transference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. - and C. #hese are therapeutic approaches. :. #his is transference reaction !here a client has an emotional reaction to!ards the nurse based on her past. 72. Ans1er: :" 9old the ne/t dose and obtain an order for a stat serum lithium level $ationale* :iarrhea and vomiting are manifestations of 7ithium to/icity. #he ne/t dose of lithium should be !ithheld and test is done to validate the observation. A. #he manifestations are not due to drug interaction. -. Cogentin is used to manage the e/tra pyramidal symptom side effects of antipsychotics. C. #he common side effects of 7ithium are fine hand tremors, nausea, polyuria and polydipsia. 73. Ans1er: C" A living, learning or !or$ing environment. $ationale* A therapeutic milieu refers to a broad conceptual approach in !hich all aspects of the environment are channeled to provide a therapeutic environment for the client. #he si/ environmental elements include structure, safety, normsI limit setting, balance and unit modification. A. -ehavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of re!ard and punishment. -. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. :. #his is not congruent !ith therapeutic milieu. 74. Ans1er: -" #ransference $ationale* #ransference is a positive or negative feeling associated !ith a significant person in the client5s past that are unconsciously assigned to another A. ;plitting is a defense mechanism commonly seen in a client !ith personality disorder in !hich the !orld is perceived as all good or all bad C. Countert-transference is a phenomenon !here the nurse shifts feelings assigned to someone in her past to the patient :. 0esistance is the client5s refusal to submit himself to the care of the nurse 75. Ans1er: -" Adventitious $ationale* Adventitious crisis is a crisis involving a traumatic event. 't is not part of everyday life. A. ;ituational crisis is from an e/ternal source that upset ones psychological e&uilibrium C and :. Are the same. #hey are transitional or developmental periods in life 76. Ans1er* C" 8a1or depression $ationale* #he :;8-'A-#0 classifies ma1or depression as an A/is ' disorder. -orderline personality disorder as an A/is ''I obesity and hypertension, A/is '''.
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77. Ans1er* -" #ransference $ationale* #ransference is the unconscious assignment of negative or positive feelings evo$ed by a significant person in the client5s past to another person. 'ntellectuali(ation is a defense mechanism in !hich the client avoids dealing !ith emotions by focusing on facts. #riangulation refers to conflicts involving three family members. ;plitting is a defense mechanism commonly seen in clients !ith personality disorder in !hich the !orld is perceived as all good or all bad. 78. Ans1er* -" 9ypochondriasis $ationale* Complains of vague physical symptoms that have no apparent medical causes are characteristic of clients !ith hypochondriasis. 'n many cases, the <' system is affected. Conversion disorders are characteri(ed by one or more neurologic symptoms. #he client5s symptoms don5t suggest severe an/iety. A client e/periencing sublimation channels maladaptive feelings or impulses into socially acceptable behavior 79. Ans1er* C" 9ypochondriasis $ationale* 9ypochodriasis in this case is sho!n by the client5s belief that she has a serious illness, although pathologic causes have been eliminated. #he disturbance usually lasts at lease G !ith identifiable life stressor such as, in this case, course e/aminations. Conversion disorder s are characteri(ed by one or more neurologic symptoms. :epersonali(ation refers to persistent recurrent episodes of feeling detached from one5s self or body. ;omatoform disorders generally have a chronic course !ith fe! remissions. 80. Ans1er* A" #ria(olam 9alcion" $ationale* #ria(olam is one of a group of sedative hypnotic medication that can be used for a limited time because of the ris$ of dependence. 4aro/etine is a scrotonin-specific reuta$e inhibitor used for treatment of depression panic disorder, and obsessive-compulsive disorder. 3luo/etine is a scrotonin-specific reupta$e inhibitor used for depressive disorders and obsessive-compulsive disorders. 0isperidome is indicated for psychotic disorders. 81. Ans1er* :" 't promotes emotional support or attention for the client $ationale* ;econdary gain refers to the benefits of the illness that allo! the client to receive emotional support or attention. 4rimary gain enables the client to avoid some unpleasant activity. A dysfunctional family may disregard the real issue, although some conflict is relieved. ;omatoform pain disorder is a preoccupation !ith pain in the absence of physical disease. 82. Ans1er* A" C' !ent to the mall !ith my friends last ;aturdayD
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$ationale* Clients !ith panic disorder tent to be socially !ithdra!n. <oing to the mall is a sign of !or$ing on avoidance behaviors. 9yperventilating is a $ey symptom of panic disorder. #eaching breathing control is a ma1or intervention for clients !ith panic disorder. #he client ta$ing medications for panic disorderI such as tricylic antidepressants and ben(odia(epines, must be !eaned off these drugs. 8ost clients !ith panic disorder !ith agoraphobia don5t have nutritional problems. 83. Ans1er* A" C'5m sleeping better and don5t have nightmaresD $ationale*8AB inhibitors are used to treat sleep problems, nightmares, and intrusive daytime thoughts in individual !ith posttraumatic stress disorder. 8AB inhibitors aren5t used to help control flashbac$s or phobias or to decrease the craving for alcohol. 84. Ans1er* :" ;topping the drug can cause !ithdra!al symptoms $ationale: ;topping antian/iety drugs such as ben(odia(epines can cause the client to have !ithdra!al symptoms. ;topping a ben(odia(epine doesn5t tend to cause depression, increase cognitive abilities, or decrease sleeping difficulties. 85. Ans1er* -" -ehavioral difficulties $ationale* Adolescents tend to demonstrate severe irritability and behavioral problems rather than simply a depressed mood. An/iety disorder is more commonly associated !ith small children rather than !ith adolescents. Cognitive impairment is typically associated !ith delirium or dementia. 7abile mood is more characteristic of a client !ith cognitive impairment or bipolar disorder. 86. Ans1er* :" 't5s a mood disorder similar to ma1or depression but of mild to moderate severity $ationale* :ysthymic disorder is a mood disorder similar to ma1or depression but it remains mild to moderate in severity. Cyclothymic disorder is a mood disorder characteri(ed by a mood range from moderate depression to hypomania. -ipolar ' disorder is characteri(ed by a single manic episode !ith no past ma1or depressive episodes. ;easonalaffective disorder is a form of depression occurring in the fall and !inter. 87. Ans1er* A" Aascular dementia has more abrupt onset $ationale* Aascular dementia differs from Al(heimer5s disease in that it has a more abrupt onset and runs a highly variable course. 4ersonally change is common in Al(heimer5s disease. #he duration of delirium is usually brief. #he inability to carry out motor activities is common in Al(heimer5s disease. 88. Ans1er* C" :rug into/ication
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$ationale* #his client !as ta$ing several medications that have a propensity for producing deliriumI digo/in a digitalis glyco/ide", furosemide a thia(ide diuretic", and dia(epam a ben(odia(epine". ;ufficient supporting data don5t e/ist to suspect the other options as causes. 89. Ans1er* :" #he client is e/periencing visual hallucination $ationale* #he presence of a sensory stimulus correlates !ith the definition of a hallucination, !hich is a false sensory perception. Aphasia refers to a communication problem. :ysarthria is difficulty in speech production. 3light of ideas is rapid shifting from one topic to another. 90. Ans1er* :" #he client loo$s at the shado! on a !all and tells the nurse she sees frightening faces on the !all. $ationale* 8inor memory problems are distinguished from dementia by their minor severity and their lac$ of significant interference !ith the client5s social or occupational lifestyle. Bther options !ould be included in the history data but don5t directly correlate !ith the client5s lifestyle. 91. Ans1er* :" 7oose association $ationale* 7oose associations are conversations that constantly shift in topic. Concrete thin$ing implies highly definitive thought processes. 3light of ideas is characteri(ed by conversation that5s disorgani(ed from the onset. 7oose associations don5t necessarily start in a cogently, then becomes loose. 92. Ans1er* C" 4aranoid $ationale* -ecause of their suspiciousness, paranoid personalities ascribe malevolent activities to others and tent to be defensive, becoming &uarrelsome and argumentative. Clients !ith antisocial personality disorder can also be antagonistic and argumentative but are less suspicious than paranoid personalities. Clients !ith histrionic personality disorder are dramatic, not suspicious and argumentative. Clients !ith schi(oid personality disorder are usually detached from other and tend to have eccentric behavior. 93. Ans1er* C" ./plain that the drug is less affective if the client smo$es $ationale* Blan(apine Sypre/a" is less effective for clients !ho smo$e cigarettes. ;erotonin syndrome occurs !ith clients !ho ta$e a combination of antidepressant medications. Blan(apine doesn5t cause euphoria, and e/trapyramidal adverse reactions aren5t a problem. 9o!ever, the client should be a!are of adverse effects such as tardive dys$inesia. 94. Ans1er* A" 7ac$ of honesty
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$ationale* Clients !ith antisocial personality disorder tent to engage in acts of dishonesty, sho!n by lying. Clients !ith schi(otypal personality disorder tend to be superstitious. Clients !ith histrionic personality disorders tend to overreact to frustrations and disappointments, have temper tantrums, and see$ attention. 95. Ans1er* A" C'5m not going to loo$ 1ust at the negative things about myselfD $ationale* As the clients ma$es progress on improving self-esteem, selfblame and negative self evaluation !ill decrease. Clients !ith dependent personality disorder tend to feel fragile and inade&uate and !ould be e/tremely unli$ely to discuss their level of competence and progress. #hese clients focus on self and aren5t envious or 1ealous. 'ndividuals !ith dependent personality disorders don5t ta$e over situations because they see themselves as inept and inade&uate. 96. Ans1er* C" Assess for possible physical problems such as rash $ationale* Clients !ith schi(ophrenia generally have poor visceral recognition because they live so fully in their fantasy !orld. #hey need to have as in-depth assessment of physical complaints that may spill over into their delusional symptoms. #al$ing !ith the client !on5t provide as assessment of his itching, and itching isn5t as adverse reaction of antipsychotic drugs, calling the physician to get the client5s medication increased doesn5t address his physical complaints. 97. Ans1er* -" .chopra/ia $ationale* .chopra/ia is the copying of another5s behaviors and is the result of the loss of ego boundaries. 8odeling is the conscious copying of someone5s behaviors. .go-syntonicity refers to behaviors that correspond !ith the individual5s sense of self. 0itualism behaviors are repetitive and compulsive. 98. Ans1er* C" 9allucination $ationale* 9allucinations are sensory e/periences that are misrepresentations of reality or have no basis in reality. :elusions are beliefs not based in reality. :isorgani(ed speech is characteri(ed by 1umping from one topic to the ne/t or using unrelated !ords. An idea of reference is a belief that an unrelated situation holds special meaning for the client. 99. Ans1er* C" 0egression $ationale* 0egression, a return to earlier behavior to reduce an/iety, is the basic defense mechanism in schi(ophrenia. 4ro1ection is a defense mechanism in !hich one blames others and attempts to 1ustify actionsI it5s used primarily by people !ith paranoid schi(ophrenia and delusional disorder. 0ationali(ation is a defense mechanism used to 1ustify one5s action. 0epression is the basic defense mechanism in the neurosesI it5s
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an involuntary e/clusion of painful thoughts, feelings, or e/periences from a!areness. 100.Ans1er* A" ;hould report feelings of restlessness or agitation at once $ationale* Agitation and restlessness are adverse effect of haloperidol and can be treated !ith antocholinergic drugs. 9aloperidol isn5t li$ely to cause photosensitivity or control essential hypertension. Although the client may e/perience increased concentration and activity, these effects are due to a decreased in symptoms, not the drug itself.
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#A$T III
#$ACTICE TEST I
%O'NDATION O% N'$SING
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%O'NDATION O% N'$SING 1. 2hich element in the circular chain of infection can be eliminated by preserving s$in integrity@ a. 9ost b. 0eservoir c. 8ode of transmission d. 4ortal of entry 2. 2hich of the follo!ing !ill probably result in a brea$ in sterile techni&ue for respiratory isolation@ a. Bpening the patient5s !indo! to the outside environment b. #urning on the patient5s room ventilator c. Bpening the door of the patient5s room leading into the hospital corridor d. 3ailing to !ear gloves !hen administering a bed bath F. 2hich of the follo!ing patients is at greater ris$ for contracting an infection@ a. A patient !ith leu$openia b. A patient receiving broad-spectrum antibiotics c. A postoperative patient !ho has undergone orthopedic surgery d. A ne!ly diagnosed diabetic patient 4. .ffective hand !ashing re&uires the use of* a. ;oap or detergent to promote emulsification b. 9ot !ater to destroy bacteria c. A disinfectant to increase surface tension d. All of the above 5. After routine patient contact, hand !ashing should last at least* a. F0 seconds b. 1 minute c. 2 minute d. F minutes G. 2hich of the follo!ing procedures al!ays re&uires surgical asepsis@ a. Aaginal instillation of con1ugated estrogen b. )rinary catheteri(ation . Nasogastric tube insertion d. Colostomy irrigation L. ;terile techni&ue is used !henever* a. ;trict isolation is re&uired b. #erminal disinfection is performed c. 'nvasive procedures are performed d. 4rotective isolation is necessary H. 2hich of the follo!ing constitutes a brea$ in sterile techni&ue !hile preparing a sterile field for a dressing change@ a. )sing sterile forceps, rather than sterile gloves, to handle a sterile item
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b. #ouching the outside !rapper of sterili(ed material !ithout sterile gloves c. 4lacing a sterile ob1ect on the edge of the sterile field d. 4ouring out a small amount of solution 1> to F0 ml" before pouring the solution into a sterile container 9. A natural body defense that plays an active role in preventing infection is* a. ,a!ning b. -ody hair c. 9iccupping d. 0apid eye movements 10. All of the follo!ing statement are true about donning sterile gloves e/cept* a. #he first glove should be pic$ed up by grasping the inside of the cuff. b. #he second glove should be pic$ed up by inserting the gloved fingers under the cuff outside the glove. c. #he gloves should be ad1usted by sliding the gloved fingers under the sterile cuff and pulling the glove over the !rist d. #he inside of the glove is considered sterile 11. 2hen removing a contaminated go!n, the nurse should be careful that the first thing she touches is the* a. 2aist tie and nec$ tie at the bac$ of the go!n b. 2aist tie in front of the go!n c. Cuffs of the go!n d. 'nside of the go!n 12. 2hich of the follo!ing nursing interventions is considered the most effective form or universal precautions@ a. Cap all used needles before removing them from their syringes b. :iscard all used uncapped needles and syringes in an impenetrable protective container c. 2ear gloves !hen administering '8 in1ections d. 3ollo! enteric precautions 1F. All of the follo!ing measures are recommended to prevent pressure ulcers e/cept* a. 8assaging the reddened are !ith lotion b. )sing a !ater or air mattress c. Adhering to a schedule for positioning and turning d. 4roviding meticulous s$in care 1E. 2hich of the follo!ing blood tests should be performed before a blood transfusion@ a. 4rothrombin and coagulation time b. -lood typing and cross-matching c. -leeding and clotting time d. Complete blood count C-C" and electrolyte levels. 1>. #he primary purpose of a platelet count is to evaluate the* a. 4otential for clot formation b. 4otential for bleeding
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c. 4resence of an antigen-antibody response d. 4resence of cardiac en(ymes 1G. 2hich of the follo!ing !hite blood cell 2-C" counts clearly indicates leu$ocytosis@ a. E,>006mm^ b. L,0006mm^ c. 10,0006mm^ d. 2>,0006mm^ 17. After > days of diuretic therapy !ith 20mg of furosemide 7asi/" daily, a patient begins to e/hibit fatigue, muscle cramping and muscle !ea$ness. #hese symptoms probably indicate that the patient is e/periencing* a. 9ypo$alemia b. 9yper$alemia c. Anore/ia d. :ysphagia 1H. 2hich of the follo!ing statements about chest M-ray is false@ a. No contradictions e/ist for this test b. -efore the procedure, the patient should remove all 1e!elry, metallic ob1ects, and buttons above the !aist c. A signed consent is not re&uired d. .ating, drin$ing, and medications are allo!ed before this test 19. #he most appropriate time for the nurse to obtain a sputum specimen for culture is* a. .arly in the morning b. After the patient eats a light brea$fast c. After aerosol therapy d. After chest physiotherapy 20. A patient !ith no $no!n allergies is to receive penicillin every G hours. 2hen administering the medication, the nurse observes a fine rash on the patient5s s$in. #he most appropriate nursing action !ould be to* a. 2ithhold the moderation and notify the physician b. Administer the medication and notify the physician c. Administer the medication !ith an antihistamine d. Apply corn starch soa$s to the rash 21. All of the follo!ing nursing interventions are correct !hen using the Strac$ method of drug in1ection e/cept* a. 4repare the in1ection site !ith alcohol b. )se a needle that5s a least 1D long c. Aspirate for blood before in1ection d. 0ub the site vigorously after the in1ection to promote absorption 22. #he correct method for determining the vastus lateralis site for '.8. in1ection is to* a. 7ocate the upper aspect of the upper outer &uadrant of the buttoc$ about > to H cm belo! the iliac crest b. 4alpate the lo!er edge of the acromion process and the midpoint lateral aspect of the arm
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c. 4alpate a 1D circular area anterior to the umbilicus d. :ivide the area bet!een the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh 2F. #he mid-deltoid in1ection site is seldom used for '.8. in1ections because it* a. Can accommodate only 1 ml or less of medication b. -ruises too easily c. Can be used only !hen the patient is lying do!n d. :oes not readily parenteral medication 2E. #he appropriate needle si(e for insulin in1ection is* a. 1H<, 1 RD long b. 22<, 1D long c. 22<, 1 RD long d. 2><, >6HD long 2>. #he appropriate needle gauge for intradermal in1ection is* a. 20< b. 22< c. 2>< d. 2G< 2G. 4arenteral penicillin can be administered as an* a. '8 in1ection or an 'A solution b. 'A or an intradermal in1ection c. 'ntradermal or subcutaneous in1ection d. '8 or a subcutaneous in1ection 2L. #he physician orders gr 10 of aspirin for a patient. #he e&uivalent dose in milligrams is* a. 0.G mg b. 10 mg c. G0 mg d. G00 mg 2H. #he physician orders an 'A solution of de/trose >? in !ater at 100ml6hour. 2hat !ould the flo! rate be if the drop factor is 1> gtt Y 1 ml@ a. > gtt6minute b. 1F gtt6minute c. 2> gtt6minute d. >0 gtt6minute 29. 2hich of the follo!ing is a sign or symptom of a hemolytic reaction to blood transfusion@ a. 9emoglobinuria b. Chest pain c. )rticaria d. :istended nec$ veins F0. 2hich of the follo!ing conditions may re&uire fluid restriction@ a. 3ever b. Chronic Bbstructive 4ulmonary :isease . 0enal 3ailure
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d. :ehydration F1. All of the follo!ing are common signs and symptoms of phlebitis e/cept* a. 4ain or discomfort at the 'A insertion site b. .dema and !armth at the 'A insertion site c. A red strea$ e/iting the 'A insertion site d. 3ran$ bleeding at the insertion site F2. #he best !ay of determining !hether a patient has learned to instill ear medication properly is for the nurse to* a. As$ the patient if he6she has used ear drops before b. 9ave the patient repeat the nurse5s instructions using her o!n !ords c. :emonstrate the procedure to the patient and encourage to as$ &uestions d. As$ the patient to demonstrate the procedure FF. 2hich of the follo!ing types of medications can be administered via gastrostomy tube@ a. Any oral medications b. Capsules !hole contents are dissolve in !ater c. .nteric-coated tablets that are thoroughly dissolved in !ater d. 8ost tablets designed for oral use, e/cept for e/tended-duration compounds FE. A patient !ho develops hives after receiving an antibiotic is e/hibiting drug* a. #olerance b. 'diosyncrasy c. ;ynergism d. Allergy F>. A patient has returned to his room after femoral arteriography. All of the follo!ing are appropriate nursing interventions e/cept* a. Assess femoral, popliteal, and pedal pulses every 1> minutes for 2 hours b. Chec$ the pressure dressing for sanguineous drainage c. Assess a vital signs every 1> minutes for 2 hours d. Brder a hemoglobin and hematocrit count 1 hour after the arteriography FG. #he nurse e/plains to a patient that a cough* a. 's a protective response to clear the respiratory tract of irritants b. 's primarily a voluntary action c. 's induced by the administration of an antitussive drug d. Can be inhibited by CsplintingD the abdomen FL. An infected patient has chills and begins shivering. #he best nursing intervention is to* a. Apply iced alcohol sponges b. 4rovide increased cool li&uids c. 4rovide additional bedclothes d. 4rovide increased ventilation
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FH. A clinical nurse specialist is a nurse !ho has* a. -een certified by the National 7eague for Nursing b. 0eceived credentials from the 4hilippine Nurses5 Association c. <raduated from an associate degree program and is a registered professional nurse d. Completed a master5s degree in the prescribed clinical area and is a registered professional nurse. F9. #he purpose of increasing urine acidity through dietary means is to* a. :ecrease burning sensations b. Change the urine5s color c. Change the urine5s concentration d. 'nhibit the gro!th of microorganisms E0. Clay colored stools indicate* a. )pper <' bleeding b. 'mpending constipation c. An effect of medication d. -ile obstruction E1. 'n !hich step of the nursing process !ould the nurse as$ a patient if the medication she administered relieved his pain@ a. Assessment b. Analysis . 4lanning d. .valuation E2. All of the follo!ing are good sources of vitamin A e/cept* a. 2hite potatoes b. Carrots c. Apricots d. .gg yol$s EF. 2hich of the follo!ing is a primary nursing intervention necessary for all patients !ith a 3oley Catheter in place@ a. 8aintain the drainage tubing and collection bag level !ith the patient5s bladder b. 'rrigate the patient !ith 1? Neosporin solution three times a daily c. Clamp the catheter for 1 hour every E hours to maintain the bladder5s elasticity d. 8aintain the drainage tubing and collection bag belo! bladder level to facilitate drainage by gravity EE. #he .7';A test is used to* a. ;creen blood donors for antibodies to human immunodeficiency virus 9'A" b. #est blood to be used for transfusion for 9'A antibodies . Aid in diagnosing a patient !ith A':; d. All of the above E>. #he t!o blood vessels most commonly used for #4N infusion are the* a. ;ubclavian and 1ugular veins b. -rachial and subclavian veins
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c. 3emoral and subclavian veins d. -rachial and femoral veins EG. .ffective s$in disinfection before a surgical procedure includes !hich of the follo!ing methods@ a. ;having the site on the day before surgery b. Applying a topical antiseptic to the s$in on the evening before surgery c. 9aving the patient ta$e a tub bath on the morning of surgery d. 9aving the patient sho!er !ith an antiseptic soap on the evening vYbefore and the morning of surgery EL. 2hen transferring a patient from a bed to a chair, the nurse should use !hich muscles to avoid bac$ in1ury@ a. Abdominal muscles b. -ac$ muscles c. 7eg muscles d. )pper arm muscles EH. #hrombophlebitis typically develops in patients !ith !hich of the follo!ing conditions@ a. 'ncreases partial thromboplastin time b. Acute pulsus parado/us c. An impaired or traumati(ed blood vessel !all d. Chronic Bbstructive 4ulmonary :isease CB4:" E9. 'n a recumbent, immobili(ed patient, lung ventilation can become altered, leading to such respiratory complications as* a. 0espiratory acidosis, ateclectasis, and hypostatic pneumonia b. Appneustic breathing, atypical pneumonia and respiratory al$alosis c. Cheyne-;tro$es respirations and spontaneous pneumothora/ d. Jussmail5s respirations and hypoventilation >0. 'mmobility impairs bladder elimination, resulting in such disorders as a. 'ncreased urine acidity and rela/ation of the perineal muscles, causing incontinence b. )rine retention, bladder distention, and infection c. :iuresis, natriuresis, and decreased urine specific gravity d. :ecreased calcium and phosphate levels in the urine
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ANS E$S AND $ATIONALE 5 %O'NDATION O% N'$SING 1. D. 'n the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as bro$en s$in. 2. C. 0espiratory isolation, li$e strict isolation, re&uires that the door to the door patient5s room remain closed. 9o!ever, the patient5s room should be !ell ventilated, so opening the !indo! or turning on the ventricular is desirable. #he nurse does not need to !ear gloves for respiratory isolation, but good hand !ashing is important for all types of isolation. 3. A. 7eu$openia is a decreased number of leu$ocytes !hite blood cells", !hich are important in resisting infection. None of the other situations !ould put the patient at ris$ for contracting an infectionI ta$ing broadspectrum antibiotics might actually reduce the infection ris$. 4. A. ;oaps and detergents are used to help remove bacteria because of their ability to lo!er the surface tension of !ater and act as emulsifying agents. 9ot !ater may lead to s$in irritation or burns. 5. A. :epending on the degree of e/posure to pathogens, hand !ashing may last from 10 seconds to E minutes. After routine patient contact, hand !ashing for F0 seconds effectively minimi(es the ris$ of pathogen transmission. 6. *. #he urinary system is normally free of microorganisms e/cept at the urinary meatus. Any procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria-free state. 7. C. All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, re&uire sterile techni&ue to maintain a sterile environment. All e&uipment must be sterile, and the nurse and the physician must !ear sterile gloves and maintain surgical asepsis. 'n the operating room, the nurse and physician are re&uired to !ear sterile go!ns, gloves, mas$s, hair covers, and shoe covers for all invasive procedures. ;trict isolation re&uires the use of clean gloves, mas$s, go!ns and e&uipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. #erminal disinfection is the disinfection of all contaminated supplies and e&uipment after a patient has been discharged to prepare them for reuse by another patient. #he purpose of protective reverse" isolation is to prevent a person !ith seriously impaired resistance from coming into contact !ho potentially pathogenic organisms. 8. C. #he edges of a sterile field are considered contaminated. 2hen sterile items are allo!ed to come in contact !ith the edges of the field, the sterile items also become contaminated. 9. *. 9air on or !ithin body areas, such as the nose, traps and holds particles that contain microorganisms. ,a!ning and hiccupping do not prevent microorganisms from entering or leaving the body. 0apid eye movement mar$s the stage of sleep during !hich dreaming occurs. 10. D. #he inside of the glove is al!ays considered to be clean, but not sterile.
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11. A. #he bac$ of the go!n is considered clean, the front is contaminated. ;o, after removing gloves and !ashing hands, the nurse should untie the bac$ of the go!nI slo!ly move bac$!ard a!ay from the go!n, holding the inside of the go!n and $eeping the edges off the floorI turn and fold the go!n inside outI discard it in a contaminated linen containerI then !ash her hands again. 12. *. According to the Centers for :isease Control C:C", blood-to-blood contact occurs most commonly !hen a health care !or$er attempts to cap a used needle. #herefore, used needles should never be recappedI instead they should be inserted in a specially designed puncture resistant, labeled container. 2earing gloves is not al!ays necessary !hen administering an '.8. in1ection. .nteric precautions prevent the transfer of pathogens via feces. 13. A. Nurses and other health care professionals previously believed that massaging a reddened area !ith lotion !ould promote venous return and reduce edema to the area. 9o!ever, research has sho!n that massage only increases the li$elihood of cellular ischemia and necrosis to the area. 14. *. -efore a blood transfusion is performed, the blood of the donor and recipient must be chec$ed for compatibility. #his is done by blood typing a test that determines a person5s blood type" and cross-matching a procedure that determines the compatibility of the donor5s and recipient5s blood after the blood types has been matched". 'f the blood specimens are incompatible, hemolysis and antigen-antibody reactions !ill occur. 15. A. 4latelets are dis$-shaped cells that are essential for blood coagulation. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting !ith blood coagulation after in1ury. 't also is used to evaluate the patient5s potential for bleedingI ho!ever, this is not its primary purpose. #he normal count ranges from 1>0,000 to F>0,0006mmF. A count of 100,0006mmF or less indicates a potential for bleedingI count of less than 20,0006mmF is associated !ith spontaneous bleeding. 16. D. 7eu$ocytosis is any transient increase in the number of !hite blood cells leu$ocytes" in the blood. Normal 2-C counts range from >,000 to 100,0006mmF. #hus, a count of 2>,0006mmF indicates leu$ocytosis. 17. A. 3atigue, muscle cramping, and muscle !ea$nesses are symptoms of hypo$alemia an inade&uate potassium level", !hich is a potential side effect of diuretic therapy. #he physician usually orders supplemental potassium to prevent hypo$alemia in patients receiving diuretics. Anore/ia is another symptom of hypo$alemia. :ysphagia means difficulty s!allo!ing. 18. A. 4regnancy or suspected pregnancy is the only contraindication for a chest M-ray. 9o!ever, if a chest M-ray is necessary, the patient can !ear a lead apron to protect the pelvic region from radiation. Pe!elry, metallic ob1ects, and buttons !ould interfere !ith the M-ray and thus should not be !orn above the !aist. A signed consent is not re&uired because a chest
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M-ray is not an invasive e/amination. .ating, drin$ing and medications are allo!ed because the M-ray is of the chest, not the abdominal region. 19. A. Bbtaining a sputum specimen early in this morning ensures an ade&uate supply of bacteria for culturing and decreases the ris$ of contamination from food or medication. 20. A. 'nitial sensitivity to penicillin is commonly manifested by a s$in rash, even in individuals !ho have not been allergic to it previously. -ecause of the danger of anaphylactic shoc$, he nurse should !ithhold the drug and notify the physician, !ho may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that re&uires a !ritten physician5s order. Although applying corn starch to the rash may relieve discomfort, it is not the nurse5s top priority in such a potentially life-threatening situation. 21. D. #he S-trac$ method is an '.8. in1ection techni&ue in !hich the patient5s s$in is pulled in such a !ay that the needle trac$ is sealed off after the in1ection. #his procedure seals medication deep into the muscle, thereby minimi(ing s$in staining and irritation. 0ubbing the in1ection site is contraindicated because it may cause the medication to e/travasate into the s$in. 22. D. #he vastus lateralis, a long, thic$ muscle that e/tends the full length of the thigh, is vie!ed by many clinicians as the site of choice for '.8. in1ections because it has relatively fe! ma1or nerves and blood vessels. #he middle third of the muscle is recommended as the in1ection site. #he patient can be in a supine or sitting position for an in1ection into this site. 23. A. #he mid-deltoid in1ection site can accommodate only 1 ml or less of medication because of its si(e and location on the deltoid muscle of the arm, close to the brachial artery and radial nerve". 24. D. A 2><, >6HD needle is the recommended si(e for insulin in1ection because insulin is administered by the subcutaneous route. An 1H<, 1 RD needle is usually used for '.8. in1ections in children, typically in the vastus lateralis. A 22<, 1 RD needle is usually used for adult '.8. in1ections, !hich are typically administered in the vastus lateralis or ventrogluteal site. 25. D. -ecause an intradermal in1ection does not penetrate deeply into the s$in, a small-bore 2>< needle is recommended. #his type of in1ection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A 20< needle is usually used for '.8. in1ections of oilbased medicationsI a 22< needle for '.8. in1ectionsI and a 2>< needle, for '.8. in1ectionsI and a 2>< needle, for subcutaneous insulin in1ections. 26. A. 4arenteral penicillin can be administered '.8. or added to a solution and given '.A. 't cannot be administered subcutaneously or intradermally. 27. D. gr 10 / G0mg6gr 1 Y G00 mg 28. C. 100ml6G0 min M 1> gtt6 1 ml Y 2> gtt6minute 29. A. 9emoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction incompatibility of the donor5s and recipient5s blood". 'n this reaction, antibodies in the recipient5s plasma combine rapidly !ith donor 0-C5sI the cells are hemoly(ed in either
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circulatory or reticuloendothelial system. 9emolysis occurs more rapidly in A-B incompatibilities than in 0h incompatibilities. Chest pain and urticaria may be symptoms of impending anaphyla/is. :istended nec$ veins are an indication of hypervolemia. 30. C. 'n real failure, the $idney loses their ability to effectively eliminate !astes and fluids. -ecause of this, limiting the patient5s inta$e of oral and '.A. fluids may be necessary. 3ever, chronic obstructive pulmonary disease, and dehydration are conditions for !hich fluids should be encouraged. 31. D. 4hlebitis, the inflammation of a vein, can be caused by chemical irritants '.A. solutions or medications", mechanical irritants the needle or catheter used during venipuncture or cannulation", or a locali(ed allergic reaction to the needle or catheter. ;igns and symptoms of phlebitis include pain or discomfort, edema and heat at the '.A. insertion site, and a red strea$ going up the arm or leg from the '.A. insertion site. 32. D. 0eturn demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching. 33. D. Capsules, enteric-coated tablets, and most e/tended duration or sustained release products should not be dissolved for use in a gastrostomy tube. #hey are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. #he nurse should see$ an alternate physician5s order !hen an ordered medication is inappropriate for delivery by tube. 34. D. A drug-allergy is an adverse reaction resulting from an immunologic response follo!ing a previous sensiti(ing e/posure to the drug. #he reaction can range from a rash or hives to anaphylactic shoc$. Tolerance to a drug means that the patient e/periences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individual5s uni&ue hypersensitivity to a drug, food, or other substanceI it appears to be genetically determined. Synergism, is a drug interaction in !hich the sum of the drug5s combined effects is greater than that of their separate effects. 35. D. A hemoglobin and hematocrit count !ould be ordered by the physician if bleeding !ere suspected. #he other ans!ers are appropriate nursing interventions for a patient !ho has undergone femoral arteriography. 36. A. Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntaryI ho!ever it can be voluntary, as !hen a patient is taught to perform coughing e/ercises. An antitussive drug inhibits coughing. ;plinting the abdomen supports the abdominal muscles !hen a patient coughs. 37. C. 'n an infected patient, shivering results from the body5s attempt to increase heat production and the production of neutrophils and phagocytotic action through increased s$eletal muscle tension and contractions. 'nitial vasoconstriction may cause s$in to feel cold to the touch. Applying additional bed clothes helps to e&uali(e the body
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temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production. 38. D. A clinical nurse specialist must have completed a master5s degree in a clinical specialty and be a registered professional nurse. #he National 7eague of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. #he American Nurses Association identifies re&uirements for certification and offers e/aminations for certification in many areas of nursing., such as medical surgical nursing. #hese certification credentialing" demonstrates that the nurse has the $no!ledge and the ability to provide high &uality nursing care in the area of her certification. A graduate of an associate degree program is not a clinical nurse specialist* ho!ever, she is prepared to provide bed side nursing !ith a high degree of $no!ledge and s$ill. ;he must successfully complete the licensing e/amination to become a registered professional nurse. 39. D. 8icroorganisms usually do not gro! in an acidic environment. 40. D. -ile colors the stool bro!n. Any inflammation or obstruction that impairs bile flo! !ill affect the stool pigment, yielding light, clay-colored stool. )pper <' bleeding results in blac$ or tarry stool. Constipation is characteri(ed by small, hard masses. 8any medications and foods !ill discolor stool N for e/ample, drugs containing iron turn stool blac$.I beets turn stool red. 41. D. 'n the evaluation step of the nursing process, the nurse must decide !hether the patient has achieved the e/pected outcome that !as identified in the planning phase. 42. A. #he main sources of vitamin A are yello! and green vegetables such as carrots, s!eet potatoes, s&uash, spinach, collard greens, broccoli, and cabbage" and yello! fruits such as apricots, and cantaloupe". Animal sources include liver, $idneys, cream, butter, and egg yol$s. 43. D. 8aintaing the drainage tubing and collection bag level !ith the patient5s bladder could result in reflu/ of urine into the $idney. 'rrigating the bladder !ith Neosporin and clamping the catheter for 1 hour every E hours must be prescribed by a physician. 44. D. #he .7';A test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus 9'A". A positive .7';A test combined !ith various signs and symptoms helps to diagnose ac&uired immunodeficiency syndrome A':;" 45. D. #achypnea an abnormally rapid rate of breathing" !ould indicate that the patient !as still hypo/ic deficient in o/ygen".#he partial pressures of arterial o/ygen and carbon dio/ide listed are !ithin the normal range. .upnea refers to normal respiration. 46. D. ;tudies have sho!n that sho!ering !ith an antiseptic soap before surgery is the most effective method of removing microorganisms from the s$in. ;having the site of the intended surgery might cause brea$s in the s$in, thereby increasing the ris$ of infectionI ho!ever, if indicated, shaving, should be done immediately before surgery, not the day before.
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A topical antiseptic !ould not remove microorganisms and !ould be beneficial only after proper cleaning and rinsing. #ub bathing might transfer organisms to another body site rather than rinse them a!ay. 47. C. #he leg muscles are the strongest muscles in the body and should bear the greatest stress !hen lifting. 8uscles of the abdomen, bac$, and upper arms may be easily in1ured. 48. C. #he factors, $no!n as Aircho!5s triad, collectively predispose a patient to thromboplebitisI impaired venous return to the heart, blood hypercoagulability, and in1ury to a blood vessel !all. 'ncreased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant heparin" therapy. Arterial blood disorders such as pulsus parado/us" and lung diseases such as CB4:" do not necessarily impede venous return of in1ure vessel !alls. 49. A. -ecause of restricted respiratory movement, a recumbent, immobili(e patient is at particular ris$ for respiratory acidosis from poor gas e/changeI atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial gro!th caused by stasis of mucus secretions. 50. *. #he immobili(ed patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. #his leads to bladder distention and urine stagnation, !hich provide an e/cellent medium for bacterial gro!th leading to infection. 'mmobility also results in more al$aline urine !ith e/cessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and an increased specific gravity.
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#$ACTICE TEST II
"aternal and Child &ealth
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"ATE$NAL AND C&ILD &EALT& 1. 3or the client !ho is using oral contraceptives, the nurse informs the client about the need to ta$e the pill at the same time each day to accomplish !hich of the follo!ing@ a. :ecrease the incidence of nausea b. 8aintain hormonal levels c. 0educe side effects d. 4revent drug interactions 2. 2hen teaching a client about contraception. 2hich of the follo!ing !ould the nurse include as the most effective method for preventing se/ually transmitted infections@ a. ;permicides b. :iaphragm c. Condoms d. Aasectomy F. 2hen preparing a !oman !ho is 2 days postpartum for discharge, recommendations for !hich of the follo!ing contraceptive methods !ould be avoided@ a. :iaphragm b. 3emale condom c. Bral contraceptives d. 0hythm method 4. 3or !hich of the follo!ing clients !ould the nurse e/pect that an intrauterine device !ould not be recommended@ a. 2oman over age F> b. Nulliparous !oman c. 4romiscuous young adult d. 4ostpartum client >. A client in her third trimester tells the nurse, C'5m constipated all the timeWD 2hich of the follo!ing should the nurse recommend@ a. :aily enemas b. 7a/atives c. 'ncreased fiber inta$e d. :ecreased fluid inta$e G. 2hich of the follo!ing !ould the nurse use as the basis for the teaching plan !hen caring for a pregnant teenager concerned about gaining too much !eight during pregnancy@ a. 10 pounds per trimester b. 1 pound per !ee$ for E0 !ee$s c. R pound per !ee$ for E0 !ee$s d. A total gain of 2> to F0 pounds L. #he client tells the nurse that her last menstrual period started on Panuary 1E and ended on Panuary 20. )sing Nagele5s rule, the nurse determines her .:: to be !hich of the follo!ing@ a. ;eptember 2L
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b. Bctober 21 c. November L d. :ecember 2L H. 2hen ta$ing an obstetrical history on a pregnant client !ho states, C' had a son born at FH !ee$s gestation, a daughter born at F0 !ee$s gestation and ' lost a baby at about H !ee$s,D the nurse should record her obstetrical history as !hich of the follo!ing@ a. <2 #2 40 A0 72 b. <F #1 41 A0 72 c. <F #2 40 A0 72 d. <E #1 41 A1 72 9. 2hen preparing to listen to the fetal heart rate at 12 !ee$s5 gestation, the nurse !ould use !hich of the follo!ing@ a. ;tethoscope placed midline at the umbilicus b. :oppler placed midline at the suprapubic region c. 3etoscope placed mid!ay bet!een the umbilicus and the /iphoid process d. ./ternal electronic fetal monitor placed at the umbilicus 10. 2hen developing a plan of care for a client ne!ly diagnosed !ith gestational diabetes, !hich of the follo!ing instructions !ould be the priority@ a. :ietary inta$e b. 8edication c. ./ercise d. <lucose monitoring 11. A client at 2E !ee$s gestation has gained G pounds in E !ee$s. 2hich of the follo!ing !ould be the priority !hen assessing the client@ a. <lucosuria b. :epression c. 9and6face edema d. :ietary inta$e 12. A client 12 !ee$s5 pregnant come to the emergency department !ith abdominal cramping and moderate vaginal bleeding. ;peculum e/amination reveals 2 to F cms cervical dilation. #he nurse !ould document these findings as !hich of the follo!ing@ a. #hreatened abortion b. 'mminent abortion c. Complete abortion d. 8issed abortion 1F. 2hich of the follo!ing !ould be the priority nursing diagnosis for a client !ith an ectopic pregnancy@ a. 0is$ for infection b. 4ain c. Jno!ledge :eficit d. Anticipatory <rieving
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1E. -efore assessing the postpartum client5s uterus for firmness and position in relation to the umbilicus and midline, !hich of the follo!ing should the nurse do first@ a. Assess the vital signs b. Administer analgesia c. Ambulate her in the hall d. Assist her to urinate 1>. 2hich of the follo!ing should the nurse do !hen a primipara !ho is lactating tells the nurse that she has sore nipples@ a. #ell her to breast feed more fre&uently b. Administer a narcotic before breast feeding c. .ncourage her to !ear a nursing brassiere d. )se soap and !ater to clean the nipples 1G. #he nurse assesses the vital signs of a client, E hours5 postpartum that are as follo!s* -4 906G0I temperature 100.E_3I pulse 100 !ea$, threadyI 0 20 per minute. 2hich of the follo!ing should the nurse do first@ a. 0eport the temperature to the physician b. 0echec$ the blood pressure !ith another cuff c. Assess the uterus for firmness and position d. :etermine the amount of lochia 1L. #he nurse assesses the postpartum vaginal discharge lochia" on four clients. 2hich of the follo!ing assessments !ould !arrant notification of the physician@ a. A dar$ red discharge on a 2-day postpartum client b. A pin$ to bro!nish discharge on a client !ho is > days postpartum c. Almost colorless to creamy discharge on a client 2 !ee$s after delivery d. A bright red discharge > days after delivery 1H. A postpartum client has a temperature of 101.E_3, !ith a uterus that is tender !hen palpated, remains unusually large, and not descending as normally e/pected. 2hich of the follo!ing should the nurse assess ne/t@ a. 7ochia b. -reasts c. 'ncision d. )rine 19. 2hich of the follo!ing is the priority focus of nursing practice !ith the current early postpartum discharge@ a. 4romoting comfort and restoration of health b. ./ploring the emotional status of the family c. 3acilitating safe and effective self-and ne!born care d. #eaching about the importance of family planning 20. 2hich of the follo!ing actions !ould be least effective in maintaining a neutral thermal environment for the ne!born@ a. 4lacing infant under radiant !armer after bathing b. Covering the scale !ith a !armed blan$et prior to !eighing c. 4lacing crib close to nursery !indo! for family vie!ing
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d. Covering the infant5s head !ith a $nit stoc$inette 21. A ne!born !ho has an asymmetrical 8oro refle/ response should be further assessed for !hich of the follo!ing@ a. #alipes e&uinovarus b. 3ractured clavicle c. Congenital hypothyroidism d. 'ncreased intracranial pressure 22. :uring the first E hours after a male circumcision, assessing for !hich of the follo!ing is the priority@ a. 'nfection b. 9emorrhage c. :iscomfort d. :ehydration 2F. #he mother as$s the nurse. C2hat5s !rong !ith my son5s breasts@ 2hy are they so enlarged@D 2hish of the follo!ing !ould be the best response by the nurse@ a. C#he breast tissue is inflamed from the trauma e/perienced !ith birthD b. CA decrease in material hormones present before birth causes enlargement,D c. C,ou should discuss this !ith your doctor. 't could be a malignancyD d. C#he tissue has hypertrophied !hile the baby !as in the uterusD 2E. 'mmediately after birth the nurse notes the follo!ing on a male ne!born* respirations LHI apical hearth rate 1G0 -48, nostril flaringI mild intercostal retractionsI and grunting at the end of e/piration. 2hich of the follo!ing should the nurse do@ a. Call the assessment data to the physician5s attention b. ;tart o/ygen per nasal cannula at 2 76min. c. ;uction the infant5s mouth and nares d. 0ecogni(e this as normal first period of reactivity 2>. #he nurse hears a mother telling a friend on the telephone about umbilical cord care. 2hich of the follo!ing statements by the mother indicates effective teaching@ a. C:aily soap and !ater cleansing is bestD b. `Alcohol helps it dry and $ills germsD c. CAn antibiotic ointment applied daily prevents infectionD d. C9e can have a tub bath each dayD 2G. A ne!born !eighing F000 grams and feeding every E hours needs 120 calories6$g of body !eight every 2E hours for proper gro!th and development. 9o! many ounces of 20 cal6o( formula should this ne!born receive at each feeding to meet nutritional needs@ a. 2 ounces b. F ounces c. E ounces d. G ounces
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2L. #he postterm neonate !ith meconium-stained amniotic fluid needs care designed to especially monitor for !hich of the follo!ing@ a. 0espiratory problems b. <astrointestinal problems c. 'ntegumentary problems d. .limination problems 2H. 2hen measuring a client5s fundal height, !hich of the follo!ing techni&ues denotes the correct method of measurement used by the nurse@ a. 3rom the /iphoid process to the umbilicus b. 3rom the symphysis pubis to the /iphoid process c. 3rom the symphysis pubis to the fundus d. 3rom the fundus to the umbilicus 29. A client !ith severe preeclampsia is admitted !ith of -4 1G06110, proteinuria, and severe pitting edema. 2hich of the follo!ing !ould be most important to include in the client5s plan of care@ a. :aily !eights b. ;ei(ure precautions c. 0ight lateral positioning d. ;tress reduction F0. A postpartum primipara as$s the nurse, C2hen can !e have se/ual intercourse again@D 2hich of the follo!ing !ould be the nurse5s best response@ a. CAnytime you both !ant to.D b. CAs soon as choose a contraceptive method.D c. C2hen the discharge has stopped and the incision is healed.D d. CAfter your G !ee$s e/amination.D F1. 2hen preparing to administer the vitamin J in1ection to a neonate, the nurse !ould select !hich of the follo!ing sites as appropriate for the in1ection@ a. :eltoid muscle b. Anterior femoris muscle c. Aastus lateralis muscle d. <luteus ma/imus muscle F2. 2hen performing a pelvic e/amination, the nurse observes a red s!ollen area on the right side of the vaginal orifice. #he nurse !ould document this as enlargement of !hich of the follo!ing@ a. Clitoris b. 4arotid gland c. ;$ene5s gland d. -artholin5s gland FF. #o differentiate as a female, the hormonal stimulation of the embryo that must occur involves !hich of the follo!ing@ a. 'ncrease in maternal estrogen secretion b. :ecrease in maternal androgen secretion c. ;ecretion of androgen by the fetal gonad d. ;ecretion of estrogen by the fetal gonad
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FE. A client at H !ee$s5 gestation calls complaining of slight nausea in the morning hours. 2hich of the follo!ing client interventions should the nurse &uestion@ a. #a$ing 1 teaspoon of bicarbonate of soda in an H-ounce glass of !ater b. .ating a fe! lo!-sodium crac$ers before getting out of bed c. Avoiding the inta$e of li&uids in the morning hours d. .ating si/ small meals a day instead of thee large meals F>. #he nurse documents positive ballottement in the client5s prenatal record. #he nurse understands that this indicates !hich of the follo!ing@ a. 4alpable contractions on the abdomen b. 4assive movement of the unengaged fetus c. 3etal $ic$ing felt by the client d. .nlargement and softening of the uterus FG. :uring a pelvic e/am the nurse notes a purple-blue tinge of the cervi/. #he nurse documents this as !hich of the follo!ing@ a. -ra/ton-9ic$s sign b. Chad!ic$5s sign c. <oodell5s sign d. 8c:onald5s sign FL. :uring a prenatal class, the nurse e/plains the rationale for breathing techni&ues during preparation for labor based on the understanding that breathing techni&ues are most important in achieving !hich of the follo!ing@ a. .liminate pain and give the e/pectant parents something to do b. 0educe the ris$ of fetal distress by increasing uteroplacental perfusion c. 3acilitate rela/ation, possibly reducing the perception of pain d. .liminate pain so that less analgesia and anesthesia are needed FH. After E hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervi/. 2hich of the follo!ing !ould the nurse anticipate doing@ a. Bbtaining an order to begin 'A o/ytocin infusion b. Administering a light sedative to allo! the patient to rest for several hour c. 4reparing for a cesarean section for failure to progress d. 'ncreasing the encouragement to the patient !hen pushing begins F9. A multigravida at FH !ee$s5 gestation is admitted !ith painless, bright red bleeding and mild contractions every L to 10 minutes. 2hich of the follo!ing assessments should be avoided@ a. 8aternal vital sign b. 3etal heart rate c. Contraction monitoring d. Cervical dilation
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E0. 2hich of the follo!ing !ould be the nurse5s most appropriate response to a client !ho as$s !hy she must have a cesarean delivery if she has a complete placenta previa@ a. C,ou !ill have to as$ your physician !hen he returns.D b. C,ou need a cesarean to prevent hemorrhage.D c. C#he placenta is covering most of your cervi/.D d. C#he placenta is covering the opening of the uterus and bloc$ing your baby.D E1. #he nurse understands that the fetal head is in !hich of the follo!ing positions !ith a face presentation@ a. Completely fle/ed b. Completely e/tended c. 4artially e/tended d. 4artially fle/ed E2. 2ith a fetus in the left-anterior breech presentation, the nurse !ould e/pect the fetal heart rate !ould be most audible in !hich of the follo!ing areas@ a. Above the maternal umbilicus and to the right of midline b. 'n the lo!er-left maternal abdominal &uadrant c. 'n the lo!er-right maternal abdominal &uadrant d. Above the maternal umbilicus and to the left of midline EF. #he amniotic fluid of a client has a greenish tint. #he nurse interprets this to be the result of !hich of the follo!ing@ a. 7anugo b. 9ydramnio c. 8econium d. Aerni/ EE. A patient is in labor and has 1ust been told she has a breech presentation. #he nurse should be particularly alert for !hich of the follo!ing@ a. Quic$ening b. Bphthalmia neonatorum c. 4ica d. 4rolapsed umbilical cord E>. 2hen describing di(ygotic t!ins to a couple, on !hich of the follo!ing !ould the nurse base the e/planation@ a. #!o ova fertili(ed by separate sperm b. ;haring of a common placenta c. .ach ova !ith the same genotype d. ;haring of a common chorion EG. 2hich of the follo!ing refers to the single cell that reproduces itself after conception@ a. Chromosome b. -lastocyst c. Sygote d. #rophoblast
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EL. 'n the late 19>0s, consumers and health care professionals began challenging the routine use of analgesics and anesthetics during childbirth. 2hich of the follo!ing !as an outgro!th of this concept@ a. 7abor, delivery, recovery, postpartum 7:04" b. Nurse-mid!ifery c. Clinical nurse specialist d. 4repared childbirth EH. A client has a midpelvic contracture from a previous pelvic in1ury due to a motor vehicle accident as a teenager. #he nurse is a!are that this could prevent a fetus from passing through or around !hich structure during childbirth@ a. ;ymphysis pubis b. ;acral promontory c. 'schial spines d. 4ubic arch E9. 2hen teaching a group of adolescents about variations in the length of the menstrual cycle, the nurse understands that the underlying mechanism is due to variations in !hich of the follo!ing phases@ a. 8enstrual phase b. 4roliferative phase c. ;ecretory phase d. 'schemic phase >0. 2hen teaching a group of adolescents about male hormone production, !hich of the follo!ing !ould the nurse include as being produced by the 7eydig cells@ a. 3ollicle-stimulating hormone b. #estosterone c. 7euteini(ing hormone d. <onadotropin releasing hormone
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ANS E$S AND $ATIONALE 5 "ATE$NAL AND C&ILD &EALT& 1. *. 0egular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of 3;9 and 79. #herefore, follicles do not mature, ovulation is inhibited, and pregnancy is prevented. #he estrogen content of the oral site contraceptive may cause the nausea, regardless of !hen the pill is ta$en. ;ide effects and drug interactions may occur !ith oral contraceptives regardless of the time the pill is ta$en. 2. C. Condoms, !hen used correctly and consistently, are the most effective contraceptive method or barrier against bacterial and viral se/ually transmitted infections. Although spermicides $ill sperm, they do not provide reliable protection against the spread of se/ually transmitted infections, especially intracellular organisms such as 9'A. 'nsertion and removal of the diaphragm along !ith the use of the spermicides may cause vaginal irritations, !hich could place the client at ris$ for infection transmission. 8ale sterili(ation eliminates spermato(oa from the e1aculate, but it does not eliminate bacterial and6or viral microorganisms that can cause se/ually transmitted infections. 3. A. #he diaphragm must be fitted individually to ensure effectiveness. -ecause of the changes to the reproductive structures during pregnancy and follo!ing delivery, the diaphragm must be refitted, usually at the G !ee$s5 e/amination follo!ing childbirth or after a !eight loss of 1> lbs or more. 'n addition, for ma/imum effectiveness, spermicidal 1elly should be placed in the dome and around the rim. 9o!ever, spermicidal 1elly should not be inserted into the vagina until involution is completed at appro/imately G !ee$s. )se of a female condom protects the reproductive system from the introduction of semen or spermicides into the vagina and may be used after childbirth. Bral contraceptives may be started !ithin the first postpartum !ee$ to ensure suppression of ovulation. 3or the couple !ho has determined the female5s fertile period, using the rhythm method, avoidance of intercourse during this period, is safe and effective. 4. C. An '): may increase the ris$ of pelvic inflammatory disease, especially in !omen !ith more than one se/ual partner, because of the increased ris$ of se/ually transmitted infections. An )': should not be used if the !oman has an active or chronic pelvic infection, postpartum infection, endometrial hyperplasia or carcinoma, or uterine abnormalities. Age is not a factor in determining the ris$s associated !ith '): use. 8ost '): users are over the age of F0. Although there is a slightly higher ris$ for infertility in !omen !ho have never been pregnant, the '): is an acceptable option as long as the ris$-benefit ratio is discussed. '):s may be inserted immediately after delivery, but this is not recommended because of the increased ris$ and rate of e/pulsion at this time.
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5. C. :uring the third trimester, the enlarging uterus places pressure on the intestines. #his coupled !ith the effect of hormones on smooth muscle rela/ation causes decreased intestinal motility peristalsis". 'ncreasing fiber in the diet !ill help fecal matter pass more &uic$ly through the intestinal tract, thus decreasing the amount of !ater that is absorbed. As a result, stool is softer and easier to pass. .nemas could precipitate preterm labor and6or electrolyte loss and should be avoided. 7a/atives may cause preterm labor by stimulating peristalsis and may interfere !ith the absorption of nutrients. )se for more than 1 !ee$ can also lead to la/ative dependency. 7i&uid in the diet helps provide a semisolid, soft consistency to the stool. .ight to ten glasses of fluid per day are essential to maintain hydration and promote stool evacuation. 6. D. #o ensure ade&uate fetal gro!th and development during the E0 !ee$s of a pregnancy, a total !eight gain 2> to F0 pounds is recommended* 1.> pounds in the first 10 !ee$sI 9 pounds by F0 !ee$sI and 2L.> pounds by E0 !ee$s. #he pregnant !oman should gain less !eight in the first and second trimester than in the third. :uring the first trimester, the client should only gain 1.> pounds in the first 10 !ee$s, not 1 pound per !ee$. A !eight gain of R pound per !ee$ !ould be 20 pounds for the total pregnancy, less than the recommended amount. 7. *. #o calculate the .:: by Nagele5s rule, add L days to the first day of the last menstrual period and count bac$ F months, changing the year appropriately. #o obtain a date of ;eptember 2L, L days have been added to the last day of the 784 rather than the first day of the 784", plus E months instead of F months" !ere counted bac$. #o obtain the date of November L, L days have been subtracted instead of added" from the first day of 784 plus November indicates counting bac$ 2 months instead of F months" from Panuary. #o obtain the date of :ecember 2L, L days !ere added to the last day of the 784 rather than the first day of the 784" and :ecember indicates counting bac$ only 1 month instead of F months" from Panuary. 8. D8 #he client has been pregnant four times, including current pregnancy <". -irth at FH !ee$s5 gestation is considered full term #", !hile birth form 20 !ee$s to FH !ee$s is considered preterm 4". A spontaneous abortion occurred at H !ee$s A". ;he has t!o living children 7". 9. *8 At 12 !ee$s gestation, the uterus rises out of the pelvis and is palpable above the symphysis pubis. #he :oppler intensifies the sound of the fetal pulse rate so it is audible. #he uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus. #he fetal heart rate at this age is not audible !ith a stethoscope. #he uterus at 12 !ee$s is 1ust above the symphysis pubis in the abdominal cavity, not mid!ay bet!een the umbilicus and the /iphoid process. At 12 !ee$s the 390 !ould be difficult to auscultate !ith a fetoscope. Although the e/ternal electronic fetal monitor !ould pro1ect the 390, the uterus has not risen to the umbilicus at 12 !ee$s.
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10. A8 Although all of the choices are important in the management of diabetes, diet therapy is the mainstay of the treatment plan and should al!ays be the priority. 2omen diagnosed !ith gestational diabetes generally need only diet therapy !ithout medication to control their blood sugar levels. ./ercise, is important for all pregnant !omen and especially for diabetic !omen, because it burns up glucose, thus decreasing blood sugar. 9o!ever, dietary inta$e, not e/ercise, is the priority. All pregnant !omen !ith diabetes should have periodic monitoring of serum glucose. 9o!ever, those !ith gestational diabetes generally do not need daily glucose monitoring. #he standard of care recommends a fasting and 2hour postprandial blood sugar level every 2 !ee$s. 11. C8 After 20 !ee$s5 gestation, !hen there is a rapid !eight gain, preeclampsia should be suspected, !hich may be caused by fluid retention manifested by edema, especially of the hands and face. #he three classic signs of preeclampsia are hypertension, edema, and proteinuria. Although urine is chec$ed for glucose at each clinic visit, this is not the priority. :epression may cause either anore/ia or e/cessive food inta$e, leading to e/cessive !eight gain or loss. #his is not, ho!ever, the priority consideration at this time. 2eight gain thought to be caused by e/cessive food inta$e !ould re&uire a 2E-hour diet recall. 9o!ever, e/cessive inta$e !ould not be the primary consideration for this client at this time. 12. *8 Cramping and vaginal bleeding coupled !ith cervical dilation signifies that termination of the pregnancy is inevitable and cannot be prevented. #hus, the nurse !ould document an imminent abortion. 'n a threatened abortion, cramping and vaginal bleeding are present, but there is no cervical dilation. #he symptoms may subside or progress to abortion. 'n a complete abortion all the products of conception are e/pelled. A missed abortion is early fetal intrauterine death !ithout e/pulsion of the products of conception. 13. *8 3or the client !ith an ectopic pregnancy, lo!er abdominal pain, usually unilateral, is the primary symptom. #hus, pain is the priority. Although the potential for infection is al!ays present, the ris$ is lo! in ectopic pregnancy because pathogenic microorganisms have not been introduced from e/ternal sources. #he client may have a limited $no!ledge of the pathology and treatment of the condition and !ill most li$ely e/perience grieving, but this is not the priority at this time. 14. D8 -efore uterine assessment is performed, it is essential that the !oman empty her bladder. A full bladder !ill interfere !ith the accuracy of the assessment by elevating the uterus and displacing to the side of the midline. Aital sign assessment is not necessary unless an abnormality in uterine assessment is identified. )terine assessment should not cause acute pain that re&uires administration of analgesia. Ambulating the client is an essential component of postpartum care, but is not necessary prior to assessment of the uterus.
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15. A8 3eeding more fre&uently, about every 2 hours, !ill decrease the infant5s frantic, vigorous suc$ing from hunger and !ill decrease breast engorgement, soften the breast, and promote ease of correct latching-on for feeding. Narcotics administered prior to breast feeding are passed through the breast mil$ to the infant, causing e/cessive sleepiness. Nipple soreness is not severe enough to !arrant narcotic analgesia. All postpartum clients, especially lactating mothers, should !ear a supportive brassiere !ith !ide cotton straps. #his does not, ho!ever, prevent or reduce nipple soreness. ;oaps are drying to the s$in of the nipples and should not be used on the breasts of lactating mothers. :ry nipple s$in predisposes to crac$s and fissures, !hich can become sore and painful. 16. D8 A !ea$, thready pulse elevated to 100 -48 may indicate impending hemorrhagic shoc$. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. #hus, the nurse should chec$ the amount of lochia present. #emperatures up to 100.EH3 in the first 2E hours after birth are related to the dehydrating effects of labor and are considered normal. Although rechec$ing the blood pressure may be a correct choice of action, it is not the first action that should be implemented in light of the other data. #he data indicate a potential impending hemorrhage. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important, but the nurse should chec$ the e/tent of vaginal bleeding first. #hen it !ould be appropriate to chec$ the uterus, !hich may be a possible cause of the hemorrhage. 17. D8 Any bright red vaginal discharge !ould be considered abnormal, but especially > days after delivery, !hen the lochia is typically pin$ to bro!nish. 7ochia rubra, a dar$ red discharge, is present for 2 to F days after delivery. -right red vaginal bleeding at this time suggests late postpartum hemorrhage, !hich occurs after the first 2E hours follo!ing delivery and is generally caused by retained placental fragments or bleeding disorders. 7ochia rubra is the normal dar$ red discharge occurring in the first 2 to F days after delivery, containing epithelial cells, erythrocyes, leu$ocytes and decidua. 7ochia serosa is a pin$ to bro!nish serosanguineous discharge occurring from F to 10 days after delivery that contains decidua, erythrocytes, leu$ocytes, cervical mucus, and microorganisms. 7ochia alba is an almost colorless to yello!ish discharge occurring from 10 days to F !ee$s after delivery and containing leu$ocytes, decidua, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria. 18. A8 #he data suggests an infection of the endometrial lining of the uterus. #he lochia may be decreased or copious, dar$ bro!n in appearance, and foul smelling, providing further evidence of a possible infection. All the client5s data indicate a uterine problem, not a breast problem. #ypically, transient fever, usually 101_3, may be present !ith breast engorgement. ;ymptoms of mastitis include influen(a-li$e manifestations. 7ocali(ed infection of an episiotomy or C-section incision rarely causes systemic symptoms, and uterine involution !ould not be affected. #he client data do
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not include dysuria, fre&uency, or urgency, symptoms of urinary tract infections, !hich !ould necessitate assessing the client5s urine. 19. C8 -ecause of early postpartum discharge and limited time for teaching, the nurse5s priority is to facilitate the safe and effective care of the client and ne!born. Although promoting comfort and restoration of health, e/ploring the family5s emotional status, and teaching about family planning are important in postpartum6ne!born nursing care, they are not the priority focus in the limited time presented by early post-partum discharge. 20. C8 9eat loss by radiation occurs !hen the infant5s crib is placed too near cold !alls or !indo!s. #hus placing the ne!born5s crib close to the vie!ing !indo! !ould be least effective. -ody heat is lost through evaporation during bathing. 4lacing the infant under the radiant !armer after bathing !ill assist the infant to be re!armed. Covering the scale !ith a !armed blan$et prior to !eighing prevents heat loss through conduction. A $nit cap prevents heat loss from the head a large head, a large body surface area of the ne!born5s body. 21. *8 A fractured clavicle !ould prevent the normal 8oro response of symmetrical se&uential e/tension and abduction of the arms follo!ed by fle/ion and adduction. 'n talipes e&uinovarus clubfoot" the foot is turned medially, and in plantar fle/ion, !ith the heel elevated. #he feet are not involved !ith the 8oro refle/. 9ypothyroiddism has no effect on the primitive refle/es. Absence of the 8oror refle/ is the most significant single indicator of central nervous system status, but it is not a sign of increased intracranial pressure. 22. *8 9emorrhage is a potential ris$ follo!ing any surgical procedure. Although the infant has been given vitamin J to facilitate clotting, the prophylactic dose is often not sufficient to prevent bleeding. Although infection is a possibility, signs !ill not appear !ithin E hours after the surgical procedure. #he primary discomfort of circumcision occurs during the surgical procedure, not after!ard. Although feedings are !ithheld prior to the circumcision, the chances of dehydration are minimal. 23. *8 #he presence of e/cessive estrogen and progesterone in the maternalfetal blood follo!ed by prompt !ithdra!al at birth precipitates breast engorgement, !hich !ill spontaneously resolve in E to > days after birth. #he trauma of the birth process does not cause inflammation of the ne!born5s breast tissue. Ne!borns do not have breast malignancy. #his reply by the nurse !ould cause the mother to have undue an/iety. -reast tissue does not hypertrophy in the fetus or ne!borns. 24. D8 #he first 1> minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to e/trauterine life. #he data given reflect the normal changes during this time period. #he infant5s assessment data reflect normal adaptation. #hus, the physician does not need to be notified and o/ygen is not needed. #he data do not indicate the presence of cho$ing, gagging or coughing, !hich are signs of e/cessive secretions. ;uctioning is not necessary.
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25. *8 Application of L0? isopropyl alcohol to the cord minimi(es microorganisms germicidal" and promotes drying. #he cord should be $ept dry until it falls off and the stump has healed. Antibiotic ointment should only be used to treat an infection, not as a prophyla/is. 'nfants should not be submerged in a tub of !ater until the cord falls off and the stump has completely healed. 26. *8 #o determine the amount of formula needed, do the follo!ing mathematical calculation. F $g / 120 cal6$g per day Y FG0 calories6day feeding & E hours Y G feedings per day Y G0 calories per feeding* G0 calories per feedingI G0 calories per feeding !ith formula 20 cal6o( Y F ounces per feeding. -ased on the calculation. 2, E or G ounces are incorrect. 27. A8 'ntrauterine ano/ia may cause rela/ation of the anal sphincter and emptying of meconium into the amniotic fluid. At birth some of the meconium fluid may be aspirated, causing mechanical obstruction or chemical pneumonitis. #he infant is not at increased ris$ for gastrointestinal problems. .ven though the s$in is stained !ith meconium, it is noninfectious sterile" and nonirritating. #he postterm meconiumstained infant is not at additional ris$ for bo!el or urinary problems. 28. C8 #he nurse should use a nonelastic, fle/ible, paper measuring tape, placing the (ero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. #he /iphoid and umbilicus are not appropriate landmar$s to use !hen measuring the height of the fundus 8c:onald5s measurement". 29. *8 2omen hospitali(ed !ith severe preeclampsia need decreased CN; stimulation to prevent a sei(ure. ;ei(ure precautions provide environmental safety should a sei(ure occur. -ecause of edema, daily !eight is important but not the priority. 4reclampsia causes vasospasm and therefore can reduce utero-placental perfusion. #he client should be placed on her left side to ma/imi(e blood flo!, reduce blood pressure, and promote diuresis. 'nterventions to reduce stress and an/iety are very important to facilitate coping and a sense of control, but sei(ure precautions are the priority. 30. C8 Cessation of the lochial discharge signifies healing of the endometrium. 0is$ of hemorrhage and infection are minimal F !ee$s after a normal vaginal delivery. #elling the client anytime is inappropriate because this response does not provide the client !ith the specific information she is re&uesting. Choice of a contraceptive method is important, but not the specific criteria for safe resumption of se/ual activity. Culturally, the G!ee$s5 e/amination has been used as the time frame for resuming se/ual activity, but it may be resumed earlier. 31. C. #he middle third of the vastus lateralis is the preferred in1ection site for vitamin J administration because it is free of blood vessels and nerves and is large enough to absorb the medication. #he deltoid muscle of a ne!born is not large enough for a ne!born '8 in1ection. 'n1ections into this muscle in a small child might cause damage to the radial nerve. #he
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anterior femoris muscle is the ne/t safest muscle to use in a ne!born but is not the safest. -ecause of the pro/imity of the sciatic nerve, the gluteus ma/imus muscle should not be until the child has been !al$ing 2 years. 32. D. -artholin5s glands are the glands on either side of the vaginal orifice. #he clitoris is female erectile tissue found in the perineal area above the urethra. #he parotid glands are open into the mouth. ;$ene5s glands open into the posterior !all of the female urinary meatus. 33. D. #he fetal gonad must secrete estrogen for the embryo to differentiate as a female. An increase in maternal estrogen secretion does not effect differentiation of the embryo, and maternal estrogen secretion occurs in every pregnancy. 8aternal androgen secretion remains the same as before pregnancy and does not effect differentiation. ;ecretion of androgen by the fetal gonad !ould produce a male fetus. 34. A. )sing bicarbonate !ould increase the amount of sodium ingested, !hich can cause complications. .ating lo!-sodium crac$ers !ould be appropriate. ;ince li&uids can increase nausea avoiding them in the morning hours !hen nausea is usually the strongest is appropriate. .ating si/ small meals a day !ould $eep the stomach full, !hich often decrease nausea. 35. *. -allottement indicates passive movement of the unengaged fetus. -allottement is not a contraction. 3etal $ic$ing felt by the client represents &uic$ening. .nlargement and softening of the uterus is $no!n as 4is$ace$5s sign. 36. *. Chad!ic$5s sign refers to the purple-blue tinge of the cervi/. -ra/ton 9ic$s contractions are painless contractions beginning around the Eth month. <oodell5s sign indicates softening of the cervi/. 3le/ibility of the uterus against the cervi/ is $no!n as 8c:onald5s sign. 37. C. -reathing techni&ues can raise the pain threshold and reduce the perception of pain. #hey also promote rela/ation. -reathing techni&ues do not eliminate pain, but they can reduce it. 4ositioning, not breathing, increases uteroplacental perfusion. 38. A. #he client5s labor is hypotonic. #he nurse should call the physical and obtain an order for an infusion of o/ytocin, !hich !ill assist the uterus to contact more forcefully in an attempt to dilate the cervi/. Administering light sedative !ould be done for hypertonic uterine contractions. 4reparing for cesarean section is unnecessary at this time. B/ytocin !ould increase the uterine contractions and hopefully progress labor before a cesarean !ould be necessary. 't is too early to anticipate client pushing !ith contractions. 39. D. #he signs indicate placenta previa and vaginal e/am to determine cervical dilation !ould not be done because it could cause hemorrhage. Assessing maternal vital signs can help determine maternal physiologic status. 3etal heart rate is important to assess fetal !ell-being and should be done. 8onitoring the contractions !ill help evaluate the progress of labor.
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40. D. A complete placenta previa occurs !hen the placenta covers the opening of the uterus, thus bloc$ing the passage!ay for the baby. #his response e/plains !hat a complete previa is and the reason the baby cannot come out e/cept by cesarean delivery. #elling the client to as$ the physician is a poor response and !ould increase the patient5s an/iety. Although a cesarean !ould help to prevent hemorrhage, the statement does not e/plain !hy the hemorrhage could occur. 2ith a complete previa, the placenta is covering all the cervi/, not 1ust most of it. 41. *. 2ith a face presentation, the head is completely e/tended. 2ith a verte/ presentation, the head is completely or partially fle/ed. 2ith a bro! forehead" presentation, the head !ould be partially e/tended. 42. D. 2ith this presentation, the fetal upper torso and bac$ face the left upper maternal abdominal !all. #he fetal heart rate !ould be most audible above the maternal umbilicus and to the left of the middle. #he other positions !ould be incorrect. 43. C8 #he greenish tint is due to the presence of meconium. 7anugo is the soft, do!ny hair on the shoulders and bac$ of the fetus. 9ydramnios represents e/cessive amniotic fluid. Aerni/ is the !hite, cheesy substance covering the fetus. 44. D8 'n a breech position, because of the space bet!een the presenting part and the cervi/, prolapse of the umbilical cord is common. Quic$ening is the !oman5s first perception of fetal movement. Bphthalmia neonatorum usually results from maternal gonorrhea and is con1unctivitis. 4ica refers to the oral inta$e of nonfood substances. 45. A8 :i(ygotic fraternal" t!ins involve t!o ova fertili(ed by separate sperm. 8ono(ygotic identical" t!ins involve a common placenta, same genotype, and common chorion. 46. C8 #he (ygote is the single cell that reproduces itself after conception. #he chromosome is the material that ma$es up the cell and is gained from each parent. -lastocyst and trophoblast are later terms for the embryo after (ygote. 47. D8 4repared childbirth !as the direct result of the 19>05s challenging of the routine use of analgesic and anesthetics during childbirth. #he 7:04 !as a much later concept and !as not a direct result of the challenging of routine use of analgesics and anesthetics during childbirth. 0oles for nurse mid!ives and clinical nurse specialists did not develop from this challenge. 48. C8 #he ischial spines are located in the mid-pelvic region and could be narro!ed due to the previous pelvic in1ury. #he symphysis pubis, sacral promontory, and pubic arch are not part of the mid-pelvis. 49. *8 Aariations in the length of the menstrual cycle are due to variations in the proliferative phase. #he menstrual, secretory and ischemic phases do not contribute to this variation. 50. *. #estosterone is produced by the 7eyding cells in the seminiferous tubules. 3ollicle-stimulating hormone and leutein(ing hormone are
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released by the anterior pituitary gland. #he hypothalamus is responsible for releasing gonadotropin-releasing hormone.
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"EDICAL S'$GICAL N'$SING 1. 8arco !ho !as diagnosed !ith brain tumor !as scheduled for craniotomy. 'n preventing the development of cerebral edema after surgery, the nurse should e/pect the use of* a. :iuretics b. Antihypertensive c. ;teroids d. Anticonvulsants 2. 9alf!ay through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse 9a(el should* a. 'ncrease the flo! of normal saline b. Assess the pain further c. Notify the blood ban$ d. Bbtain vital signs. 3. Nurse 8aureen $no!s that the positive diagnosis for 9'A infection is made based on !hich of the follo!ing* a. A history of high ris$ se/ual behaviors. b. 4ositive .7';A and !estern blot tests c. 'dentification of an associated opportunistic infection d. .vidence of e/treme !eight loss and high fever 4. Nurse 8aureen is a!are that a client !ho has been diagnosed !ith chronic renal failure recogni(es an ade&uate amount of high-biologic-value protein !hen the food the client selected from the menu !as* a. 0a! carrots b. Apple 1uice c. 2hole !heat bread d. Cottage cheese 5. Jenneth !ho has diagnosed !ith uremic syndrome has the potential to develop complications. 2hich among the follo!ing complications should the nurse anticipates* a. 3lapping hand tremors b. An elevated hematocrit level c. 9ypotension d. 9ypo$alemia 6. A client is admitted to the hospital !ith benign prostatic hyperplasia, the nurse most relevant assessment !ould be* a. 3lan$ pain radiating in the groin b. :istention of the lo!er abdomen c. 4erineal edema d. )rethral discharge 7. A client has undergone !ith penile implant. After 2E hrs of surgery, the client5s scrotum !as edematous and painful. #he nurse should* a. Assist the client !ith sit( bath b. Apply !ar soa$s in the scrotum c. .levate the scrotum using a soft support
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d. 4repare for a possible incision and drainage. 8. Nurse ha(el receives emergency laboratory results for a client !ith chest pain and immediately informs the physician. An increased myoglobin level suggests !hich of the follo!ing@ a. 7iver disease b. 8yocardial damage c. 9ypertension d. Cancer 9. Nurse 8aureen !ould e/pect the a client !ith mitral stenosis !ould demonstrate symptoms associated !ith congestion in the* a. 0ight atrium b. ;uperior vena cava c. Aorta d. 4ulmonary 10. A client has been diagnosed !ith hypertension. #he nurse priority nursing diagnosis !ould be* a. 'neffective health maintenance b. 'mpaired s$in integrity c. :eficient fluid volume d. 4ain 11. Nurse 9a(el teaches the client !ith angina about common e/pected side effects of nitroglycerin including* a. high blood pressure b. stomach cramps c. headache d. shortness of breath 12. #he follo!ing are lipid abnormalities. 2hich of the follo!ing is a ris$ factor for the development of atherosclerosis and 4A:@ a. 9igh levels of lo! density lipid 7:7" cholesterol b. 9igh levels of high density lipid 9:7" cholesterol c. 7o! concentration triglycerides d. 7o! levels of 7:7 cholesterol. 13. 2hich of the follo!ing represents a significant ris$ immediately after surgery for repair of aortic aneurysm@ a. 4otential !ound infection b. 4otential ineffective coping c. 4otential electrolyte balance d. 4otential alteration in renal perfusion 14. Nurse Posie should instruct the client to eat !hich of the follo!ing foods to obtain the best supply of Aitamin -12@ a. dairy products b. vegetables c. <rains d. -roccoli 15. Jaren has been diagnosed !ith aplastic anemia. #he nurse monitors for changes in !hich of the follo!ing physiologic functions@
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a. -o!el function b. 4eripheral sensation c. -leeding tendencies d. 'nta$e and out put 16. 7ydia is scheduled for elective splenectomy. -efore the clients goes to surgery, the nurse in charge final assessment !ould be* a. signed consent b. vital signs c. name band d. empty bladder 17. 2hat is the pea$ age range in ac&uiring acute lymphocytic leu$emia A77"@ a. E to 12 years. b. 20 to F0 years c. E0 to >0 years d. G0 G0 L0 years 18. 8arie !ith acute lymphocytic leu$emia suffers from nausea and headache. #hese clinical manifestations may indicate all of the follo!ing e/cept a. effects of radiation b. chemotherapy side effects c. meningeal irritation d. gastric distension 19. A client has been diagnosed !ith :isseminated 'ntravascular Coagulation :'C". 2hich of the follo!ing is contraindicated !ith the client@ a. Administering 9eparin b. Administering Coumadin c. #reating the underlying cause d. 0eplacing depleted blood products 20. 2hich of the follo!ing findings is the best indication that fluid replacement for the client !ith hypovolemic shoc$ is ade&uate@ a. )rine output greater than F0ml6hr b. 0espiratory rate of 21 breaths6minute c. :iastolic blood pressure greater than 90 mmhg d. ;ystolic blood pressure greater than 110 mmhg 21. 2hich of the follo!ing signs and symptoms !ould Nurse 8aureen include in teaching plan as an early manifestation of laryngeal cancer@ a. ;tomatitis b. Air!ay obstruction c. 9oarseness d. :ysphagia 22. Jarina a client !ith myasthenia gravis is to receive immunosuppressive therapy. #he nurse understands that this therapy is effective because it* a. 4romotes the removal of antibodies that impair the transmission of impulses b. ;timulates the production of acetylcholine at the neuromuscular 1unction.
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c. :ecreases the production of autoantibodies that attac$ the acetylcholine receptors. d. 'nhibits the brea$do!n of acetylcholine at the neuromuscular 1unction. 23. A female client is receiving 'A 8annitol. An assessment specific to safe administration of the said drug is* a. Aital signs &Eh b. 2eighing daily c. )rine output hourly d. 7evel of consciousness &Eh 24. 4atricia a 20 year old college student !ith diabetes mellitus re&uests additional information about the advantages of using a pen li$e insulin delivery devices. #he nurse e/plains that the advantages of these devices over syringes includes* a. Accurate dose delivery b. ;horter in1ection time c. 7o!er cost !ith reusable insulin cartridges d. )se of smaller gauge needle. 25. A male client5s left tibia is fractures in an automobile accident, and a cast is applied. #o assess for damage to ma1or blood vessels from the fracture tibia, the nurse in charge should monitor the client for* a. ;!elling of the left thigh b. 'ncreased s$in temperature of the foot c. 4rolonged reperfusion of the toes after blanching d. 'ncreased blood pressure 26. After a long leg cast is removed, the male client should* a. Cleanse the leg by scrubbing !ith a bris$ motion b. 4ut leg through full range of motion t!ice daily c. 0eport any discomfort or stiffness to the physician d. .levate the leg !hen sitting for long periods of time. 27. 2hile performing a physical assessment of a male client !ith gout of the great toe, NurseAivian should assess for additional tophi urate deposits" on the* a. -uttoc$s b. .ars c. 3ace d. Abdomen 28. Nurse Jatrina !ould recogni(e that the demonstration of crutch !al$ing !ith tripod gait !as understood !hen the client places !eight on the* a. 4alms of the hands and a/illary regions b. 4alms of the hand c. A/illary regions d. 3eet, !hich are set apart 29. 8ang Pose !ith rheumatoid arthritis states, Cthe only time ' am !ithout pain is !hen ' lie in bed perfectly stillD. :uring the convalescent stage, the nurse in charge !ith 8ang Pose should encourage* a. Active 1oint fle/ion and e/tension
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b. Continued immobility until pain subsides c. 0ange of motion e/ercises t!ice daily d. 3le/ion e/ercises three times daily 30. A male client has undergone spinal surgery, the nurse should* a. Bbserve the client5s bo!el movement and voiding patterns b. 7og-roll the client to prone position c. Assess the client5s feet for sensation and circulation d. .ncourage client to drin$ plenty of fluids 31. 8arina !ith acute renal failure moves into the diuretic phase after one !ee$ of therapy. :uring this phase the client must be assessed for signs of developing* a. 9ypovolemia b. renal failure c. metabolic acidosis d. hyper$alemia 32. Nurse Pudith obtains a specimen of clear nasal drainage from a client !ith a head in1ury. 2hich of the follo!ing tests differentiates mucus from cerebrospinal fluid C;3"@ a. 4rotein b. ;pecific gravity c. <lucose d. 8icroorganism 33. A 22 year old client suffered from his first tonic-clonic sei(ure. )pon a!a$ening the client as$s the nurse, C2hat caused me to have a sei(ure@ 2hich of the follo!ing !ould the nurse include in the primary cause of tonic clonic sei(ures in adults more the 20 years@ a. .lectrolyte imbalance b. 9ead trauma c. .pilepsy d. Congenital defect 34. 2hat is the priority nursing assessment in the first 2E hours after admission of the client !ith thrombotic CAA@ a. 4upil si(e and papillary response b. cholesterol level c. .chocardiogram d. -o!el sounds 35. Nurse 7inda is preparing a client !ith multiple sclerosis for discharge from the hospital to home. 2hich of the follo!ing instruction is most appropriate@ a. C4ractice using the mechanical aids that you !ill need !hen future disabilities ariseD. b. C3ollo! good health habits to change the course of the diseaseD. c. CJeep active, use stress reduction strategies, and avoid fatigue. d. C,ou !ill need to accept the necessity for a &uiet and inactive lifestyleD. 36. #he nurse is a!are the early indicator of hypo/ia in the unconscious client is* a. Cyanosis b. 'ncreased respirations
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c. 9ypertension d. 0estlessness 37. A client is e/periencing spinal shoc$. Nurse 8yrna should e/pect the function of the bladder to be !hich of the follo!ing@ a. Normal b. Atonic c. ;pastic d. )ncontrolled 38. 2hich of the follo!ing stage the carcinogen is irreversible@ a. 4rogression stage b. 'nitiation stage c. 0egression stage d. 4romotion stage 39. Among the follo!ing components thorough pain assessment, !hich is the most significant@ a. .ffect b. Cause c. Causing factors d. 'ntensity 40. A G> year old female is e/periencing flare up of pruritus. 2hich of the client5s action could aggravate the cause of flare ups@ a. ;leeping in cool and humidified environment b. :aily baths !ith fragrant soap c. )sing clothes made from 100? cotton d. 'ncreasing fluid inta$e 41. Atropine sulfate Atropine" is contraindicated in all but one of the follo!ing client@ a. A client !ith high blood b. A client !ith bo!el obstruction c. A client !ith glaucoma d. A client !ith ).#.' 42. Among the follo!ing clients, !hich among them is high ris$ for potential ha(ards from the surgical e/perience@ a. GL-year-old client b. E9-year-old client c. FF-year-old client d. 1>-year-old client 43. Nurse Pon assesses vital signs on a client undergone epidural anesthesia. 2hich of the follo!ing !ould the nurse assess ne/t@ a. 9eadache b. -ladder distension c. :i((iness d. Ability to move legs 44. Nurse Jatrina should anticipate that all of the follo!ing drugs may be used in the attempt to control the symptoms of 8eniere+s disease e/cept* a. Antiemetics
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b. :iuretics c. Antihistamines d. <lucocorticoids 45. 2hich of the follo!ing complications associated !ith tracheostomy tube@ a. 'ncreased cardiac output b. Acute respiratory distress syndrome A0:;" c. 'ncreased blood pressure d. :amage to laryngeal nerves 46. Nurse 3aith should recogni(e that fluid shift in an client !ith burn in1ury results from increase in the* a. #otal volume of circulating !hole blood b. #otal volume of intravascular plasma c. 4ermeability of capillary !alls d. 4ermeability of $idney tubules 47. An HF-year-old !oman has several ecchymotic areas on her right arm. #he bruises are probably caused by* a. increased capillary fragility and permeability b. increased blood supply to the s$in c. self inflicted in1ury d. elder abuse 48. Nurse Anna is a!are that early adaptation of client !ith renal carcinoma is* a. Nausea and vomiting b. flan$ pain c. !eight gain d. intermittent hematuria 49. A male client !ith tuberculosis as$s Nurse -rian ho! long the chemotherapy must be continued. Nurse -rian5s accurate reply !ould be* a. 1 to F !ee$s b. G to 12 months c. F to > months d. F years and more 50. A client has undergone laryngectomy. #he immediate nursing priority !ould be* a. Jeep trachea free of secretions b. 8onitor for signs of infection c. 4rovide emotional support d. 4romote means of communication
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ANS E$S AND $ATIONALE 5 "EDICAL S'$GICAL N'$SING 1. C. <lucocorticoids steroids" are used for their anti-inflammatory action, !hich decreases the development of edema. 2. A. #he blood must be stopped at once, and then normal saline should be infused to $eep the line patent and maintain blood volume. 3. *. #hese tests confirm the presence of 9'A antibodies that occur in response to the presence of the human immunodeficiency virus 9'A". 4. D. Bne cup of cottage cheese contains appro/imately 22> calories, 2L g of protein, 9 g of fat, F0 mg cholesterol, and G g of carbohydrate. 4roteins of high biologic value 9-A" contain optimal levels of amino acids essential for life. 5. A. .levation of uremic !aste products causes irritation of the nerves, resulting in flapping hand tremors. 6. *. #his indicates that the bladder is distended !ith urine, therefore palpable. 7. C. .levation increases lymphatic drainage, reducing edema and pain. 8. *. :etection of myoglobin is a diagnostic tool to determine !hether myocardial damage has occurred. 9. D. 2hen mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent bac$ !ard flo! into the pulmonary vein, the pulmonary circulation is under pressure. 10. A. 8anaging hypertension is the priority for the client !ith hypertension. Clients !ith hypertension fre&uently do not e/perience pain, deficient volume, or impaired s$in integrity. 't is the asymptomatic nature of hypertension that ma$es it so difficult to treat. 11. C. -ecause of its !idespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and di((iness. 12. A. An increased in 7:7 cholesterol concentration has been documented at ris$ factor for the development of atherosclerosis. 7:7 cholesterol is not bro$en do!n into the liver but is deposited into the !all of the blood vessels. 13. D. #here is a potential alteration in renal perfusion manifested by decreased urine output. #he altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery. 14. A. <ood source of vitamin -12 are dairy products and meats. 15. C. Aplastic anemia decreases the bone marro! production of 0-C5s, !hite blood cells, and platelets. #he client is at ris$ for bruising and bleeding tendencies. 16. *8 An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. #he vital signs are the final chec$ that must be completed before the client leaves the room so that continuity of care and assessment is provided for. 17. A. #he pea$ incidence of Acute 7ymphocytic 7eu$emia A77" is E years of age. 't is uncommon after 1> years of age.
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18. D. Acute 7ymphocytic 7eu$emia A77" does not cause gastric distention. 't does invade the central nervous system, and clients e/perience headaches and vomiting from meningeal irritation. 19. *. :isseminated 'ntravascular Coagulation :'C" has not been found to respond to oral anticoagulants such as Coumadin. 20. A. )rine output provides the most sensitive indication of the client5s response to therapy for hypovolemic shoc$. )rine output should be consistently greater than F0 to F> m76hr. 21. C. .arly !arning signs of laryngeal cancer can vary depending on tumor location. 9oarseness lasting 2 !ee$s should be evaluated because it is one of the most common !arning signs. 22. C. ;teroids decrease the body5s immune response thus decreasing the production of antibodies that attac$ the acetylcholine receptors at the neuromuscular 1unction 23. C. #he osmotic diuretic mannitol is contraindicated in the presence of inade&uate renal function or heart failure because it increases the intravascular volume that must be filtered and e/creted by the $idney. 24. A. #hese devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly. 25. C. :amage to blood vessels may decrease the circulatory perfusion of the toes, this !ould indicate the lac$ of blood supply to the e/tremity. 26. D8 .levation !ill help control the edema that usually occurs. 27. *8 )ric acid has a lo! solubility, it tends to precipitate and form deposits at various sites !here blood flo! is least active, including cartilaginous tissue such as the ears. 28. *. #he palms should bear the client5s !eight to avoid damage to the nerves in the a/illa. 29. A. Active e/ercises, alternating e/tension, fle/ion, abduction, and adduction, mobili(e e/udates in the 1oints relieves stiffness and pain. 30. C8 Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately. 31. A. 'n the diuretic phase fluid retained during the oliguric phase is e/creted and may reach F to > liters daily, hypovolemia may occur and fluids should be replaced. 32. C. #he constituents of C;3 are similar to those of blood plasma. An e/amination for glucose content is done to determine !hether a body fluid is a mucus or a C;3. A C;3 normally contains glucose. 33. *. #rauma is one of the primary cause of brain damage and sei(ure activity in adults. Bther common causes of sei(ure activity in adults include neoplasms, !ithdra!al from drugs and alcohol, and vascular disease. 34. A. 't is crucial to monitor the pupil si(e and papillary response to indicate changes around the cranial nerves. 35. C. #he nurse most positive approach is to encourage the client !ith multiple sclerosis to stay active, use stress reduction techni&ues and avoid fatigue because it is important to support the immune system !hile remaining active.
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36. D. 0estlessness is an early indicator of hypo/ia. #he nurse should suspect hypo/ia in unconscious client !ho suddenly becomes restless. 37. *. 'n spinal shoc$, the bladder becomes completely atonic and !ill continue to fill unless the client is catheteri(ed. 38. A. 4rogression stage is the change of tumor from the preneoplastic state or lo! degree of malignancy to a fast gro!ing tumor that cannot be reversed. 39. D. 'ntensity is the ma1or indicative of severity of pain and it is important for the evaluation of the treatment. 40. *8 #he use of fragrant soap is very drying to s$in hence causing the pruritus. 41. C8 Atropine sulfate is contraindicated !ith glaucoma patients because it increases intraocular pressure. 42. A. A GL year old client is greater ris$ because the older adult client is more li$ely to have a less-effective immune system. 43. *. #he last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder. 44. D. <lucocorticoids play no significant role in disease treatment. 45. D. #racheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage. 46. C. 'n burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-li$e substance. #he substance causes the capillary !alls to become more permeable and significant &uantities of fluid are lost. 47. A. Aging process involves increased capillary fragility and permeability. Blder adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise li$e lesions caused by collection of e/travascular blood in loosely structured dermis. 48. D. 'ntermittent pain is the classic sign of renal carcinoma. 't is primarily due to capillary erosion by the cancerous gro!th. 49. *8 #ubercle bacillus is a drug resistant organism and ta$es a long time to be eradicated. )sually a combination of three drugs is used for minimum of G months and at least si/ months beyond culture conversion. 50. A8 4atent air!ay is the most priorityI therefore removal of secretions is necessary.
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#S9C&IAT$IC N'$SING 8arco approached Nurse #rish as$ing for advice on ho! to deal !ith his alcohol addiction. Nurse #rish should tell the client that the only effective treatment for alcoholism is* a. 4sychotherapy b. Alcoholics anonymous A.A." c. #otal abstinence d. Aversion #herapy Nurse 9a(el is caring for a male client !ho e/perience false sensory perceptions !ith no basis in reality. #his perception is $no!n as* a. 9allucinations b. :elusions c. 7oose associations d. Neologisms Nurse 8onet is caring for a female client !ho has suicidal tendency. 2hen accompanying the client to the restroom, Nurse 8onet shoulda a. <ive her privacy b. Allo! her to urinate c. Bpen the !indo! and allo! her to get some fresh air d. Bbserve her Nurse 8aureen is developing a plan of care for a female client !ith anore/ia nervosa. 2hich action should the nurse include in the plan@ a. 4rovide privacy during meals b. ;et-up a strict eating plan for the client c. .ncourage client to e/ercise to reduce an/iety d. 0estrict visits !ith the family A client is e/periencing an/iety attac$. #he most appropriate nursing intervention should include@ a. #urning on the television b. 7eaving the client alone c. ;taying !ith the client and spea$ing in short sentences d. As$ the client to play !ith other clients A female client is admitted !ith a diagnosis of delusions of <0AN:.)0. #his diagnosis reflects a belief that one is* a. -eing Jilled b. 9ighly famous and important c. 0esponsible for evil !orld d. Connected to client unrelated to oneself A 20 year old client !as diagnosed !ith dependent personality disorder. 2hich behavior is not li$ely to be evidence of ineffective individual coping@ a. 0ecurrent self-destructive behavior b. Avoiding relationship c. ;ho!ing interest in solitary activities d. 'nability to ma$e choices and decision !ithout advise A male client is diagnosed !ith schi(otypal personality disorder. 2hich signs !ould this client e/hibit during social situation@
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a. 4aranoid thoughts b. .motional affect c. 'ndependence need d. Aggressive behavior 9. Nurse Claire is caring for a client diagnosed !ith bulimia. #he most appropriate initial goal for a client diagnosed !ith bulimia is@ a. .ncourage to avoid foods b. 'dentify an/iety causing situations c. .at only three meals a day d. Avoid shopping plenty of groceries 10. Nurse #ony !as caring for a E1 year old female client. 2hich behavior by the client indicates adult cognitive development@ a. <enerates ne! levels of a!areness b. Assumes responsibility for her actions c. 9as ma/imum ability to solve problems and learn ne! s$ills d. 9er perception are based on reality 11. A neuromuscular bloc$ing agent is administered to a client before .C# therapy. #he Nurse should carefully observe the client for@ a. 0espiratory difficulties b. Nausea and vomiting c. :i((iness d. ;ei(ures 12. A L> year old client is admitted to the hospital !ith the diagnosis of dementia of the Al(heimer5s type and depression. #he symptom that is unrelated to depression !ould be@ a. Apathetic response to the environment b. C' don5t $no!D ans!er to &uestions c. ;hallo! of labile effect d. Neglect of personal hygiene 1F. Nurse #rish is !or$ing in a mental health facilityI the nurse priority nursing intervention for a ne!ly admitted client !ith bulimia nervosa !ould be to@ a. #each client to measure ' X B b. 'nvolve client in planning daily meal c. Bbserve client during meals d. 8onitor client continuously 1E. Nurse 4atricia is a!are that the ma1or health complication associated !ith intractable anore/ia nervosa !ould be@ a. Cardiac dysrhythmias resulting to cardiac arrest b. <lucose intolerance resulting in protracted hypoglycemia c. .ndocrine imbalance causing cold amenorrhea d. :ecreased metabolism causing cold intolerance 1>. Nurse Anna can minimi(e agitation in a disturbed client by@ a. 'ncreasing stimulation b. limiting unnecessary interaction c. increasing appropriate sensory perception d. ensuring constant client and staff contact
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1G. A F9 year old mother !ith obsessive-compulsive disorder has become immobili(ed by her elaborate hand !ashing and !al$ing rituals. Nurse #rish recogni(es that the basis of B.C. disorder is often* a. 4roblems !ith being too conscientious b. 4roblems !ith anger and remorse c. 3eelings of guilt and inade&uacy d. 3eeling of un!orthiness and hopelessness 1L. 8ario is complaining to other clients about not being allo!ed by staff to $eep food in his room. 2hich of the follo!ing interventions !ould be most appropriate@ a. Allo!ing a snac$ to be $ept in his room b. 0eprimanding the client c. 'gnoring the clients behavior d. ;etting limits on the behavior 1H. Conney !ith borderline personality disorder !ho is to be discharge soon threatens to Cdo somethingD to herself if discharged. 2hich of the follo!ing actions by the nurse !ould be most important@ a. As$ a family member to stay !ith the client at home temporarily b. :iscuss the meaning of the client5s statement !ith her c. 0e&uest an immediate e/tension for the client d. 'gnore the clients statement because it5s a sign of manipulation 19. Poey a client !ith antisocial personality disorder belches loudly. A staff member as$s Poey, C:o you $no! !hy people find you repulsive@D this statement most li$ely !ould elicit !hich of the follo!ing client reaction@ a. :epensiveness b. .mbarrassment c. ;hame d. 0emorsefulness 20. 2hich of the follo!ing approaches !ould be most appropriate to use !ith a client suffering from narcissistic personality disorder !hen discrepancies e/ist bet!een !hat the client states and !hat actually e/ist@ a. 0ationali(ation b. ;upportive confrontation c. 7imit setting d. Consistency 21. Cely is e/periencing alcohol !ithdra!al e/hibits tremors, diaphoresis and hyperactivity. -lood pressure is 1906HL mmhg and pulse is 92 bpm. 2hich of the medications !ould the nurse e/pect to administer@ a. Nalo/one Narcan" b. -en(lropine Cogentin" c. 7ora(epam Ativan" d. 9aloperidol 9aldol" 22. 2hich of the follo!ing foods !ould the nurse #rish eliminate from the diet of a client in alcohol !ithdra!al@ a. 8il$ b. Brange Puice
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c. ;oda d. 0egular Coffee 2F. 2hich of the follo!ing !ould Nurse 9a(el e/pect to assess for a client !ho is e/hibiting late signs of heroin !ithdra!al@ a. ,a!ning X diaphoresis b. 0estlessness X 'rritability c. Constipation X steatorrhea d. Aomiting and :iarrhea 2E. #o establish open and trusting relationship !ith a female client !ho has been hospitali(ed !ith severe an/iety, the nurse in charge should@ a. .ncourage the staff to have fre&uent interaction !ith the client b. ;hare an activity !ith the client c. <ive client feedbac$ about behavior d. 0espect client5s need for personal space 25. Nurse 8onette recogni(es that the focus of environmental 8'7'.)" therapy is to* a. 8anipulate the environment to bring about positive changes in behavior b. Allo! the client5s freedom to determine !hether or not they !ill be involved in activities c. 0ole play life events to meet individual needs d. )se natural remedies rather than drugs to control behavior 2G. Nurse #rish !ould e/pect a child !ith a diagnosis of reactive attachment disorder to* a. 9ave more positive relation !ith the father than the mother b. Cling to mother X cry on separation c. -e able to develop only superficial relation !ith the others d. 9ave been physically abuse 2L. 2hen teaching parents about childhood depression Nurse #rina should say@ a. 't may appear acting out behavior b. :oes not respond to conventional treatment c. 's short in duration X resolves easily d. 7oo$s almost identical to adult depression 2H. Nurse 4erry is a!are that language development in autistic child resembles* a. ;canning speech b. ;peech lag c. ;huttering d. .cholalia 29. A G0 year old female client !ho lives alone tells the nurse at the community health center C' really don5t need anyone to tal$ toD. #he #A is my best friend. #he nurse recogni(es that the client is using the defense mechanism $no!n as@ a. :isplacement b. 4ro1ection
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c. ;ublimation d. :enial F0. 2hen !or$ing !ith a male client suffering phobia about blac$ cats, Nurse #rish should anticipate that a problem for this client !ould be@ a. An/iety !hen discussing phobia b. Anger to!ard the feared ob1ect c. :enying that the phobia e/ist d. :istortion of reality !hen completing daily routines F1. 7inda is pacing the floor and appears e/tremely an/ious. #he duty nurse approaches in an attempt to alleviate 7inda5s an/iety. #he most therapeutic &uestion by the nurse !ould be@ a. 2ould you li$e to !atch #A@ b. 2ould you li$e me to tal$ !ith you@ c. Are you feeling upset no!@ d. 'gnore the client F2. Nurse 4enny is a!are that the symptoms that distinguish post traumatic stress disorder from other an/iety disorder !ould be* a. Avoidance of situation X certain activities that resemble the stress b. :epression and a blunted affect !hen discussing the traumatic situation c. 7ac$ of interest in family X others d. 0e-e/periencing the trauma in dreams or flashbac$ FF. Nurse -en1ie is communicating !ith a male client !ith substance-induced persisting dementiaI the client cannot remember facts and fills in the gaps !ith imaginary information. Nurse -en1ie is a!are that this is typical of@ a. 3light of ideas b. Associative looseness c. Confabulation d. Concretism FE. Nurse Poey is a!are that the signs X symptoms that !ould be most specific for diagnosis anore/ia are@ a. ./cessive !eight loss, amenorrhea X abdominal distension b. ;lo! pulse, 10? !eight loss X alopecia c. Compulsive behavior, e/cessive fears X nausea d. ./cessive activity, memory lapses X an increased pulse F>. A characteristic that !ould suggest to Nurse Anne that an adolescent may have bulimia !ould be* a. 3re&uent regurgitation X re-s!allo!ing of food b. 4revious history of gastritis c. -adly stained teeth d. 4ositive body image FG. Nurse 8onette is a!are that e/tremely depressed clients seem to do best in settings !here they have* a. 8ultiple stimuli b. 0outine Activities c. 8inimal decision ma$ing
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d. Aaried Activities FL. #o further assess a client5s suicidal potential. Nurse Jatrina should be especially alert to the client e/pression of* a. 3rustration X fear of death b. Anger X resentment c. An/iety X loneliness d. 9elplessness X hopelessness FH. A nursing care plan for a male client !ith bipolar ' disorder should include* a. 4roviding a structured environment b. :esigning activities that !ill re&uire the client to maintain contact !ith reality c. .ngaging the client in conversing about current affairs d. #ouching the client provide assurance F9. 2hen planning care for a female client using ritualistic behavior, Nurse <ina must recogni(e that the ritual* a. 9elps the client focus on the inability to deal !ith reality b. 9elps the client control the an/iety c. 's under the client5s conscious control d. 's used by the client primarily for secondary gains E0. A F2 year old male graduate student, !ho has become increasingly !ithdra!n and neglectful of his !or$ and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schi(ophrenia is made. 't is unli$ely that the client !ill demonstrate* a. 7o! self esteem b. Concrete thin$ing c. .ffective self boundaries d. 2ea$ ego E1. A 2F year old client has been admitted !ith a diagnosis of schi(ophrenia says to the nurse C,es, its march, 8arch is little !omanD. #hat5s literal you $no!D. #hese statement illustrate* a. Neologisms b. .cholalia c. 3light of ideas d. 7oosening of association E2. A long term goal for a paranoid male client !ho has un1ustifiably accused his !ife of having many e/tramarital affairs !ould be to help the client develop* a. 'nsight into his behavior b. -etter self control c. 3eeling of self !orth d. 3aith in his !ife EF. A male client !ho is e/periencing disordered thin$ing about food being poisoned is admitted to the mental health unit. #he nurse uses !hich communication techni&ue to encourage the client to eat dinner@ a. 3ocusing on self-disclosure of o!n food preference
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b. )sing open ended &uestion and silence c. Bffering opinion about the need to eat d. Aerbali(ing reasons that the client may not choose to eat EE. Nurse Nina is assigned to care for a client diagnosed !ith Catatonic ;tupor. 2hen Nurse Nina enters the client5s room, the client is found lying on the bed !ith a body pulled into a fetal position. Nurse Nina should@ a. As$ the client direct &uestions to encourage tal$ing b. 0a$e the client into the dayroom to be !ith other clients c. ;it beside the client in silence and occasionally as$ open-ended &uestion d. 7eave the client alone and continue !ith providing care to the other clients E>. Nurse #ina is caring for a client !ith delirium and states that Cloo$ at the spiders on the !allD. 2hat should the nurse respond to the client@ a. C,ou5re having hallucination, there are no spiders in this room at allD b. C' can see the spiders on the !all, but they are not going to hurt youD c. C2ould you li$e me to $ill the spidersD d. C' $no! you are frightened, but ' do not see spiders on the !allD EG. Nurse Ponel is providing information to a community group about violence in the family. 2hich statement by a group member !ould indicate a need to provide additional information@ a. CAbuse occurs more in lo!-income familiesD b. CAbuser Are often 1ealous or self-centeredD c. CAbuser use fear and intimidationD d. CAbuser usually have poor self-esteemD EL. :uring electroconvulsive therapy .C#" the client receives o/ygen by mas$ via positive pressure ventilation. #he nurse assisting !ith this procedure $no!s that positive pressure ventilation is necessary because@ a. Anesthesia is administered during the procedure b. :ecrease o/ygen to the brain increases confusion and disorientation c. <rand mal sei(ure activity depresses respirations d. 8uscle rela/ations given to prevent in1ury during sei(ure activity depress respirations. EH. 2hen planning the discharge of a client !ith chronic an/iety, Nurse Chris evaluates achievement of the discharge maintenance goals. 2hich goal !ould be most appropriately having been included in the plan of care re&uiring evaluation@ a. #he client eliminates all an/iety from daily situations b. #he client ignores feelings of an/iety c. #he client identifies an/iety producing situations d. #he client maintains contact !ith a crisis counselor E9. Nurse #ina is caring for a client !ith depression !ho has not responded to antidepressant medication. #he nurse anticipates that !hat treatment procedure may be prescribed.
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a. Neuroleptic medication b. ;hort term seclusion c. 4sychosurgery d. .lectroconvulsive therapy >0. 8ario is admitted to the emergency room !ith drug-included an/iety related to over ingestion of prescribed antipsychotic medication. #he most important piece of information the nurse in charge should obtain initially is the* a. 7ength of time on the med. b. Name of the ingested medication X the amount ingested c. 0eason for the suicide attempt d. Name of the nearest relative X their phone number
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ANS E$S AND $ATIONALE 5 #S9C&IAT$IC N'$SING 1. C. #otal abstinence is the only effective treatment for alcoholism 2. A. 9allucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality. 3. D. #he Nurse has a responsibility to observe continuously the acutely suicidal client. #he Nurse should !atch for clues, such as communicating suicidal thoughts, and messagesI hoarding medications and tal$ing about death. 4. *8 .stablishing a consistent eating plan and monitoring client5s !eight are important to this disorder. 5. C. Appropriate nursing interventions for an an/iety attac$ include using short sentences, staying !ith the client, decreasing stimuli, remaining calm and medicating as needed. 6. *. :elusion of grandeur is a false belief that one is highly famous and important. 7. D. 'ndividual !ith dependent personality disorder typically sho!s indecisiveness submissiveness and clinging behavior so that others !ill ma$e decisions !ith them. 8. A. Clients !ith schi(otypal personality disorder e/perience e/cessive social an/iety that can lead to paranoid thoughts 9. *. -ulimia disorder generally is a maladaptive coping response to stress and underlying issues. #he client should identify an/iety causing situation that stimulate the bulimic behavior and then learn ne! !ays of coping !ith the an/iety. 10. A. An adult age F1 to E> generates ne! level of a!areness. 11. A. Neuromuscular -loc$er, such as ;)CC'N,7C9B7'N. Anectine" produces respiratory depression because it inhibits contractions of respiratory muscles. 12. C. 2ith depression, there is little or no emotional involvement therefore little alteration in affect. 13. D. #hese clients often hide food or force vomitingI therefore they must be carefully monitored. 14. A. #hese clients have severely depleted levels of sodium and potassium because of their starvation diet and energy e/penditure, these electrolytes are necessary for cardiac functioning. 15. *. 7imiting unnecessary interaction !ill decrease stimulation and agitation. 16. C. 0itualistic behavior seen in this disorder is aimed at controlling guilt and inade&uacy by maintaining an absolute set pattern of behavior. 17. D. #he nurse needs to set limits in the client5s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation. 18. *. Any suicidal statement must be assessed by the nurse. #he nurse should discuss the client5s statement !ith her to determine its meaning in terms of suicide. 19. A. 2hen the staff member as$ the client if he !onders !hy others find him repulsive, the client is li$ely to feel defensive because the &uestion is belittling. #he natural tendency is to counterattac$ the threat to self image.
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20. *. #he nurse !ould specifically use supportive confrontation !ith the client to point out discrepancies bet!een !hat the client states and !hat actually e/ists to increase responsibility for self. 21. C. #he nurse !ould most li$ely administer ben(odia(epine, such as lora(epan ativan" to the client !ho is e/periencing symptom* #he client5s e/periences symptoms of !ithdra!al because of the rebound phenomenon !hen the sedation of the CN; from alcohol begins to decrease. 22. D. 0egular coffee contains caffeine !hich acts as psychomotor stimulants and leads to feelings of an/iety and agitation. ;erving coffee top the client may add to tremors or !a$efulness. 23. D. Aomiting and diarrhea are usually the late signs of heroin !ithdra!al, along !ith muscle spasm, fever, nausea, repetitive, abdominal cramps and bac$ache. 24. D. 8oving to a client5s personal space increases the feeling of threat, !hich increases an/iety. 25. A. .nvironmental 8'7'.)" therapy aims at having everything in the client5s surrounding area to!ard helping the client. 26. C. Children !ho have e/perienced attachment difficulties !ith primary caregiver are not able to trust others and therefore relate superficially 27. A. Children have difficulty verbally e/pressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression. 28. D. #he autistic child repeat sounds or !ords spo$en by others. 29. D. #he client statement is an e/ample of the use of denial, a defense that bloc$s problem by unconscious refusing to admit they e/ist 30. A. :iscussion of the feared ob1ect triggers an emotional response to the ob1ect. 31. *. #he nurse presence may provide the client !ith support X feeling of control. 32. D. ./periencing the actual trauma in dreams or flashbac$ is the ma1or symptom that distinguishes post traumatic stress disorder from other an/iety disorder. 33. C. Confabulation or the filling in of memory gaps !ith imaginary facts is a defense mechanism used by people e/periencing memory deficits. 34. A. #hese are the ma1or signs of anore/ia nervosa. 2eight loss is e/cessive 1>? of e/pected !eight" 35. C. :ental enamel erosion occurs from repeated self-induced vomiting. 36. *. :epression usually is both emotional X physical. A simple daily routine is the best, least stressful and least an/iety producing. 37. D. #he e/pression of these feeling may indicate that this client is unable to continue the struggle of life. 38. A. ;tructure tends to decrease agitation and an/iety and to increase the client5s feeling of security. 39. *. #he rituals used by a client !ith obsessive compulsive disorder help control the an/iety level by maintaining a set pattern of action. 40. C. A person !ith this disorder !ould not have ade&uate self-boundaries
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41. D. 7oose associations are thoughts that are presented !ithout the logical connections usually necessary for the listening to interpret the message. 42. C. 9elping the client to develop feeling of self !orth !ould reduce the client5s need to use pathologic defenses. 43. *. Bpen ended &uestions and silence are strategies used to encourage clients to discuss their problem in descriptive manner. 44. C. Clients !ho are !ithdra!n may be immobile and mute, and re&uire consistent, repeated interventions. Communication !ith !ithdra!n clients re&uires much patience from the nurse. #he nurse facilitates communication !ith the client by sitting in silence, as$ing open-ended &uestion and pausing to provide opportunities for the client to respond. 45. D. 2hen hallucination is present, the nurse should reinforce reality !ith the client. 46. A. 4ersonal characteristics of abuser include lo! self-esteem, immaturity, dependence, insecurity and 1ealousy. 47. D. A short acting s$eletal muscle rela/ant such as succinylcholine Anectine" is administered during this procedure to prevent in1uries during sei(ure. 48. C. 0ecogni(ing situations that produce an/iety allo!s the client to prepare to cope !ith an/iety or avoid specific stimulus. 49. D. .lectroconvulsive therapy is an effective treatment for depression that has not responded to medication 50. *. 'n an emergency, lives saving facts are obtained first. #he name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.
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$eferences 8aternal and Child Nursing by Adele 4illiterri 2ong5s Nursing Care of 'nfants and Children Hth .dition 8; 8anuals of Nursing 4ractice by 7ippincott 4sychiatric 8ental 9ealth Nursing Eth .dition by 3ortinash 8anagement and 7eadership for Nurse Administrators >th .dition by 7inda 0oussel .ssentials of <erontological Nursing by 4atricia #ablos$i 3undamentals of Nursing 2nd .dition by Posie Quiambao-)dan 0N, 8AN Nursing 4ractice in the Community Eth .dition by Araceli 8aglaya Community 9ealth Nursing ;ervices in the 4hilippines 9th .dition- :B9 3undamentals of Nursing Lth .dition by -arbara Jo(ier .t al. 8odules for -asic Nursing ;$ills Gth .dition by Panice 0ider .llis Japlan NC7.M-0N 200H-2009 .dition by -arbara 'r!in ;aunders Q XA 0evie! for the NC7.M-0N ./amination Frd .dition by 7inda Anne ;ilvestre ;ia+s Nursing Questions and Ans!ers 200> .dition by 8aria 7oreto .vangelista-;ia NC7.M-0N 8ade 'ncredibly .asy by 7ippincott and 2illiams 7ippincott5s 0evie! ;eries 4ediatric Nursing 2nd .dition 8osby+s 0evie! Questions for the NC7.M-0N ./amination >th .dition ;aunders NC7.M-0N ./amination Frd edition 7ippincott5s 0evie! for NC7.M-0N Hth edition :avis NC7.M-0N ;uccess 2nd edition 7ippincott5s 0evie! ;eries N 8aternal Ne!born Nursing 2nd .dition -runner and ;uddart 0evie! for NC7.M-0N ;pringhouse 8ade 'ncredibly .asy Paypee+s Comprehensive 0evie! of C<3N; 7ippincott5s 0evie! ;eries N 8edical ;urgical Nursing 2nd .dition
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