NURSING PRACTICE I 1. A nurse nurse calls the physician of a client scheduled for a cardiac catheterization because the client has numerous questions regarding the procedure and has requested to speak to the physician. The physician is very upset and arrives at the unit to visit the client after prompting by the nurse. The nurse is outside of the client’s room and hears the physician tell the client in a derogatory manner that the nurse” doesn’t know anything.” hich legal tort has the physician violates! a. "ibel b. #lander c. Assault d. $egligence Answer: B %efamation takes place when something untrue is said &slander' or written &libel' about a person( resulting in in)ury to that person’s good name and reputation. An assault occurs when a pe rson puts another person in fear of a harmful or an offensive contact. $egligence involves the actions of professionals that fall below the standard of care for a specific professional group. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 32. 2. A nurse nurse is assessing a client who has )ust been measured and fitted for crutches. The nurse determines that the client’s crutches are fitted correctly if* a. The elbow is at a 45 degrees angle when the hand is on the handgrip b. The elbow is straight when the hand is on the handgrip c. The client’s a6illa is resting on the crutches pad during ambulation d. The top of the crutch is even with the a6illa Answer: A 7or optional upper e6tremity leverage( the elbow should be at appro6imately 45 degrees of fle6ion when the hand is resting on the handgrip. The top of the crutch need to be two to three fingerwidths lower than the a6illa. hen crutch walking( all weight needs to be on the hands to prevent nerve palsy from pressure on the a6illa. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 84. 4. The first attempt to elevate nursing as a profession by enriching and broadening the preparation of nurses and by educating them in 9niversity setting is an idea conceived by* a. -osario %elgado b. :ulita ;. #ote)o c. 7lorence $ightingale d. 7aye Abdellah Answer: B :ulita ;. #ote)o is a nurse and lawyer who became the first dean of the 9niversity of the
. A nurse nurse is instructing a client how to safely use crutches for ambulating at home. hich measure would the nurse recommend to minimize the risk of falls while ambulating with the crutches! a. 9se grab bars in the bathtub or shower b. -emove scatter rugs in the home c. ?eep all pets out of the house d. 9se softsoled slippers when walking with the crutches Answer: B To reduce the risk of falls( all obstacles should be removed from the home. $ot all pets are trip hazards &fish( birds( guinea pigs'. @rab bars in the bathtub or shower will not necessarily assist the client while walking with crutches. #hoes with nonslip soles should be worn. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 8. . A client client is being discharged and will receive o6ygen therapy at home. The n urse is teaching the client
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and family about o6ygen safety measures. hich of the following statements by the client indicates the need for further teaching! a. BC realize that C should check the o6ygen level of the portable tank on a consistent basis.” b. BC will keep my scented candles within feet of my o6ygen tank.” c. BC will not sit in front of my woodburning fireplace with my o6ygen on.” d. BC will call the physician if C e6perience any shortness of breath.” Answer: B D6ygen is a highly combustible gas( although it will not spontaneously burn or cause an e6plosion. Ct can easily cause fire to ignite in a client’s room if it contacts a spark from a cigarette( burning candle or electrical equipment. Dptions A( A( ( and % are appropriate o6ygen safety measures. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 115. 3. The four main concepts common to nursing that appear in each of the current conceptual models are* a.
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and family about o6ygen safety measures. hich of the following statements by the client indicates the need for further teaching! a. BC realize that C should check the o6ygen level of the portable tank on a consistent basis.” b. BC will keep my scented candles within feet of my o6ygen tank.” c. BC will not sit in front of my woodburning fireplace with my o6ygen on.” d. BC will call the physician if C e6perience any shortness of breath.” Answer: B D6ygen is a highly combustible gas( although it will not spontaneously burn or cause an e6plosion. Ct can easily cause fire to ignite in a client’s room if it contacts a spark from a cigarette( burning candle or electrical equipment. Dptions A( A( ( and % are appropriate o6ygen safety measures. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 115. 3. The four main concepts common to nursing that appear in each of the current conceptual models are* a.
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a. -ecaps the needle b. -emoves the gloves c. ashes the hands d. . 11. 11. A client client who is scheduled for gallbladder surgery is mentally impaired and is unable to communicate. Cn regard to obtaining permission for the surgical procedure( which nursing intervention would be most appropriate! a. /nsure that the family has signed the informed consent b. /nsure that the client has signed the informed consent c. Cnform the family about the advance directive process d. Cnform the family about the process of a living will Answer* A A client must be alert( alert( able to communicate( communicate( and competent competent to sign the informed informed consent. Cf Cf the client is is unable to( then the family can sign the consent. A living will lists the medical treatment a person chooses to omit or refuse if the person becomes unable to make decisions and is terminally ill. Advanced Advanced directives are forms of communication in which persons can give direction on how they would like to be treated when they cannot speak for themselves. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page G2. 12. A client client diagnosed with tuberculosis &TI' is scheduled to go to the radiology department for a chest 6ray evaluation. hich nursing intervention would be appropriate when preparing to transport the client! a. Apply a mask to the client b. Apply a mask and gown to the client c. Apply a mask( gown( and gloves to the client d. $otify the 6ray department that the personnel can be sure to wear a mask when the client arrives. Answer* A lients known or suspected of having TI should wear a mask when out of the room to prevent the spread of the infection to others. A gown or gloves are not necessary. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page G2. 14. A nurse nurse is observing a client using a walker. The nurse determines that the client is using the walker
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correctly if the client* a. . A nurse has an order to obtain a 2>hour urine collection of a client with renal disorder. The nurse avoids which of the following to ensure proper collection of the 2>hour specimen! a. Fave the client void at the start time( and place this specimen in the container. b. %iscard the first voidingH save all subsequent voiding during the 2>hour time period. c. 38.
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18. A nurse has an order to obtain a urinalysis from a client with an indwelling urinary catheter. The nurse avoids which of the following( which could contaminate the specimen! a. Dbtaining the specimen from the urinary drainage bag b. lamping the tubing of the drainage bag c. Aspirating a sample from the port on the drainage bag d. iping the port with an alcohol swab before inserting the syringe Answer* A A urine specimen is not taken from the urinary drainage bag. 9rine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. Cn addition( it may become contaminated with bacteria from opening the system. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page G3 1=. A nursing assistant is caring for an elderly client with cystitis who has an indwelling urinary catheter. The registered nurse provides directions regarding care and ensures that the nursing assistant* a. 9ses soap and water to cleanse the perineal area b. ?eeps the drainage bag above the level of the bladder c. "oops the tubing under the client’s leg d. "ets the drainage tubing rest under the leg Answer* A 43
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21. hich of the following signs and symptoms would the nurse e6pect to find when assessing a n Asian patient for postoperative pain following abdominal surgery! a. %ecreased blood pressure and heart rate and shallow respirations b. +uiet crying c. Cmmobility( diaphoresis( and avoidance of deep b reathing or coughing d. hanging position q 2 hours A$#/-* An Asian patient is likely to hide his pain. onsequently the nurse must observe for ob)ective signs. Cn an abdominal surgery patient( these might include immobility( diaphoresis and avoidance of deep breathing or coughing( as well as increased heart rate( shallow respirations &stemming from pain upon moving the diaphragm and respiratory muscles'( and guarding or rigidity of the abdominal wall. #uch a patient is unlikely to display emotion such as crying. #ource* $urse Test* a review series( 7undamentals of $ursing. . 5 2. A physician asks a nurse to discontinue the feeding tube in a client who is in a chronic vegetative
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state. The physician tells the nurse that the request was made by the client’s spouse and children. The nurse understands the legal basis for carrying out the order and first checks the client’s record for documentation of* a. A court approval to discontinue the treatment. b. A written order by the ph ysician to remove the tube. c. Authorization by the family to discontinue the treatment. d. Approval by the institutional /thics ommittee. A$#/-* The family or a legal guardian can make treatment decisions for the client who is unable to do so. Dnce the decision is made( the physician writes the order. @enerally( the family makes decisions in collaboration with the physicians( other health care workers( and other trusted advisors. #ource* 43. 23. A nurse provides medication instructions to a home health care client. To ensure safe administration of medication in the home( the nurse* a. %emonstrate the proper procedure for taking prescribed medications. b. Allows the client to verbalize and demonstrate correct administration procedure. c. Cnstruct the client that it is D? to double up on medications if a dose has been missed. d. onducts pill counts on each home visit. Answer* I To ensure safe administration of medication( the nurse allows the client to verbalize and demonstrate correct procedure and administration of medication. %emonstrating the proper procedure for the client does not ensure that the client safely perform this procedure. Ct is not acceptable to double up on medication( and conducting a pill count on each visit is not realistic or appropriate. #ource* G2 28. A client is admitted to the hospital for a bowel resection following a diagnosis of a bowel tumor. %uring the admission assessment( the client tells the nurse that a living will was prepared three years ago. The client asks the nurse if this document is still effective. The most appropriate nursing response is which of the following! a. BJes it is.” b. BJou will have to ask your lawyer.” c. BCt should be reviewed yearly with your physician.” d. BC have no idea.” Answer* The client should discuss the living will with the physician and it should be reviewed annually to ensure that it contains the client’s present wishes and desires. Dption A is incorrect. Dption % is not at all helpful to the client and is in fact a communication block. Although a lawyer would need to be consulted if the living will needed to be changed( the most appropriate and accurate nursing response would be to inform the client that the living will should be reviewed annually. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 1. 2=. A nurse’s note that a postoperative client has not been obtaining relief of pain with prescribed narcotics( but only while a particular licensed practical nurse &"<$' is assigned to the client. The nurse* a. -eviews the client’s medication administration record and immediately discuss the situation with the nursing supervisor b. $otifies the physician that the client n eeds an increase in narcotic dosage c. %ecides to avoid assigning the "<$ to the care of clients receiving narcotics d. onfronts the "<$ with the information about the client having pain control problems and asks if the "<$ is using the narcotics personally Answer* A Cn the situation( the nurse has noted an unusual occurrence( but before deciding what action to take ne6t( the nurse needs more data than )ust suspicion. This can be obtained by reviewing the client’s record.
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#tate and federal labor and narcotic regulations( as well as institutional policies and procedures( must be followed. Ct is therefore most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. The client does not n eed an increase in narcotics. To avoid assigning the "<$ to clients receiving narcotics only ignores the issue. A confrontation is not the most advisable action( because the appropriate administrative authorities need to be consulted f irst. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page G. 2G. A client’s vital signs have noticeably deteriorated over the past four hours following surgery. A nurse does not recognize the significance of these changes in vital signs and take no action. The client later requires emergency surgery. The nurse could be prosecuted for which of these! a. Tort b. Eisdemeanor c. ommon law d. #tatutory law Answer* A A tort is a wrongful act intentionally or unintentionally committed against a person or his or her property. The nurse’s inaction in the situation described is con sistent with the definition of a tort offense. Dption I is an offense under criminal law. Dption describes case law that has evolved over time via precedents. Dption % describes laws that are enacted by #tate( 7ederal( or local governments. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 35. 45. A nurse plans to carry out a multidisciplinary research pro)ect on the effects of immobility on clients’ stress levels. The nurse understands that which principle is most important when planning this pro)ect! a. ollaboration with other disciplines is essential to the successful practice of nursing. b. The corporate $urse /6ecutive should be consulted( because the pro)ect will take nursing time. c. All clients have the right to refuse to participate in research using human sub)ects. d. The cooperation of the physicians on staff must be ensured for the pro)ect to succeed. Answer* The proposed pro)ect is research and includes human sub)ects. Although options a( b and d need to be considered( they are all secondary to the overriding principle of legal and ethical practice of nursing that any client has the right to refuse to participate in research using human sub)ects. #ource* 43 41. A multidisciplinary health care team is planning care for client with hyperparathyroidism. The health care team develops which most important outcome for the client! a. %escribes the administration of aluminum hydro6ide gel. b. -estricts fluids to 1555 m" per day. c. alk down the hall for 1 minutes( three times per day. d. %escribes the use of loperamide &Cmodium' Answer* Eobility of the client with hyperparathyroidism should be encouraged as much as possible because of the calcium imbalance that occurs in this disorder and predisposition to the formation of renal calculi. 7luids should not be restricted. %iscussing the use of this medication is not the priority in this client. #ource*
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mechanism in maintaining blood volume and conserving water. #upplemental potassium usually is given to a patient with a low serum potassium level or one who is receiving a diuretic or other medication &such as digo6in' that has a mild diuretic effect. A low sodium diet is usually prescribed for a patient with a high serum sodium level( as in F7( F<$ or prolonged episodes of edema. %iuresis is increased naturally when a healthy patient increases his intake of fluids( especially those containing caffeine. . The natural sedative in meat and milk products &especially warm milk' that can help induce sleep is* a. 7lurazepam b. Temazepam c. Tryptophan d. Eethotrimeprazine A$#/-* Tryptophan is a natural sedativeH flurazepam &%almane'( temazepam &-estoril'( and methotrimeprazine &"evoprome' are hypnotic sedatives. #ource* $urse Test* a review series( 7undamentals of $ursing. 48. A nurse administers the morning dose of digo6in &"ano6in' to the client. hen the nurse charts the medication( the nurse discovers that a dose of 5.2 mg was administered rather than the prescribed dose
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of 5.12 mg. hich nursing action is most appropriate! a. Administer the additional 5.12 mg b. Tell the client that the dose administered was not the total amount and administer the additional dose c. Tell the client that too much medication was administered and an error was made d. omplete an incident report Answer* % Cn accord with the agency’s policy( nurses are required to file incident reports when a situation arises that could or did cause client harm. The nurse also contacts the physician. Cf a dose of 5.12 mg was prescribed( and a dose of 5.2 mg was administered( then the client received too much medication. Additional medication is not required and in fact should be detrimental. The client should be informed when an error has occurred( but in a professional manner so as to cause great fear and concern. Cn many situations( the physician will discuss this with the client. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 11. 4=. A registered nurse &-$' is orienting a nursing assistant to the clinical nursing unit. The -$ would intervene if the nursing assistant did which of the following during a routine hand washing procedure! a. ?ept hands lower than elbows b. 9sed 4 to ml of soap from the dispenser c. ashed continuously for 15 to 1 seconds d. %ried from forearm down to fingers Answer* % 5. A client has an order for Benemas until clear” before ma)or bowel surgery. After preparing the equipment and solution( the nurse assists the client into which of the following positions to administer the enema! a' "eftlateral #im’s position b' -ightlateral #im’s position c' "eft sidelying with the head of the bed elevated > degrees d' -ight sidelying with the head of the bed elevated > degrees Answer* A 7or administration of an enema( the client is placed in a leftlateral #im’s positions so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the #im’s position.
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#ource* 34. >1. The nurse has complete tracheostomy care for a client whose tracheostomy tube has a nondisposable inner cannula. The nurse reinserts the inner cannula into the tracheostomy immediately after* a. #uctioning the client’s airway. b. -insing it with sterile water. c. Tapping it against a sterile surface to dry it d. %rying it thoroughly with sterile gauze Answer* After washing and rinsing the inner cannula( the nurse dries it by tapping it against a sterile surface. The nurse then reinserts the cannula into the tracheostomy and turns it clockwise to lock it into place. Dptions A( I and % are inaccurate actions. #ource* %e"aune( #.( , "adner( <.( &1GG='. 7undamentals of nursing* #tandards and practice( Albany( $J* %elmar( p.=54 >1. A nurse is caring for a client who has an order for de6troamphetamine &%e6trine' 2mg 4. Iefore performing a venipuncture to initiate continuous intravenous &C;' therapy( a nurse would* a. Apply a tourniquet below the chosen vein site. b. Cnspect the C; solution for particles or contamination. c. #ecure a arm board to the )oint located above the C; site. d. >. hich assessment is most important for the nurse to make before advancing a client from liquid to solid! a. 7ood preferences. b. Appetite. c. . A nurse is preparing to access an implanted vascular port to administer chemotherapy. The nurse* a. Anchors the port with the dominant hand.
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b. 3. An elderly woman is brought to the emergency room. Dn physical assessment( the nurse notes old and new ecchymotic areas on both arms and buttocks. The nurse asks the client how the bruises were sustained. The client( although reluctant( tells the nurse in confidence that he r daughter frequently hits her if she gets in the way. hich of the following is the moist appropriate nursing response! a. BC promise C will not tell anyone but let’s see what we can do about this.” b. BC have a legal obligation to report this type of abuse.” c. B"et’s talk about ways that will prevent your daughter from hitting you.” d. BThis should not be happening( and if it happens again you must call the e mergency department.” Answer* I onfidential issues are not to be discussed with nonmedical personnel or the person’s family or friends without the person’s permission. lients should be assured that information is kept confidential( unless it places the nurse under a legal obligation. The nurse must report situations related to child or elderly abuse( gunshot wounds( and certain infectious disease. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition ( page 144. >8. A client tells the home health care nurse of the decision to refuse e6ternal cardiac massage. hich of the following is the most appropriate initial nursing actions! a. $otify the physician of the client’s request b. %ocument the client’s request in the home health nursing care plan c. onduct a client conference with the home health care staff to share the client’s request d. %iscuss the client’s request with the family Answer* A /6ternal cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify a physician because a written B %o not resuscitate B &%$-' order from the physician must be present. The %$- order must be renewed on a regular basis per agency policy. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 14>. >=. A nurse manager employs a leadership style in which decisions regarding the management of the nursing unit are made without input from the staff. Type of leadership style that is implemented by this nurse manager is* a. Autocratic b. #ituational c. %emocratic d. "aissezfaire Answer* A The autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals. %ecisions are made without inputs from the staff. %emocratic styles best empower staff toward e6cellence because this style of leadership allows nurses an opportunity to grow professionally. #ituational leadership style utilizes a style depending on the situation and events. "aissezfaire allows staff to work without assistance( direction( or supervision. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition ( page 148. >G. A registered nurse &-$' in charge is preparing the assignments for the day. The -$ assigns a
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nursing assistant to make beds and bathe one of the clients on the unit and assigns another nursing assistant to fill the water pitchers and to serve )uice to all the clients. Another -$ is assigned to administer all medications. Iased on the assignments designed by the -$ in charge( which type of nursing care is being implemented! a. 7unctional nursing b. team nursing c. /6emplary model of nursing d. 5 in both eyes( this means* a. The patient can see twice as well as normal b. The patient has double vision c. The patient has less than normal vision d. the patient has normal vision Answer* . $ormal vision is 25L25. A finding of 25L>5 would mean that a patient has les than normal vision. #ource* 7undamentals of $ursing by Taylor( "illis and "emone( th /d.( p.315 1. The nurse in a well baby clinic is providing safety instructions to a mother of a 1monthold infant. hich of the following safety instructions is most appropriate at this age! a. over electrical outlets b. -emove hazardous ob)ects from low p laces c. "ock all poisons d. $ever shake the infant’s head. Answer* %. The ageappropriate instruction that is most important is to instruct the mother not to shake or vigorously )iggle the baby’s head. Dptions A(. I , are most important instructions to provide to the mother as the child reaches the age of 3 months and begins to e6plore the environment. #ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 1>> 2. A nurse is receiving a client in transfer from the post anesthesia care unit following an abovetheknee amputation. The nurse should take which of the following most important actions when positioning the client at this time! a. hours after surgery. 7ollowing the first 2> hours( the stump is placed flat on the bed to prevent hip contracture. /dema is also controlled by stump wrapping techniques.
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#ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 14G 4. A nurse manager is planning to implement a change in the method of the documentation system in the nursing unit. Eany problems have occurred as a result of the present documentation system and the nurse manager determines that a change is required. The initial step in the process of change for the nurse manager is which of the following! a. 5 >. A nurse has received the client assignment for the day and is organizing the required tasks. hich of the following will not be a component of the plan for time management! a.
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#ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2 nd edition( page 141. 8. a patient has intravenous fluids infusing in the right arm. hen taking a blood pressure on this patient( the nurse would* a. Take the blood pressure in the right arm. b. Take the blood pressure in the left arm. c. 9se the smallest possible cuff d. report inability to take the blood pressure Answer* I. The blood pressure should be taken in the arm opposite the one with the infusion. Ilood pressure should not be taken in the arm with an C; infusion because the pressure of inflating the cuff may allow the artery to clot. #ource* 7undamentals of $ursing by Taylor( "illis and "emone( th /d.( p.= =. A client is 2 days post operative. The vital signs are* I< 125L85( F- 115( -- 23( and Temperature 155.> degrees 7ahrenheit &4= de grees elsius'. The client suddenly becomes profoundly short of breath( skin color is gray. hich assessment would have alerted the nurse first to the clientMs change in condition! a. Feart rate b. -espiratory rate c. Ilood pressure d. Temperature Answer I* Tachypnea is one of the first clues that the client is not o6ygenating appropriately. The compensatory mechanism for decreased o6ygenation is increased respiratory rate. "ewis( #.E.( Feitkemper( E.E.( , %irksen( #. -. &255>'. Eedical#urgical $ursing* Assessment , management of clinical problems. #t. "ouis* Eosby. G. onstipation is one of the most frequent complaints of elders. hen a ssessing this problem( which action should be the nurseMs priority! a. Add a thickening agent to the fluids b. Dbtain a health and dietary history c. -efer to a provider for a physical e6amination d. Eeasure height and weight Answer* I Cnitially( the nurse should obtain information about the chronicity of and details about constipation( recent changes in bowel habits( physical and emotional health( edications( activity pattern( and food and fluid history. This information may suggest causes as well as an appropriate( safe treatment plan. #ource* /delman( .". and Eandle( .E.&2552'. Fealth promotion throughout the lifespan. 35. hile caring for a client( the nurse notes a pulsating mass in the clientMs periumbilical area. hich of the following assessments is appropriate for the nurse to perform! a. Eeasure the length of the mass b. Auscultate the mass c. '. Eedical surgical nursing. &15th edition'.
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31. A client being treated for hypertension returns to the community clinic for follow up. The client says( N C know these pills are important( but C )ust canMt take these water pills anymore. C drive a truck for a living( and C canMt be stopping every 25 minutes to go to the bathroom.N hich of these is the best nursing diagnosis! a. $oncompliance related to medication side effects b. ?nowledge deficit related to misunderstanding of disease state c. %efensive coping related to chronic illness d. Altered health maintenance related to occupation Answer* A The client kept his appointment( and stated he knew the pills were important. Fe is unable to comply with the regimen from side effects( not a lack of knowledge about the disease process. #ource* ?ey( :.". and Fayes( /.-. &2554'. th edition'. '. Eedical surgical nursing. &15th edition'. . A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is a. difference in the intake and output b. changes in the mucous membranes c. skin turgor d. weekly weight Answer* % The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A onekilogram or 2.2 pounds of weight gain is equal to appro6imately 1(555 mls of retained fluid. Dther options are considered as part of data collection( but they are not the most accurate indicator for Ofluid balance. #ource* Altman( @. &255>'. %elmar’s 7undamental and Advanced $ursing #kills( 2nd ed. Albany( $J* %elmar. 3. Dne of the ethical obligations of nursing is accountability. Accountability means that the staff nurse is responsible for*
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a. The behavior of clients who a re noncompliant b. The consequences of his or her actions( even mistakes in )udgment c. The behavior of other staff members who are negligent in their nursing care d. The consequences of an administrative decision to decrease nursing staff Answer* I Accountability means responsibility for nursing actions and the consequences of those actions( even if an honest mistake in )udgment is made. #ource* Tutor %avis’s $"/0-$ #uccess( 2 nd edition 33. An -$ has been assigned for si6 clients for the 12hour shift. The -$ is responsible for every aspect of planning( giving( and evaluating their care during the shift. hen leaving at 8*55 am( the nurse will pass this same responsibility to the incoming n urse. This illustrates nursing care delivered via the* a. ase method b. 7unctional method c. Team method d.
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85. To monitor a client’s fluid volume more closely( a central venous pressure &;<' line has been inserted via the right subclavian vein. The nurse needs to know that ;< assesses the pressure in* a. The left atrium b. The right atrium c. The left ventricle d. The right ventricle. Answer* I ;< is a reflection of pressures in the right atrium and systemic veins. Although ;< is the least sensitive indicator of left ventricular enddiastolic pressure &increased with decreased ventricular compliance because of EC and left ventricular failure'( the ;< line is a safer one than pulmonary artery &. Cn preparing preop in)ections for a 4 year old( which size needle would the nurse be most correct in selecting to administer CE in)ection! a. 2 @ L= inch b. 21@( 1 inch c. 1= @( 1 inch d. 1= @( 1 P inch Answer* I.
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Cn selecting the correct needle to administer an CE in)ection to a preschool child( the nurse should always ook at the child and use )udgment in evaluating muscle mass and amount of subcutaneous fat. Cn this case( in the absence of further data( the nurse would be most correct in selecting a needle gauge and length appropriate for the Baverage” preschool child. A medium gauge needle 21@ that is 1 inch long would be asppropriate. #ource* Tutor K %avi’s $"/0 -$( #uccess( 2 nd /dition 8. Er. ". is homeless and has gangrene on his foot. The ph ysician has recommended hospitalization and surgery. Er. ". has refused. The nurse knows which of the following is true! The client a. annot be hospitalized against his will. b. an be restrained if one physician declares him incompetent c. annot choose which treatment to refuse. d. Eay sign against medical advice &AEA'. Answer* %. Against Eedical Advice( or AEA is a term used with a patient who checks him or herself out of a hospital against the advice of his or her doctor. hile it may not b e medically wise for the person to leave early( in most cases the wishes of the patient are considered first. The patient is usually asked to sign a form stating that he or she is aware that he or she is leaving the facility against medical advice( and the AEA term is used on reports concerning the patient. This is for legal reasons in case there are complications to limit liability on the part of the medical facility. Cn a mental hospital setting( a patient is typically allowed to check out of the hospital by giving at least a dayMs notice &though in some )urisdictions the time may vary depending on whether the patient is under NinformalN or NformalN voluntary commitment'. This is so that if the doctor feels that the patient would be a danger to self or others( the doctor has time to begin commitment proceedings against the patient to compel the patient to remain in the hospital for treatment. #ource* http*LLen.wikipedia.orgLwikiLAgainstQmedicalQadvice 83. Es. -. has been medicated for her surgery. The operating room &D-' nurse( when going through the clientMs chart( realizes that the consent form has not been signed. hich of the following is the best action for the nurse to take! a. Tell the physician that the consent form is not signed. b. Assume it is emergency surgery and the consent is implied. c. @et the consent form and have the client sign it. d. Fave a family member sign the consent form. Answer* A. Cnformed consent is an agreement by a client to accept a course of treatment or a procedure after complete information( including the risks of treatment and facts relating to it( has been provided by the physician. Ct is therefore( the e6change between a client and a physician. Dbtaining informed consent for specific medical and surgical treatments is the responsibility of the physician. Dften( the nurses responsibility is too witness the giving of informed consent. This involves the ff* 1. itnessing the e6change between the client and the physician 2. /stablishing that the client really did understand 4. itnessing the client’s signature #ource* 7undamentals of $ursing by ?ozier( /rb( Ilais and ilkinson( th /d.( pp.22= 22G 88. Er. T. is a client on your medicalsurgical unit. Fis cousin is a physician and wants to see the chart. hich of the following is the best response for the nurse to take! a. Tell the cousin that the request cannot be granted. b. Fand the cousin the clientMs chart to review. c. all the attending physician and have the doctor speak with the cousin.
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d. Ask Er. T. to sign an authorization( and have someone review the chart with the cousin. Answer* %. -ationale* The client’s record is protected legally as a private record of the client’s care. Thus( access to the record is restricted to health professionals involved in giving care to the client. Cnsurance companies( for e6ample( have no legal right to demand access to medical records( eventhough they may be determining compensation to the client. Fowever a client who is making acclaim for compensation may ask to have the medical history used as evidence. Cn this instance( the client must sign an authorization for review( copying or release of information form the record. This form clearly indicates what information is to be released and to whom. Cn no instance may a nurse allow access to the client’s record by significant others or any person other than a caregiver. #ource* 7undamentals of $ursing by ?ozier( /rb( Ilais and ilkinson( th /d.( p. 183 8=. Es. ". is admitted to the floor. #he is in the terminal stages of AC%#. %uring the admission assessment( the nurse would ask her if she had which of the following e6cept! a. An organ donation card. b. Fealthcare pro6y. c. "iving will d. %urable power of attorney for health care Answer * A -ationale* An advanced medical directive is a statement the client makes prior to receiving heath care( specifyingthe client’s wishes regarding heath care decisions. There are three types of advance medical directives(the living will( the health care pro6y and the %urable power of attorney for health care. The living will states what medical treatment the client chooses to omit or refuse in the event that the client is unable to make those decisions and is terminally ill. ith a health care pro6y( the client appoints a pro6y( usually a relative or a trusted friend( to make medical decisions on the client’s behalf( in the event that the client is unable to do so. A durable power of attorney is a notarized statement appointing someone else to manage health care treatment decisions when the client is unable to do so. #ource* 7undamentals of $ursing by ?ozier( /rb( Ilais and ilkinson( th /d.( p. 245 8G. The nurse enters a room and finds a fire. hich is the best initial action! a. Activate the fire alarm or call the operator( depending on the institutionMs system. b. @et a fire e6tinguisher and put out the fire. c. /vacuate any people in the room( beginning with the most ambulatory and ending with the least mobile. d. lose all the windows and doors( and turn off any o6ygen or electrical appliances. Answer * . -ationale* 9pon the detection of smoke andLor fire( follow the -A/ plan described below. -escue -escueL-emove person&s' from the immediate fire sceneLroom. Alert Alert personnel by activating the nearest fire alarm pull station then call the ontrol enter to report the e6act location of the fire. onfine onfine fire and smoke by closing all doors in the area. /6tinguish /6tinguish a small fire by using a portable fire e6tinguisher or use to escape from a large fire. /vacuate the building immediately and( once outside( report to your supervisor. #ource* http*LLwww.bu.eduLehsmcLflipchartLfirepro.htm =5. Es. -. has had both wrists restrained because she is agitated and pulls out her C; lines. hich of the following would the nurse observe if Es. -. is not suffering
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any ill effects from the restraints! That a. Es. -.Ms capillary refill is less than two seconds. b. #he has difficulty moving her fingers and making a fist. c. Fer skin is reddened where the mitts were tied around her wrist. d. The client complains of numbness and tingling in her hand. Answer* A. -ationale* The client &in restraints' must periodically be evaluated for integrity of distal circulation( motor movement( and sensory level of the restrained e6tremities. &p.2234' apillary refill time is an evaluation of peripheral perfusion and cardiac output. apillaries usually refill in a fraction of a second but normal times range up to 4 seconds for color to return. ith diminished blood flow( the return to the baseline color is delayed and a refill time of 4 seconds is sometimes called sluggish. &p. 1481' #ource* Eedical #urgical $ursing Ilack( Fawks( ?eene =1. hen a patient you are admitting to the unit asks you why you are doing a history and e6am since the doctor )ust did one( your best reply is* a.” Cn addition to providing us with valuable information about your health status( the nursing assessment will allow us to plan and deliver individualized( holistic nursing care that draws on your strengths.” b. BCts hospital policy. C know it must be tiresome( but C will try to make this quickR” c. BC am a student nurse and need to develop the skill of assessing your health status and need for nursing care. This information will help me develop a plan of care individualized to your unique needs.” d. e want to make sure that your responses are consistent and that all our data are accurate.” Answer* A. Though it may be true that you need to develop assessment skills &c' ( the chief reason you are doing a nursing history and e6am is because there needs to be a documented nursing admission assessment to serve as a basis for nursing care. #ource* 7undamentals of $ursing by Taylor( "illis and "emone( th /d.( p.25 =2. Er. C. is supine. hich of the following can the nurse do to prevent e6ternal rotation of the legs! a. G =4. Er. T. is a > quadriplegic. Fe has slid down in the bed. hich of the following is the best method for the nurse to use to reposition him! a. Dne nurse lifting under his buttocks while he uses the trapeze. b. Dne nurse lifting him under his shoulders from behind. c. Two people lifting him up in bed with a draw sheet. d. Two people log rolling the client from one side to the other. Answer* . -ationale* Two people are required to move clients who are unable to assist because of their condition or weight. Two nurses can use a turn sheet to move a client up in bed. A turn sheet distributes the client’s weight more evenly( decreases friction(
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and e6erts a more even force on the client during the move. Cn addition( it prevents in)ury on the client’s skin. #ource* Eedical #urgical $ursing Ilack( Fawks( ?eene p.G18 =>. Jou are surprised to detect an elevated temperature &152 7' in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile.. The first thing you do is to* a. inform the charge nurse. b. Cnform the surgeon c. ;alidate your finding d. %ocument your finding Answer* . Jou should first validate your finding if it is unusual( deviates from normal and is unsupported by other data. #hould your initial recoding prove to be in error( it would have been prematurity to notify the charge nurse. #ource* 7undamentals of $ursing by Taylor( "illis and "emone( th /d.( p.25 =. The nurse knows the difference between the left lateral and the #ims position is that the a. "ateral position places the clientMs weight on the anterior upper chest and the left shoulder. b. #ims position is semiprone( halfway between lateral and prone. c. "ateral position places the weight on the right hip and shoulder. d. #ims position places the weight on the right shoulder and hip. Answer* I. -ationale* Cn &left' lateral position( the person lies on one side of the body &left'. The top hip and knee are fle6ed and placed in front of the body to create a wider( triangular base of support. Cn #im’s position( the patient assumes a posture halfway between the lateral and prone p ositions. The patient assumes a side lying position with lowermost arm behind the body and uppermost leg fle6ed. #ource* Eedical #urgical $ursing Ilack( Fawks( ?eene &p. >3=( G1>' =3. a professional nurse committed to the principle of autonomy would be careful to* a.
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#ource* Eedical #urgical $ursing Ilack( Fawks( ?eene p.G1G ==. Es. 7. suffered a stroke and has rightsided hemiparesis. The nurse is going to transfer her from bed to wheelchair. hich of the following is the best method! a. S angle to the bed. Answer* %. -ationale* Cn transferring a client between a bed and a wheelchair( lower the bed to its lowest position so the client’s feet will rest flat on the floor. "ock the wheels of the bed. degree angle to the bed. This enables the client to pivot into the chair and lessens the amount of body rotation required. #ource* Eedical #urgical $ursing Ilack( Fawks( ?eene p.G2> G2 =G. The nurse knows which of the following is the proper technique for medical asepsis! a. @loving for all client contact. b. @owning to care for a oneyearold child with infectious diarrhea. c. 9sing your hands to turn off the faucet after handwashing. d. hanging hospital linen weekly. Answer* I. -ationale* Eedical asepsis includes all practices intended to confine a specific microorganism to a specific area( limiting the number( growth( and transmission of microorganisms. Db)ects are often referred to as clean or dirty. lean or disposable gowns are worn during procedures when the nurses’ uniform is likely to become soiled. #ource* Eedical #urgical $ursing Ilack( Fawks( ?eene p. 38=( 3=8 G5. The nurse is conducting a class on aseptic technique and universal precautions. hich of the following statements is correct and should be included in the discussion! a. The term universal precautions is synonymous with disease or categoryspecific isolation precautions. b. Eedical asepsis is designed to decrease e6posure to bloodborne pathogens. c. 9niversal precautions are designed to reduce the number of potentially infectious agents. d. Eedical asepsis is designed to confine microorganisms to a specific area( limiting the number( growth( and transmission of microorganisms. Answer* %. -ationale* The % did not recommend that universal precautions replace diseasespecific or category specific precautions( but that they be used in con)unction with them. 9niversal precautions ¬ medical asepsis' decrease e6posure to bloodborne pathogens. Csolation precautions ¬ universal precautions' are designed to prevent the spread of infections or potentially infectious microorganisms. "etter % provides a correct definition of medical asepsis. #ource* Eedical #urgical $ursing Ilack( Fawks( ?eene p.38= 3=5 G1. The nurse is to open a sterile package from central supply. hich is the correct direction to open the first flap! a. Away from the nurse. b. To the nurseMs left or right. c. Ct does not matter as long as the nurse on ly touches the outside edge. d. Toward the nurse. Answer* A.
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-ationale* To open a &sterile' wrapped package on a surface( place the package in the center of the work area so that the top flap of the wrapper opens away from you. This position prevents the nurse from subsequently reaching over the e6posed sterile contents( which could contaminate them. #ource* 7undamentals of $ursing by ?ozier( /rb( Ilais and ilkinson( p.3G> G2. hich of the following statements or questions would be appropriate in establishing a discharge plan for a patient who has had ma)or abdominal surgery! a. BC will bet you will be so glad to be home in your own bed.” b. Bhat are your e6pectations for recovery from your surgery!” c. BIe sure and take your pain medications and change your dressing.” d. BJou will )ust be fineR . Es. <. is transferred to a skilled nursing facility from the hospital because she is unable to ambulate due to a left femoral fracture. The nurse knows Es. <.Ms greatest risk factor for developing a pressure ulcer is that she a. Cs apathetic but oriented to person( place( and time. b. Fas slightly limited mobility and needs assistance to move from bed to chair. c. Fas good skin turgor( no edema( and her capillary refill is less than three seconds. d. Cs ft > in tall( 145 lb( and eats more than half of most meals. Answer * I. -ationale* Although pressure is the ma)or cause of pressure ulcers( immobility and inactivity are also important risk factors. Cmmobility refers to an alteration in the amount and control of movement a person has. Cnactivity refers to an alteration in a person’s ability to ambulate independently. #ource* Eedical #urgical $ursing Ilack( Fawks( ?eene p. 8=38=8 G. An elderly male client is transferred to a skilled nursing facility from the hospital because he is unable to ambulate due to a left femoral fracture. hen doing a skin assessment( the nurse notices a 4cm( round area partial thickness skin loss that looks like a blister on the clientMs sacrum. The nurse knows this is a a. #tage CC pressure ulcer. b. #tage C pressure ulcer. c. #tage CCC pressure ulcer. d. #tage C; pressure ulcer. Answer* A. -ationale* #tages of pressure ulcer formation* #tage C $on blanchable erythema of intact skin.
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#tage CC 88 G8. The nurse takes an =am medication to the patient and properly identifies her. The patient asks the nurse to leave the medication on the bedside table and stats that she will take it when with breakfast when it comes. hat is the best response to this request! a. "eave the medication and return later to make sure that it was taken. b. Tell her that it is against the rules( and take the medication with you. c. Tell her that you cannot leave the medication but will return with it when breakfast arrives. d. Take the drug from the room and record it as refused. Answer* . #afe nursing practice requires that a medication never be left at the patient’s bedside. Ct is not correct to say that the patient has refused medication in this situation. #ource* 7undamentals of $ursing by Taylor( "illis and "emone( th /d.( p.88 G=. hy is the intravenous method of medication administration is called the Bmost dangerous route of administration!” a. The vein can take only a small amount of fluid at a time. b. The vein may harden and become nonfunctional. c. Ilood clots may become a serious problem. %s. The drug is placed directly into the bloodstream and its action is immediate. Answer* %. The intravenous route is a direct access to the bloodstream( and medications act quickly when given intravenously. The condition of the veins is not a s important as the rapid effect of the medication administered intravenously. #ource* 7undamentals of $ursing by Taylor( "illis and "emone( th /d.( p.88 GG. Er. A. is going home from the emergency room with directions to a pply a cold pack to his ankle sprain. Fe asks how he will know if the cold pack has worked. The nurse tells him a. there should be less pain after applying the cold pack. b. that the skin will be blanched and numb afterward. c. he will notice the redblue bruises will turn purple. d. after the first application( the swelling will be decreased. Answer* A. -ationale* old compresses should be applied for 25 minutes at a temperature of 1S to relieve inflammation and swelling. hen using cold compresses( the nurse observes
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for adverse reactions such as burning or numbness( mottling of the skin( redness( e6treme paleness( and a bluish skin discoloration. #ource* 7undamentals of $ursing by
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NURSING PRACTICE II 1. The dynamic care of this nursing tool provides measurement of progress. hat is the scientific process for quality care! a. $ursing policies b. $ursing standard c. $ursing procedures d. $ursing process Answer* % The nursing process is a systematic( scientific( dynamic( on going interpersonal process in which the nurses and the clients are viewed as a system with each affecting the other and both being affected by the factors within the behavior. The process is a series of actions that lead toward a particular result. This process of decision making results in optimal health care for the clients to whom the nurse applies the process #ource* %DF &@reen and Jellow' pp. >4 2. hich of the following serves as basis for evaluating nursing care plan for the patient and or family! a. Activities undertaken b. $ursing diagnosis c. Iaseline information d. #et ob)ectives of the p lan Answer* % Db)ectives refer to more specific statements of the desired results or outcomes of care. They specify the criteria by which the degree of effectiveness of care is to be measured. #ource* $ursing th /d( pp. G= 4. The %ental Fealth . The setting under which health assessment will be made is best decided by* a. hat is practical and effective b. The public health supervisor c. hat is the agencies standard operating procedure d. Ioth the nurse and the client Answer* % The nursing care plan is prepared )ointly with the family. This is consistent with the principle that the nurse works with and not for the family. #he involves the family in determining health needs and problems in establishing priorities( in selecting appropriate courses of actions( implementing them and evaluating outcomes. Through participatory planning( the nurse makes the family feel that the health of its members is a family responsibility and commitment. #ource* $ursing th /d( pp. => #ituation 1* Ieing a
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c. ommunity organizer d. hange agent Answer* % A change agent is the one who motivates changes in health behavior of individuals( families( group and community including lifestyle in order to promote and maintain health. #ource* ommunity Fealth $ursing #ervices in the . 3. A nurse that develops the family’s capability to take care of the sick( disabled( or dependent members* a.
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b. th /d( pp.1=5 11. hich one of the following is not a pillar of th /d( pp. =4 14. Cnfant mortality rate means death under one year of age per 1555 live births. hich formula below is correct! a. %eaths under one year 0 155 "ive births of the same year b. %eaths under one year 0 1555 "ive births of the same year c. "ive births of the same year 0 155 %eaths under one year d. "ive births of the same year 0 1555 %eaths under one year Answer* I Cnfant mortality rate measures the risk of d ying during the 1 st year of life. Ct is a good inde6 of the general health condition of a community since it reflects the changes in the environmental and medical conditions of a community. #ource* %DF & @reen and Jellow ' pp. 445 1>. These are essential characteristics you must consider most in providing primary health care e6cept* a. Accessibility of health service b. Fealth
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c. Eultisectoral approach to health care d. Appropriate technology Answer* I A( and % together with the support mechanism made available characterized the primary health care. #ource* %DF & @reen and Jellow ' pp. 3G #ituation 2* The following 2553 data are available in your health center. Jou analyze these for planning purposes. $o. of population 2>(555 5 1. The crude birth rate for 2553 is* a. 2>L1555 b. 2L1555 c. 45L1555 d. 42L1555 Answer* I rude Iirth -ateTotal U of live births registered in a given calendar year 0 1555 Eid Jear 555 355555 2>555 2L1555 #ource* %DF & @reen and Jellow ' pp. 445 13. The maternal mortality rate is* a. 15L1555 b. 25L1555 c. 12L1555 d. 1L1555 Answer* A EE- Total U of deaths from maternal causes registered for a given year 0 1555 Total U of livebirths registered of same year 3Q 0 1555 355 3555 355 15L1555 #ource* %DF & @reen and Jellow ' pp. 445 18. The infant mortality rate is* a. L1555 b. >L1555 c. 4L1555 d. 2L1555 Answer* A CE-Total U of deaths under 1yr of age registered in a given calendar year 0 1555
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Total U of registered live births of same calendar year 4 0 1555 355 4555 355 #ource* %DF & @reen and Jellow ' pp. 445 1=. The case fatality rate for 5V b. 45V c. 22V d. 4V Answer* 7-$o. of registered deaths from a specific disease for a given year 0 155 $o of registered cases from same specific disease in same year 155 0 155 >5 15555 >5 22V #ource* %DF & @reen and Jellow ' pp. 444 1G. The crude death rate is* a. >1L1555 b. 4=L1555 c. 41L1555 d. 2L1555 Answer. A rude %eath -ate Total U of deaths registered in a given calendar year 0 1555 Eid Jear 555 G55555 2>555 48.L1555 4=L1555 #ource* %DF & @reen and Jellow ' pp. 444 25. hat is believed to be a guarantee of effective delivery of health services! a. Cntegration b. -eorganization c. %evolution d. th /d( pp. 2 21. hy was there devolution! a. To bring services nearer to the people
pg. 31
b. To empower local politicians c. To become self reliant d. To stop funding from national funds Answer* Dne of the most significant laws that radically changed the landscape of health care delivery system in the country is -A 8135 or more commonly known as the "ocal @overnment ode. The ode aims to transform local government units into self reliant communities and active partners in the attainment of national goals through a more responsive and accountable local government structure instituted through a system of decentralization. #ource* $ursing th /d( pp. 2 22. 7or a group of children where interaction with causative agents of disease has not taken place( the nurse concern is to provide* a. %iagnostic and curative type b. All this type of care c. th /d( pp.1=5 24. hen modifying harmful health practices( among minority families( the most important factor to remember is* a. /nsure that the change blends with their culture b. Cncrease health knowledge of the family c. Cnvolve the family in bringing about change d. . The following are approved types of toilet facilities under level C e6cept* a. pit latrines b. reed odorless earth closet c. pour flush toilet d. water sealed and flush type with septic vault Answer* %. "evel C $on water carriage toilet facility K no water is necessary to wash the waste into the receiving space. /6* pit latrines( reed odorless wart closet Toilet facilities requiring small amount of water to wash the waste into the receiving space. /6* pour flush toilet and aqua privies.
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"evel CC Kon site toilet facilities of the water carriage type with water sealed and flush type with septic vaultLtank disposal facilities. "evel CCC water carriage types of toilet facilities connected to septic tanks a ndL or to sewerage system to treatment plant. #ource* ommunity Fealth $ursing #ervices in the 5=5 liters of water per capital per day to an average of 155 households. "evel C &51>5 liters per minute. "evel CCC &aterworks system or Cndividual Fouse onnections' A system with a source( a reservoir( a piped distributor network and household taps. Ct is generally suited for densely populated urban areasH this type of facility requires a minimum treatment of disinfection. #ource* ommunity Fealth $ursing #ervices in the th /dition( pp. 853( >8=( 83>(
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>8= #ituation 4* These are laws related to devolution. 28. hich one of the following is the local government code! a. -A >584 b. -A 484 c. /D 11G d. -A 8135 Answer* % -A 8135 or commonly known as "ocal @overnement ode. -A >584 liberalizes the treatment of leprosy -A 484 declares that all communicable diseases should be reported to the nearest health station. 2=. hich laws cover /thical onduct of G c. -A 3814 d. -A 338 Answer* A -A 845 is known as the Eagna arta for G K "egal basis for 24 is Traditional and Alternative Fealth are #ource* ommunity Fealth $ursing #ervices in the 45. Ct is an act requiring compulsory immunization against hepatitis I for infants and children below eight &=' years old. a. -A8=>3 b. -A 343 c. -A 38= d. -A =8>G Answer* A. -A 8=>3 is an act requiring compulsory immunization against hepatitis I for infants and children below eight &=' years old. #ource* ommunity Fealth $ursing #ervices in the G is the lean air Act. Approved in year 2555 but took effect on :anuary of 2551. #ource* ommunity Fealth $ursing #ervices in the * "uzviminda is a commercial se6 worker in Fong ?ong. #he came home due to maculopapular rashes. Fer diagnosis is FC;LAC%# 41. hat is the causative agent in FC;LAC%#! a. Trichomonas vaginalis b. Fuman T cell "ymphotropic virus c. Treponema
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d. hlamydia trachomatis Answer* I A Trichomoniasis #yphilis % hlamydia #ource* %DF & @reen and Jellow ' pp. 455 42. hat is the mode of transmission in the case of "uzviminda with FC;LAC%#! a. ontaminated syringes b. %irect contact with contaminated fluids c. Ilood transfusion d. #e6ual contact Answer* % "uzviminda is a commercial se6 worker so she must have acquired it through se6ual contact. #ource* %DF & @reen and Jellow ' pp. 455 44. hat is the confirmatory test for AC%#LFC;! a. estern Ilot b. #putum e6am c. /"C#A &W' d. %/0A Answer* A I confirmatory test for TI presumptive test % diagnostic test for Dsteoporosis #ource* %DF & @reen and Jellow ' pp. 2G> 4>. Ct is a chronic parasitic infection which greatly reduces human productivity and quality of life. Ct is frequently encountered in communities where eating of fresh or inadequately cooked crabs is a practice. a. #TF b.
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h. imminent deliveries i. in case of imminent deliveries by risk mothers( they should still be referred to the appropriate level of health facility if the risk remains after delivery but if the risk condition has disappeared then no referral is needed. ). $o premature rupture of membranes k. Adequate pelvis l. Abdominal enlargement is appropriate for age of gestation #ource* ommunity Fealth $ursing #ervices in the d. 1 Answer* A. Cnstruct member of the family to watch mother for hemorrhage for at least two hours )ust after the nurse or midwife has left the house after de livery. The first two hors after delivery are dangerous due to atony of the uterus. #ource* ommunity Fealth $ursing #ervices in the . Typical findings on physical e6amination by a qualified health worker* inability to suck &trimus' and L or stiffness( generalized muscle rigidity and L or convulsion &muscle spasm'. #ource* F$ by %DF page 2GG 4G. Fow much ;itamin A should be given to the 311 months old infants who is e6periencing ;it. A deficiency! a. 255 555 C9
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b. >55 555 C9 c. 155 555 C9 d. 5 555 C9 Answer* . 7or ;it. A deficiency( 155( 555 C9 of ;it. A is given. %osing is give today( give tomorrow( give after 2 weeks. #ource* F$ #ervices in the 5. Eicronutrient supplementation is included in what program of the %DF! a. /6panded 1. /6pected results of #entrong #igla Eovement for the individuals includes all of the following e6cept* a. Adopt healthy lifestyle b. %emand for quality health services c. %evelop systems for surveillanceL merits d. . Cmprove healthy seeking behavior Cnstitutions 1. %evelop policies 2. %evelop quality services for healthy providers 4. %evelop system for surveillanceL merits >. Advocate for laws #ource* ommunity Fealth $ursing #ervice in the 2. An e6pected result of #entrong #igla Eovement for the institution includes which of the following! a. Adopt healthy lifestyle b. %emand for quality health services c. . Cmprove healthy seeking behavior Cnstitutions 1. develop policies 2. develop quality services for healthy p roviders 4. develop system for surveillanceL merits >. advocate for laws
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#ource* ommunity Fealth $ursing #ervice in the 4. />. hich of the following is a primary element of /. Assessment and evaluation of the program’s overall performance. . #urveillance( studies and research #ource* ommunity Fealth $ursing #ervices in the . Csolation techniques in the home are difficult to do but fundamental principles must be followed. #oiled articles with discharges should be boiled in water before laundry. Fow long should these articles be boiled! a. Dne hour b. Two hours c. Dne half day d. Thirty minutes Answer* % Articles soiled with discharges should first be boiled in water 45 minutes before laundering. Those which could be burned should be burned. #ource* %DF & Ilue and Jellow' pp. 32 >3. %isinfection of water supply sources are required on the following e6cept* a. newly constructed water supply facilities b. water supply facility that has been repairedLimproved c. water supply sources found to be negative bacteriologically by laboratory analysis. d. ontainer disinfection of drinking water collected from a water facility that is sub)ect to recontamination like open dug wells( unimproved springs and surface water. Answer* . %isinfection of water supply sources is required on the following* a. newly constructed water supply facilities b. water supply facility that has been repairedLimproved c. water supply sources found to be positive bacteriologically by laboratory analysis. d. ontainer disinfection of drinking water collected from a water facility that is sub)ect to recontamination
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like open dug wells( unimproved springs and surface water. #ource* ommunity Fealth $ursing #ervices in the 8. The following are principles of ommunity Fealth $ursing e6cept* a. Fealth teaching is the p rimary responsibility of the community health nurse b. The community health nurse utilizes the already e6isting active organized groups in the community c. The community health nurse participate in the de velopment of an overall health plan for the communities and in its implementation and evaluation d. The community health nurse must understand fully the ob)ectives and policies of the agency she represents Answer* To participate in the development of an overall health plan for the community and in its implementation and evaluation( is one the ob)ectives of ommunity Fealth $ursing. Dption A( I( and % are principles of ommunity Fealth $ursing #ource* ommunity Fealth $ursing #ervices in the =. All of the following are complications of gonorrhea e6cept one* a. G. The ten elements of reproductive health includes all of the following e6cept* a. Eaternal and child health and nutrition b. Een’s reproductive health c. ;iolence against women d. -ehabilitation on reproductive health disorders Answer* % Ten /lements of -eproductive Fealth a. Eaternal and hild Fealth and $utrition b. 7amily
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;itamin % help in the mineralization of bones by enhancing absorption of calcium ;itamin ? involves in the synthesis of blood clotting proteins and a bone protein that regulates calcium level. #ource* ommunity Fealth $ursing #ervices in the . $ight control . /valuation scheme #ource* F$ in the . 7ollowing are initial steps to gain entry in Drganizing a ommunity for Fealth Action 1. @ather initial information about the community from other members of the -F9 or from records and reports
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2. Eake your courtesy calls 4. . Arrange meeting with identified leaders( request barangay officials to sign for a meeting a. 1( 2( 4( > b. 2( >( 1( 4 c. 4( 1( >( 2 d. 1( 2( >( 4 Answer* % The following are initial steps to be done* 1. @ather initial information about the community from other members of the -F9 or from records and reports. 2. "ist down names of persons to contact for a courtesy call 4. Arrange first meeting with identified key leaders( request barangay officials to sign invitation for a meeting >.
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and research. hoices I( ( and % are incomplete #ource* F$ by %DF G th /d G. hich one is not a function of calcium! a. Ione and teeth mineralization b. Absorption of iron in the formation of Fgb c. Ilood clotting d. muscle rela6ation and contraction Answer* I hoice describes function of copper and Lor ;itamin #ource* %DF & @reen and Jellow ' ( pp. 143 35. A deficiency in protein leads to* a. ?washiorkor b. -icketts c. Ieriberi d. Femorrhage Answer* A -icketts results from ;itamin % deficiency. Ieriberi from ;iamin I deficiency. Femorrhage may result from ;itamin k deficiency. 31. hat is the characteristic rashL eruptions in chicken po6! a. Eacular b. days and leaves granular scabs. $ot more than one day before and more than 3 days after appearance of first crop of vesicles. #ource* %DF & @reen and Jellow ' ( pp. 2>4 32. hat is the period of communicability of chicken po6! a. 2 days before to 8 days after the appearance of vesicle b. 1 day before to 3 days after the appearance of vesicles c. 1 day before to 8 days after the appearance of vesicles d. 2 days before to 3 days after the appearance of vesicle Answer* I #ource* %DF & @reen and Jellow ' ( pp. 2>4 34. hat is the primary source of infection of chicken po6! a. respiratory secretions of infected persons b. skin lesions c. scabs d. vesicular skin eruptions Answer* A #ecretions from respiratory tract of the persons is the source of infectionH lesions of skin are of little consequence. #cabs themselves are not infective. #ource* F$ by %DF G th /d page 2>2 3>. hat are the 2 most common complications of chicken po6! a. Eeningitis and TI b.
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d. /ncephalitis and endocarditis Answer* I months d. 3 months Answer* A 2 months. hoice % is the total length of treatment for ategory C patients. 2 months intensive and > months maintenance. #ource* %DF & @reen and Jellow ' ( pp. 25= 38. e have three levels of assessment. Cn the first level assessment( which among these problems is not a health threat! a. broken stairs b. strained marital relationship c. self medication d. illegitimacy Answer* % Cllegitimacy is listed under foreseeable crisis. A( I and are all health threats. #ource* $ursing th /d.( by Eaglaya( pp. 3=85 3=. Cn the B7amily service and
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A is categorized into health threat( health deficit and foreseeable crisis. I refers to the probability of minimizing or totally eradicating the problem. % refers to the nature or magnitude of the future problems that can be minimized or totally prevented if intervention is done on the problem. #ource* $ursing th /d.( by Eaglaya( pp. =3 85. hat is the minimum interval between doses of hepatitis vaccine! a. 4 weeks b. 2 weeks c. 3 weeks d. > weeks A$#/-* % #ource* F$ by %DF( G th /d. 81. At what age and route of administration is measles given! a. G months( CE b. 15 months( CE c. G months( C% d. G months( #+ A$#/-* % #ource* F$ by %DF( G th /d 82. hen is the 2 nd dose of I@ vaccine given! a. 1 month after the first dose b. 9pon school entry c. 4 months after the first dose d. 12 years old A$#/-* I I@ immunization is given to school entrants both in public and private schools regardless of the presence or absence of a I@ scar. #ource* F$ by %DF( G th /d #CT9ATCD$ 2* The 2555 $utritional guidelines is formulated to improve the nutritional status of 7ilipinos. The following questions are concerned with nutrition. 84. 0eropthalmia is characterized by* a. Tunnel vision b. 7loaters c. $ight blindness d. indow ;ision A$#/-* 0erpthalmia or night blindness results due to destruction of rods and cones. Tunnel vision is related to open angle glaucoma. 7loaters occur in retinal detachment because of intraocular hemorrhage. Situation: The public health nurse participate in activities aimed towards the achievement of the goals of each and every program. 8>. Fospital waste management program is a new requirement before construction of a facility. The hospital personnel required to train in waste management to prevent which of the following! a. ommunicable diseases b. $osocomial infection c. ross infection d. Transmission of diseases Answer* I
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8. Approved type of toilet facilities may need water or not depending on receiving space. hat type of toilet is without need of water! a. . ater supply sources found to be positive bacteriologically by laboratory analysis. #ource* %DF & @reen and Jellow ' ( pp. 413 88. The nurse should know that the e6amination of drinking water by the government of nongovernment must be coordinated by the municipality through -F9. ertification of potability of an e6isting water source is issued by the* a. #anitary engineer b. Eunicipality c. #ecretary of health or h is representative d. %DF Answer* ertification of potability of an e6isting water source is issued by the #ecretary of Fealth or his duly authorized representative . #ource* %DF & @reen and Jellow' ( pp. 413 8=. /very municipality through its -F9 must formulate an operational for quality monitoring and surveillance of their water supply every year using the areaprogram based approach. Assistance may be solicited from the internal planning #ervice in the collaboration with the* a. %DF b. /nvironmental Fealth #ervice c. #ecretary of health d. Eayor Answer* I /very municipality through its -F9 must formulate an operational for quality monitoring and surveillance of their water supply every year using the areaprogram based approach. Assistance may be solicited from the internal planning #ervice in the collaboration with the /nvironmental Fealth #ervice. #ource* %DF & @reen and Jellow' ( pp. 413 8G. The B#entrong #igla Eovement” &##E' is a )oint program of the %epartment of Fealth and the "ocal @overnment 9nits. hat is the aim of this movement!
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a. 3 months b. from birth to 2 year or longer c. from birth up to one year only d. 7rom birth to years Answer* A $utritional @uideline 2 states that breastfeed infants e6clusively from birth to >3 months and then give appropriate food while continuing breasfeeding. #ource* #ource* %DF & @reen and Jellow ' ( pp. 12G Situation: A home visit is a professional face to face contact made by a nurse to the client or his family. =2. hich of the following is the first step a nurse must do when conducting a home visit! a.
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infection from individuals to families to the community. #ource* %DF & @reen and Jellow' ( pp. > =>. onsidering the steps and procedures in bag technique which side of the linen or paper lining of the . Award
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Answer* % A( I and are the priorities of ##E. #ource* %DF & @reen and Jellow' ( pp. 12= =G. All of the following are the standard requirements of #entrong #igla Eovement e6cept* a. Cnfrastructure b. /quipment c. G2. Cn the international framework of -F( the focus is on* a. 5 years group age b. omen’s health c. %isplaced people with -F problems d. Iarren couple Answer* I Cn the international framework( the focus is on women’s health not only as a mother during her child bearing( but throuout life( from infancy to post reproductive health with full e6ercise of her reproductive life. #ource* %DF & @reen and Jellow' ( pp. = G4. hich of the following is not an element of -F! a.
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#ource* %DF & @reen and Jellow' ( pp. =3 G>. Cn the
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Answer* % #ource* %DF & @reen and Jellow '( pp. 244 155. All of these are health deficits e6cept* a. Ilindness form measles b. "ameness from polio c. -esettlement in a new community d. Aphasia after a ;A Answer* -esettlement in a new community belongs to your foreseeable crisis. #ource* $ursing th /d. Iy Eaglaya( pp. 85
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NURSING PRACTICE III 1. hich of the following would the nurse identify as an advantage to using a cervical cap for contraception! a. = hours b. Cs disposable and available over the counter c. Allows #permicide application 2 hours before intercourse d. Einimizes risk for allergic reactions to plastic Answer. A The cervical cap is a small rubber or plastic dome that fits snugly over the cervi6. Ct provides continuous protection for >= hours( no matter how many times intercourse occurs. Additional #permicide is not necessary for repeated acts of intercourse. The cervical cap is not disposable or available over the counter( as is the female condom. A cervical cap must be fitted to the individual by a health care provider. There is risk for allergic reaction if the woman develops allergies to plastic( rubber or #permicide. #ource* "ippincott’s -eview #eries Eaternal and $ewborn $ursing by #tright(4rd edition p.=5. 2. hich of the following statements by a male client would indicate that he understands the instructions for use of a condom! a. BC should lubricate the condom with an oilbased product to avoid friction that could rupture the condom.” b. BC should unroll the condom and check it for holes before applying it.” c. BC should hold the rim of the condom while withdrawing my penis from the vagina to avoid leakage.” d. BC should begin se6ual intercourse without the condom and don the condom )ust before e)aculation.” Answer. Dilbased lubricants can break down late6 condoms. The condom should be unrolled onto the penis( starting at the tip of the penis. Folding the rim keeps the condom from slipping off the leaking semen into the vagina. #mall amounts of semen are released before e)aculation and can result in pregnancy. #ource* 4. A woman using a diaphragm for contraception should be instructed to leave it in place for at least how long after intercourse! a. 1 hour b. 3 hours c. 12 hours d. 2= hours Answer. I The diaphragm should remain in place for at least 3 hours after intercourse but not longer than 12 hours to avoid the possibility of to6ic shock syndrome. #ource* "ippincott’s -eview #eries Eaternal and $ewborn $ursing by #tright(4rd edition p.8G. >. The client has completed an athome pregnancy test with positive results. hich of the following indicates that the client understands the meaning of the test results! a. BC understand that this means C have ovulated in the past 2> hours.” b. BC understand that this means C am not pregnant.” c. BC understand that this means C might be pregnant.” d. BC understand that this means C am pregnant.” Answer. A positive athome pregnancy test indicates the presence of growing trophoblastic tissue and not necessarily a uterine pregnancy. #ource*
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c. 7ollicle#timulating hormone d. year old woman comes to the physician’s office for a routine checkup at 4> weeks gestation. Abdominal palpation reveals the fetal position as right occipital anterior &-DA'. To which of the following sites would the nurse e6pects to find the fetal heart tones. a. Ielow the umbilicus( on mother’s left side. b. Ielow the umbilicus( on mother’s right side.
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c. Above the umbilicus( on mother’s left side. d. Above the umbilicus( on mother’s right side. Answer. I Dcciput and back are pressing against right side of mother’s abdomenH 7FT would be heard below umbilicus on the right side. and % found in breech presentation. A is found on "DA. #ource* $"/0-$ Cnternational /dition by ?aplan( page 228 15. The client has come to the clinic because she suspects that she is pregnant. hich of the following would be the most definitive way to confirm the diagnosis! a. lient’s report of amenorrhea for 4 months b. . 1>. A client with preeclampsia is receiving magnesium sulfate and o6ytocin &
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a. "ower blood pressure b. . 18. The client is concerned about facial chloasma that has developed since her last prenatal visit. The best response by the nurse is* a. BJou should apply a facial skin bleach twice a day.” b. BAvoiding sun e6posure may keep the pigmentation from getting any darker.” c. BThis is a permanent condition caused by hormonal changes. Jou may be able to cover it with makeup.” d. BThis is a condition associated with the development of skin cancer. C will make an appointment for you with a dermatologist.” Answer. I Cncreased pigmentation during pregnancy is a response to increased estrogen levels. Ct can be worsened by the sun( is harmless( and generally fades after the pregnancy ends. #ource* weeks Answer. I The client’s ne6t appointment( if all assessment data are within normal limits( should be scheduled in 2 weeks. eekly appointments are recommended after 43 weeks gestation. /very fourth week is the recommended interval for the first 2= weeks gestation. #ource* www.
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1G. hen <-DE occurs( which of the following provides evidence of the nurses understanding of the client’s immediate needs! a. The chorion and amnion rupture > hours before the onset of labor. b. <-DE removes the fetus’ most effective defense against infection. c. $ursing care is based on fetal viability and gestational age. d. <-DE is associated with malpresentation and possibly incompetent cervi6. Answer. I <-DE can precipitate many potential and actual problemsH one of the serious is the fetus’ loss of an effective defense against infection. This is the client’s most immediate need at this time. Typically( <-DE occurs about 1 hour( not > hours( before labor begins. 7etal viability and gestational age are less immediate cervi6 may be causes of <-DE. #ource* "ippincott’s -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4 rd edition( p 2>. 25. A client who is 4> weeks gestation has been having contractions every 15 minutes regularly. Cn addition to instructing her to lie do wn and rest while continuing to time contractions( the nurse should also tell her to* a. -efrain from eating or drinking an ything b. Take slow deep breathes with each contraction c. @o to the hospital if contractions continue for more than 1 hour d. %rink 4 to > cups of water. Answer. % Fydration has been shown to decrease premature labor contractions. Therefore( drinking water or other noncaffeinated beverage is recommended. Cf contractions continue at 15 minutes apart or less for an hour with rest( the client should call her healthcare provider. 21. The nurse is caring for a laboring client with a known history of cocaine abuse. hat complication is most likely for this client! a. T1 <1 A1 "2 Answer. % The client has been pregnant four times( including current pregnancy &@'. Iirth at 4= weeks’ gestation is considered full term &T'( while birth from 25 weeks to 4= weeks is considered preterm &<'. A spontaneous abortion occurred at = weeks &A'. #he has two living children &"'. #ource* "ippincott’s -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4 rd edition( p 455. 24. A pregnant client states that she Bwaddles” when she walks. The nurse’s e6planation is based on which of the following as the cause!
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a. The large size of the newborn b. . 2>. According to -ubin( during which of the following periods would the new mother frequently review her labor and delivery e6perience! a. "ettingdown b. "ettinggo c. Takinghold d. Takingin Answer. % -ubin identifies three stages* takingin( takinghold( and lettinggo. According to -ubin( during the takingin period( the new mother may review her labor and delivery e6perience frequently. Eany mothers do e6perience a Bletdown” feeling after giving birth related to the magnitude of birth e6perience and doubts about the ability to cope effectively with the demands of childrearing. Fowever( -ubin does not describe a lettingdown period. The lettinggo stage( which generally occurs after the new mother returns home( is a time of family reorganization. %uring the takinghold stage( the mother becomes concerned with her ability to parent successfully and accepts increasing responsibility for the newborn. #ource* "ippincott’s -eview #eries Eaternal and $ewborn $ursing by #tright(4rd edition p.13=. 2. The nurse discovers a loop of the umbilical cord protruding through the vagina when preparing to perform a vaginal e6amination. The most appropriate intervention is to* a. all the physician immediately b.
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umbilicus and deviated to the right of midline. hich of the following would be the nurse’s priority action at this time! a. Assist the mother to void b. ;igorously massage the fundus c. Administer additional o6ytocin to contract the uterus d. @ive a tocolytic drug intravenously Answer. A A distended bladder will elevate and displace the uterus to the right. Therefore the nurse should assist the mother to void. A displaced uterus is usually caused by a full bladder. ;igorous massage of the fundus will not correct this and may cause unnecessary discomfort. D6ytocin would be used if the uterus was not contracting. There is no data to suggest a need for that at this time. A tocolytic would be used if the uterus required rela6ation( such as in premature labor. #ource* "ippincott’s -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4 rd edition( p 411. 2=. The nurse is assessing the fundal height of a client at 23 weeks gestation. The nurse should e6pect the fundus to be* a. "evel with the umbilicus b. Falfway between symphysis and umbilicus c. #lightly below ensiform cartilage d. At 23cm. Answer. % 7undal height in centimeters correlates well with weeks of gestation between 222> weeks and 4> weeks. Thus( at 23 weeks’ gestation( fundal height is probably about 23 cm. #ource* www. V b. "eukocyte count* 1G(555Lmm c.
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d. The membranes have ruptured. Answer. A The change in the cervi6 is the only indicator of true labor #ource* . 41. After > hours of active labor( the nurse notes that the contractions of a primigravid client are not strong enough to dilate the cervi6. hich of the following would the nurse anticipate! a. Dbtaining an order to begin C; o6ytocin b. Administering a light sedative to allow the patient to rest for several hours c. hours after birth( during which time the mother and newborn recover from the physical process of birth and the mother’s organs undergo the initial read)ustment to the nonpregnant state. #ource* "ippincott’s -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4 rd edition( p 12 44. The highest priority in nursing care of the laboring client is* a. . 4>. hich of the following fundal heights indicates less than 12 weeks’ gestation when the date of the "E< is unknown! a. 9terus in the pelvis b. 9terus at the 6iphoid c. 9terus in the abdomen d. 9terus at the umbilicus Answer. A hen the "E< is unknown( the gestational age of the fetus is estimated by uterine size or position &fundal height'. The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation. At appro6imately 12 to 1> weeks( the fundus is out of the pelvis above the syphysis pubis. The fundus is at the level of the
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umbilicus at appro6imately 25 weeks’ gestation and reaches the 6iphoid at term or >5 weeks. #ource* "ippincott’s -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4 rd edition( p 141. 4. hich of the following danger signs should be reported promptly during the antepartum period! a. onstipation b. Ireast tenderness c. $asal stuffiness d. "eaking amniotic fluid Answer. % %anger signs that require prompt reporting are leaking of amniotic fluid( vaginal bleeding( blurred vision( rapid weight gain( elevated blood pressure. onstipation( breast tenderness( and nasal stuffiness are common discomforts associated with pregnancy. #ource* "ippincott’s -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4 rd edition( p 141. 43. 7F- can be auscultated with a fetoscope as early as which of the following! a. weeks’ gestation b. 15 weeks’ gestation c. 1 weeks’ gestation d. 25 weeks’ gestation Answer. % The 7F- can be auscultated with the fetoscope at about 25 weeks’ gestation. 7F- usually is auscultated at the midline suprapubic region with a %oppler ultrasound transducer at 15 to 12 weeks’ gestation. 7Fcannot be heard any earlier than 15 weeks’ gestation. #ource* "ippincott’s -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4 rd edition( p 145. 48. A client at = weeks’ gestation calls complaining of slight nausea in the morning hours. hich of the following client interventions should the nurse question! a. Taking 1 teaspoon of bicarbonate of soda in an =ounce glass of water b. /ating a few lowsodium crackers before getting o ut of bed c. Avoiding the intake of liquids in the morning hours d. /ating si6 small meals a day instead of three large meals Answer. A 9sing bicarbonate would increase the amount of sodium ingested( which can cause complications. /ating lowsodium crackers would be appropriate. #ince liquids can increase nausea( a voiding them in the morning hours when nausea is usually the strongest is appropriate. /ating si6 small meals a day would keep the stomach full( which often decreases nausea. #ource* "ippincott’s -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4 rd edition( p 45G. 4=. A client with severe preeclampsia is admitted with a I< 135L115( proteinuria( and severe pitting edema. hich of the following would be mot important to include in the client’s plan of care! a. %aily weights b. #eizure precautions c. -ight lateral positioning d. #tress reduction Answer. I omen hospitalized with severe preeclampsia need decreased $# stimulation to prevent a seizure. #eizure precautions provide environmental safety should a seizure occur. Iecause of edema( daily weight is important but not the p riority.
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important nursing assessments of this client include* a. Cntake and output( level of consciousness( and blood pressure. b. Ilood pressure( pulse( and uterine activity c. %eep tendon refle6( hourly urine output( and respiratory rate d. Cntake and output( blood pressure( and refle6es. Answer. /arly signs of magnesium to6icity that may lead to respiratory arrest are loss of patellar refle6es and decreased respiratory rate &X12Lmin'. #ince magnesium is e6creted from the body through the renal system( hourly urine output should be assessed. Although blood pressure is a standard assessment for most antepartum clients( there is minimal blood pressure change( if any( associated with administration of magnesium sulfate. #ource* 5. A client’s amniotic fluid is greenishtinged. The fetal presentation is verte6. 7etal heart rate &7F-' and uterine activity have remained within normal limits. At the time of delivery( the nurse should anticipate the need for* a. An infant laryngoscope and suction catheters b. 7orceps c. A transport isolette d. /mergency cesarean setup Answer. A Eeconium released by the fetus causes amniotic fluid to be greenishtinged. Although the presence of meconium is associated with fetal distress( there is no evidence of immediate danger to the fetus during labor in this case. Fowever( the infant is at risk for aspirating meconium at the time of delivery. #teps to prevent aspiration include thorough suctioning of the nasopharyn6 including visualization of the vocal cords to remove cords to remove meconium particles before the first breath. #ource* 1. 7ollowing amniotomy( the most important nursing action is to* a. -eposition the mother on her left side b. 2. Assessment of a normal episiotomy immediately post delivery is most likely to reveal* a. @aping between the sutures b. #light bruising c. 4. Cf the fetal head is determined to be presenting in a position of complete e6tension( the nurse should anticipate a* a.
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b. >. A nurse is caring for four postpartum clients who each have an order for Eethergine &methylgonovine maleate'. Iased on the data collected during the nurse’s initial shift assessment( which client would not receive the medication! a. The client with a blood pressure of 13LG> b. The client with a hematocrit of 44V c. The client with a white blood cell count of 22(555 d. The client with a temperature of 151S7 Answer. A Fypertension is a side effect of this medicationH therefore( Eethergine is contraindicated for women with high pressure. /levated temperature and elevated blood count are not contraindications for administering Eethergine. Iecause Eethergine is given to prevent or reverse postpartum hemorrhage( it may also help prevent a decrease in hematocrit levels. #ource* www. . A 22year old woman is admitted to the hospital and delivers a healthy 8lbs 2 oz girl. The mother decides to bottlefeed her infant. hich of the following statements( if made by the mother after a teaching session( indicates to the nurse that the patient needs further teaching! a. BC’ll pump my breast and use warm packs to relieve breast pain.” b. BC’ll use a tight bra and ice packs to relieve engorgement discomfort.” c. BC’ll take the medication prescribed by the doctor for pain.” d. BC’ll take the pills ordered by my doctor to help stop the production of milk.” Answer. A This stimulates hormonal responses thereby increasing production of milk causing engorgement. Dptions I( ( and d are all correct management for engorgement in mothers not breastfeeding. Cce packs relieve discomfort. 3. The nurse in the postpartum unit cares for a 28year old woman who delivered her first child the previous day. %uring her assessment of the patient( the nurse notes multiple varicosities on the patient’s lower e6tremities. The nurse should* a. Teach the patient to rest in bed when the baby sleeps b. /ncourage early and frequent ambulation c. Apply warm soaks for 25 minutes every four hours’ d. perform passive range of motion e6ercises three times daily Answer. I Ct facilitates emptying of blood vessel in the lower e6tremities. A is incorrect because bed rest can cause thrombophlebitis. is not preventive but an intervention which needs physician’s order. % is incorrect because early ambulation is more effective. #ource* $"/0-$ Cnternational /dition by ?aplan( page 155 >8. Ct is most important for the nurse to have which drug readily available when the client is being treated with heparin therapy for thrombophlebitis! a. alcium gluconate b. Aquamephyton c.
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d. 7errous sulfate Answer. =. A priority intervention that the nurses do immediately after delivery is suctioning out the baby’s mouth and nares. hy! a. #uctioning decreases surface tension and prevents alveolar collapse. b. #uctioning assists with increasing the pulmonary vascular resistance in the lungs( resulting in a decrease in the blood flow to the pulmonary bed. c. #uctioning removes =5115 ml of fluids that remain in the respiratory passages( permitting adequate movement of air. d. #uctioning is not necessary because the birth process squeezes all fluid out of the lungs Answer. Ct is stated that =5115 ml of fluid remains in the respiratory passages that must be removed to permit adequate movement of air. #urfactant decreases surface tension and prevents alveolar collapse. Although the initial chest recoil assists in clearing fluid from the airways and permits further inspiration( most clinicians believe mucus and fluid should be suctioned from the newborn’s mouth( nose( and throat. #uctioning does not increase the pulmonary vascular resistance. #ource* www. G. The nurse is admitting a neonate 2 hours after delivery. hich assessment data should the nu rse be concerned about! a.Fands and feet blue b. $asal flaring c.Einimal response to verbal stimulation d.Apical heart rate 13 Answer. I $asal flaring could be a sign of respiratory distress and requires immediate intervention. The other assessment data are normal findings for a neonate at 2 hours of age. #ource* hours following delivery and is generally caused by retained placental fragments or bleeding disorders. "ochia rubra is the normal dark red discharge occurring in the first 2 and 4 days after delivery( containing epithelial cells( erythrocytes( leukocytes( and deciduas. "ochia serosa is a pink to brownish serosanguineous discharge occurring from 4 to 15 days after delivery that contains deciduas( erythrocytes( leukocytes( cervical mucus( and microorganisms. "ochia Alba is an almost colorless to yellowish discharge occurring from 15days to 4 weeks after delivery and containing leukocytes( deciduas( epithelial cells( fats( cervical mucus( cholesterol crystals and bacteria. 1. The nurse assesses the vital signs of the client( > hours’ postpartum that are as follows* I< G5L35H temperature 155.>S7H pulse 155 weak( threadyH - 25 per minute. hich of the following should the nurse do first!
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a. -eport the temperature to the physician b. -echeck the blood pressure with another cuff c. Assess the uterus for firmness and position d. %etermine the amount of lochia Answer. % A weak( thready pulse elevated to 155I=7 in the first 2> hours after birth are related to the dehydrating effects of labor and are considered normal. Although rechecking 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. The 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 check the e6tent of vaginal bleeding first. Then it would be appropriate to check the uterus( which may be a possible cause of the hemorrhage. #ource* "ippincott’s -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4 rd edition( p 454. 2. hen preparing to listen to the fetal heart rate at 12 weeks’ gestation( the nurse would use which of the following! b. #tethoscope placed midline at the umbilicus c. %oppler placed midline at the suprapubic region d. 7etoscope placed midway between the umbilicus and the 6iphoid process e. /6ternal electronic fetal monitor placed at the umbilicus Answer. I At 12 weeks’ gestation( the uterus rises out of the pelvis and is palpable above the symphysis pubis. The %oppler intensifies the sound of the fetal pulse rate so it is audible. The uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of umbilicus. The fetal heart rate at this age is not audible with a stethoscope. The uterus at 12 week is )ust above the symphysis pubis in the abdominal cavity( not midway between the umbilicus and 6iphoid process. At 12weeks the 7F- would be difficult to auscultate with a fetoscope. Although the e6ternal electronic fetal monitor would pro)ect the 7F-( the uterus has not risen to the umbilicus at 12 weeks. #ource* "ippincott’s -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4 rd edition( p 455. 4. hich of the following additional assessment findings would be most suspicious and lead the nurse to suspect postpartum Bblues” in a client who is an6ious and crying! a. "oss of appetite( constipation( abdominal pain b. %espondency( loss of appetite( difficulty sleeping c. Cncreased appetite( urinary retention( diarrhea d. . hich of the following would the nurse e6pect to find when assessing a client who delivered a newborn 12 hours ago! a. "ochia alba b. #oft boggy fundus c. Transient tachycardia d. omplaints of hunger Answer. % 7ollowing delivery( the nurse would e6pect to find complaints of hunger and thirst. Additional assessment
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findings for this time period include lochia rubraH a fundus that is firm( located midline and at the level of the umbilicus or slightly lowerH and transient bradycardia. #ource* "ippincott’s -eview #eries Eaternal and $ewborn $ursing by #tright(4rd edition p.13=. . hich of the following intervention results in convection heat loss in the newborn! a. -emoval from an incubator for procedures b.
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$eonates generally aren’t able to effectively coordinate sucking( swallowing( and breathing until 4> to 43 weeks gestation. Cf fed orally before that time( they are at greater risk of aspiration. Typically they will be fed through a gavage tube until they are able to drink from a bottle or breastfeed. Cntake can be accurately assessed with oral and gavage feedings. The stomach of a preterm infant can digest small amounts of formula or breast milk. Thrush is an oral yeast infection commonly caused du ring passage through the birth canal( and gavage feeding will not prevent it from occurring. #ource* . The nurse conducts a new parent support group for her community. Two mothers ask how their =
pg. 65
monthold children can be so different in height and weight! hat is the appropriate response! a. This is an abnormality that should be referred to the physician. b. Dne of the children is displaying a Ngrowth spurt. c. -ates of growth vary and individual differences occur for each child. d. The sequence of growth and development is unpredictable for each child. Answer* . -ates of growth vary and individual differences occur for each child. Although there are general norms for growth and development rates( each child is an individual who will progress at his or her own individual pace. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 4 , > 3. hildren are usually brought to the clinic for health care by a parent. At what age is it appropriate for the nurse to question the child about presenting symptoms! a. 4 years b. years c. 8 years d. G years Answer* 8 years Iy age 8( most children are able to clearly and in chronological order describe symptoms. Their vocabulary is e6tensive enough to have words to describe what they are feeling( time of onset( changes from the norm( etc. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 1G( 25 ,48 33. hen sharing the purpose of the %enver %evelopment #creening Test &%enver CC' with parents of an 1=monthold( the nurse should e6plain that* a. The %enver CC is a test that will predict future intellectual ability. b. The %enver CC is a screening test used to detect children who may be slow in development. c. The %enver CC is used for early detection of speech disorders. d. The %enver CC measures psychological( cognitive( and social development. Answer* I The %enver CC is a screening test used to detect children who may be slow in development. The %enver CC is used to screen children for possible developmental delays in the areas of grossmotor skills( language( finemotor skills( and p ersonalsocial development. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. >G5 38. >yearold scores two failures on the %enver CC. hich of the following statements is most accurate! a. The child is not as intelligent as e6pected for age and should be referred to a learning specialist. b. The child has a speech problem and should be referred to a speech therapist. c. The child is at risk for school problems and should be retested. d. The failures are to be e6pected in preschoolers who may not be cooperative with testing. Answer* The child is at risk for school problems and should be retested. The %enver CC is a screening test( not a diagnostic testH therefore children who score a failure should be retested. The child is considered atrisk until other diagnostic indicators can determine a specific problem. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 2 3=. hat is the most important sign of readiness to watch for when toilet training the child! a. ability to walk b. able to indicate that the diaper is wet c. physical and psychological readiness d. e6hibits willingness to please parents Answer* physical and psychological readiness Ct is the child’s welfare that should be the paramount consideration in toilet training. The physical and
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psychological readiness of the child will make the activity successful. #ource* ong’s /ssentials of 1G 3G. The mother of a 12monthold infant who is hospitalized is upset that she must leave her baby to go home for a short time. hat should the nurse suggest to this concerned parent! a. -eturn as soon as possible to attend to her daughterMs needs. b. "eave a personal article with the child and reassure her that she will return. c. all a family relative to stay at all times with the ch ild when the mother leaves. d. Ask a nurse to sit at the childMs bedside in her absence. Answer* I "eave a personal article with the child and reassure her that she will return. The goal is to preserve the childMs trust. #trategies such as leaving a personal article( picture( or favorite toy help minimize the an6iety of separation. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 1= 85.
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:udy /. hite( p. 11 84. The nurse provides anticipatory guidance to parents of a 4yearold child. Cnstructions should include* a. To restrain the child in the car seat facing rear in the back seat of the car. b. The use of syrup of ipecac for accidental poisonings. c. %rug and alcohol education. d. The proper use of sports equipment. Answer* I The use of syrup of ipecac for accidental poisonings. $urses are instrumental in teaching parents how to make the toddlerMs environment safe by providing instructions about keeping syrup of ipecac available( having the . A teenager refuses to wear the clothes his mother bought for him. Fe states he wants to look like the other kids at school and wear clothes like they wear. The nurse e6plains this behavior is an e6ample of teenage rebellion related to internal conflicts of* a. Autonomy vs. shame and doubt. b. Trust vs. mistrust. c. Cdentity vs. role confusion. d. Cnitiative vs. inferiority. Answer* Cdentity vs. role confusion. /riksonMs theory of psychosocial development states that the child is faced with conflicts that need to be resolved. /rikson identifies stages of personality development. Cdentity vs. role confusion &12 to 1G years' is a period when adolescents search for answers regarding their future. %uring this time( the child re)ects the identity presented by his parents and attempts to create his own identity. Cdentity is often based on peers. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 18,1= 8. Fospitalization of a child results in disturbance of the dynamics in family life. The most appropriate nursing diagnosis is* a. %iversional activity deficit related to separations from siblings and peers. b. #leep patterns disturbance related to unfamiliar surroundings. c. Altered family processes related to hospitalization. d. Cneffective individual coping related to procedures. Answer* Altered family processes related to hospitalization. Cdentification of nursing diagnoses that apply to the specific problem&s' of the child and family is an essential step of the nursing process. 7amilycentered care addresses the needs of the family members( including the childMs siblings. The primary goals are to maintain the relationship with the child and siblings during the period of separation while ho spitalized and avoid boredom and distress for the hospitalized child. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 23 83. The charge nurse is developing plans to reduce the stress of hospitalized( chronically ill children. oping for these children will be improved if* a. They are allowed 2>hour open visitation with their peers. b. They are assigned a primary nurse. c. They avoid making all decisions while hospitalized. d. All tutoring is postponed until discharge Answer* I They are assigned a primary nurse.
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the same nurse&s'( with whom the child develops trust and rapport. #ource* ong’s /ssentials of 8=. The nurse is preparing an =yearold child for a procedure. hat is the most appropriate nursing intervention! a. =5. hen preparing to e6amine a preschool child( the nurse should* a. @ive detailed e6planations to alleviate the childMs an 6iety. b. @ive reassurance and feedback to the child during the e6amination. c. #uggest that the child act like Nthe big kidsN when he or she is e6amined. d. #ay that the shirt is the only clothing that must be removed. Answer* I @ive reassurance and feedback to the child during the e6amination The preschooler may be somewhat an6ious so the nurse should give feedback and reassurance about what will be done. hildren do not need detailed e6planations nor do they need to be told to a ct older than they are. Eost children at this age are willing to remove clothing. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 48
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=1. The pediatric nurse practitioner is working with a group developing school playgrounds. The playground designers must identify the ma)or causes of potential in)ury for the schoolaged child. The nurse e6plains that the most f requent accidents in schoolage children involve* a. Eotor vehicles( diving( and drugs a nd alcohol. b. #wing sets( drowning( and poisonings. c. Iicycles( skateboards( and inline skates. d. Aspiration Aspiration of food( plastic bags( and stairways. Answer* Iicycles( Iicycles( skateboards( and inline skates. #choolage children en)oy activities like skateboarding and biking that may cause in)uries. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 1> =2. A father father brings his yearold to the doctorMs office for a wellchild visit. The father is embarrassed by his childMs behavior during the visit. The father states that every time the child comes for an immunization she begins to cry and scream. An appropriate response to this father is* a. NAll children have a ma)or fear of needlesH preschoolers often believe pain is a punishment.B b. NJour NJour child most likely had a traumatic e6perience at an early age.B c. N$e6t time the mother should accompany the child for an immunization.B d. NCt is best to ignore this type of behavior as the child is seeking attention Answer* A NAll children have have a ma)or fear of of needles( preschoolers preschoolers often believe pain is a punishment.B . The mother of a yearold e6presses concern about her child who believes that N@randma is still aliveN 4 months after the grandmotherMs death. The nurse e6plains that* a. Eagical thinking often accounts for a preschooler who believes that dead people will come back. b. There is a need for psychological counseling for this child and family. c. This is a form of regression e6hibited by the preschooler. d. The child is in denial regarding @randmaMs death. Answer* A Eagical thinking often often accounts for a preschooler preschooler who believes that dead people will will come back. The preschooler believes that death is reversible. Their magical thinking and egocentricity often results in their belief that the deceased will come back to life.
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c. 7ormula is the only source of nutrition given for the first year. d. 7ruits and vegetables are good sources of iron. Answer* I -ice cereal is the the first solid solid introduced that is is least allergenic of the cereals. -ice cereal is the first solid food because it is a rich source of iron and rarely induces allergic reactions. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 8 =3. The nurse would assess for which of the following as the most frequent cause of decreased hemoglobin and hematocrit levels in children a. %ietary deficiency b. /6cess fluid intake c. hronic blood loss d. 7requent cuts and bruises Answer* A %ietary deficiency The ma)or reason for low hemoglobin and hematocrit in infants and children is deficiency of iron intake through diet. Cronfortified rice cereal is the first solid food recommended for infants beginning about > months of age as fetal iron stores are depleted. #ource: #ource: -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 485 =8. A recently recently hospitalized 2yearold client screams and shouts that he wants a Nbottle.N Fis parents are puzzled( and state that he has drank from a cup for the past year. The The nurse e6plains that* a. Crritability is e6hibited in all age groups. b. Temper Temper tantrums often represent the childMs need for parental attention. c. ;arious ;arious forms of punishment are necessary when such behaviors occur. d. -egression to an earlier behavior often helps the child cope with stress and an6iety. Answer* % -egression -egression to an earlier earlier behavior often helps the child cope cope with stress and an6iety. an6iety. -egression is common in toddlersH it lessens the threat of illness( hospitalization( or separation. A need to revert to use of the bottle( refusal to use the potty( or temper tantrums represent forms of behaviors e6hibited as regression. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 1= ==. The nurse discusses dental care with the parents of a 4yearold. The nurse e6plains that by the age of 4( their child should have* a. NtemporaryN teeth. b. 15 NtemporaryN teeth. c. 1 NtemporaryN teeth. d. 25 NtemporaryN teeth. Answer* % 25 NtemporaryN teeth. hildren have 25 deciduous teeth that erupt between 3 months and 45 months of age. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 12 =G. hen observing an 1=monthold child( the nurse notes a rounded belly( sway back( bowlegs( and slightly large head. The nursing conclusion is that* a. The child appears to b e a normal toddler. b. The child is likely developmentally delayed. c. The child may be malnourished( especially with respect to calcium. d. The enlarged head is of great concern and requires a thorough neurological e6am. Answer* A The child appears appears to be a normal toddler. toddler. The typical toddler has lordosis and a protruding belly. Th The e head still appears somewhat large in proportion to the rest of the body. Iecause these are normal findings( there is no need to be concerned about developmental delays( malnutrition( or neurological problems.
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#ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. > G5. hen using the otoscope to e6amine the ears of a 2yearold child( the nurse should* a. 2 G1. hen assessing a >yearold child with a persistent cough( the nurse would assess respirations by observing which muscle group! a. Thoracic b. Abdominal c. Accessory d. Cntercostal Answer* I Abdominal Cnfants and young children use the diaphragm and abdominal muscles for respiration( so the nurse would watch the rise and fall of the abdomen to count respirations. 9se of accessory or intercostal muscles may be observed in respiratory distress. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. >5 G2. #creening for strabismus and amblyopia should be part of the physical assessment of which children! a. All children under 1= b. Cnfants c. . To assess the height of an 1=monthold child who is brought to the clinic for routine e6amination( the nurse should*
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a. Eeasure arm span to estimate adult height. b. 9se a tape measure. c. 9se a horizontal measuring board. d. Fave the child stand on an upright scale and use the measuring arm. Answer* 9se a horizontal measuring board. hildren younger than 2 or 4 should be measured lying down( preferably on a horizontal measuring board( to get an accurate assessment of height. A tape measure would be used to measure head circumference. An armspan measure is not an appropriate estimation of adult height. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 4= G. The nurse who is e6amining a child understands that visual acuity of 25L25 as measured by the #nellen chart is reached by age* a. 2 years. b. > years. c. 3 years. d. = years. Answer* 3 years. hile difficult to assess directly in infants and young children( visual acuity does not approach that of adults until school age or about 3 years. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. >2 G3. A 1yearold male child is scheduled for a routine e6am at the pediatric clinic. The childMs birth weight was = lbs. 2 oz. The child now weighs 1= pounds( > oz. The nurse knows that this weight is* a. Ielow the e6pected weight. b. Appropriate for the childMs age. c. Above the e6pected weight. d. Cndividualized and thus unpredictable. Answer* A Ielow the e6pected weight. The first year of life is one of rapid growth. The birth weight usually doubles by 3 months and triples by the end of the first year. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. G8. A 3monthold child returns from surgery. <-$ orders are available for pain management. The nurse would administer the pain medication when the baby is observed* a. rying loudly( grimacing( restlessness. b. %isplaying a change of color( decreased temperature. c. %emonstrating shortness of breath( lack of responsiveness. d. #leeping more( refusing to eat. Answer* A rying loudly( grimacing( restlessness. A childMs response to pain depends on his or her developmental stage. The infant is unable to describe or quantify pain because of limited vocabulary. Cnfant behaviors( such as crying( facial e6pressions( and change of activity are used to identify pain and distress. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 1= G=. A mother of a >yearold tells the nurse that her so n is a Npicky eater.N The nurse should inform the mother that she should* a. Cncrease the amount of carbohydrates in the daily menu plan. b. Administer vitamins twice a day to her child. c. Ie more concerned with the quantity of food than the quality of food. d. -ecognize this is common for preschoolers as their caloric requirements have decreased slightly.
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Answer* % -ecognize this is common for preschoolers as their caloric requirements have decreased slightly. The preschooler will be influenced by othersM eating habits and demonstrate their likes and dislikes for food preferences. The caloric requirement decreases slightly( to G5 kcalLkgLday. +uality( not quantity( is important. Ct is not necessary to give vitamins after infancy unless the child is at nutritional risk. #ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and :udy /. hite( p. 12 GG. hen e6amining the child( the nurse should remember that tonsillar tissue* a. /nlarges until adolescence and then shrinks. b. ontinues to enlarge throughout childhood and adolescence. c. Cs readily visible in toddlers. d. $ormally has a small amount of e6udate. Answer* A /nlarges until adolescence and then shrinks. Tonsils enlarge throughout childhood and gradually begin to shrink with puberty. /6udate should not be present on tonsils. #ource* http*LLen.wikipedia.orgLwikiLTonsils 155. Cn discussing se6ual maturation with a health class( the nurse would include the information that secondary se6 characteristics begin to appear at* a. 15 years in girls( 12 years in boys. b. 12 years in girls( 13 years in boys. c. 15 years in boys( 15 years in girls. d. 12 years in girls and boys. Answer* A 15 years in girls( 12 years in boys. #econdary se6 characteristics begin at 15 to 12 years for girls and 12 to 1> yea rs for boys. #ource* http*LLen.wikipedia.orgLwikiL
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NURSING PRACTICE IV 1. A client with pulmonary edema is started on furosemide &"asi6'. hat would the nurse include in the discharge teaching! a. A decrease in urine output is to be e6pected. b. The client should eat foods with plenty of potassium. c. The client should e6pect an increase in swelling in the hands and feet. d. The client should take the medication at bedtime. -atio* answer* I 7urosemide &"asi6' is a loop diuretic that will increase urine output and decrease edema. @ive furosemide early in the day so that the increased urination will not disturb the client’s sleep. Arrange for a potassium rich diet or potassium supplements as needed due to the loss of potassium with the increased diuresis. 2. Cf airflow is obstructed while attempting to ventilate a victim during <-( what should the rescuer do! a. @ive two slow breathes followed by 1 chest compressions. b. V c. 5V d. 35V -atio* answer* A A flow rate of 2 "Lmin gives an D2 concentration of appro6imately 2=V. 7ace masks will deliver D 2 concentrations of 45V with flow rates of 312 "Lmin. A nonrebreathing mask( which delivers high concentrations of D2 and deliver D2 concentrations of 35G5V. >. Analysis of arterial blood gasses &AI@s' and o6ymetry are the b est methods to assess which of the following! a. Acidbase balance. b. Adequate o6ygenation. c. The efficiency of gas transfer in the lungs. d. Ei6ed venous gas sample. -atio* answer* Two methods that are used to assess the efficiency of gas transfer in the lungs are analysis of AI@s and o6ymetry. AI@s are used to measure acidbase balance(but o6ymetry is not. An assessment of
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An oral glucose tolerance test &D@TT' is a fasting test and the client will be $ After a hypophysectomy &surgical removal of the pituitary gland' there is a return to normal pituitary secretion. Fypopituitarism can cause a deficit of growth hormone( gonadotropins( thyroid stimulating hormones( and ATF. The client needs to watch for changes in mental status( energy level( muscle strength( and cognitive function. ushing’s disease is a disorder of hypersecretion. @rave’s disease is a hypersecretion of the thyroid gland. %iabetes mellitus is related to the function of the pancreas and is not related to the function of the pituitary. G. ;asopressin &
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-atio* answer* A /6cess corticoids in the individual with Addison’s disease contribute to weight gain and calcium and protein loss. #o the recommended diet for these individuals is one of high protein and calcium intake while maintaining lower caloric intake to prevent weight gain. 15. The client with Addison’s disease is ordered glucocorticoid therapy. hich of the following statements indicates hat the client has a correct understanding of the medication regimen! a. B%osage ad)ustments in my medication dosages may be needed.” b. BDn days C feel good( C will not need to take the medication.” c. BC will ad)ust my dosages based on my home blood glucose test results.” d. BC am on an everyotherday dosing regimen.” -atio* answer* A @lucocorticoid medication therapy is established with a basal dose. The typical regimen begins with twothirds of the daily dose taken in the morning &= AE' and the remaining onethird later &> . After pituitary surgery( the nurse should carefully assess the client and report which of the following findings immediately! a. A urine test positive for glucose a nd ketones. b. A blood glucose level greater than >5 mgLdl. c. 9rine output of 12 litersLday
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d. 9rine specific gravity less than 1.515 -atio* answer* % 9rine test that are positive for glucose and ketones as well as I@ levels less than >5 mgLdl are diagnostic for diabetes mellitus rather than diabetes insipidus. A urinary output of 12 liters is a normal daily output. 5 " of fluid a day. 1. hich of the following lab results are consistent with a diagnosis of ushing’s disease! a. A two hour postprandial blood glucose of >5 mgLdl b. A urinary calcium level of 3.2 mgLdl. c. A potassium &?' level of 2.8 m/qL" d. A sodium &$a' level of 12= m/qL" -atio* answer* % lients with ushing’s disease have hypertremia( not hyponatremia( and this sodium retention is typically accompanied by potassium depletion. Ione reabsorption of calcium increases the urine calcium level. The secretion of aldosterone results in hypertension( hypokalema( and edema. Cn addition( hyperglycemia rather than hypoglycemia is seen due to alteration in glucose metabolism. 13. A client with chronic lymphocytic leukemia has a central venous access device. #he has a tunneled central catheter called a Fickman. The nurse knows that this catheter is inserted surgically and threaded to the subclavian( and then is advanced into the superior vena cava )ust above the )unction with the a.
left atrium
b.
right atrium
c.
left ventricle
d.
right ventricle
-ationale* The right atrium is the correct answer. The superior vena cava brings deo6ygenated blood to the right atrium. The central venous catheter is threaded into the superior vena cava appro6imately 2 to 4 cm above the )unction with the right atrium. 18. A 2 day old neonate is receiving phototherapy for hyperbilirubinemia. %uring this therapy( it is essential that the nurse* a. b.
decrease the unit’s level of light every 2 hours keep the neonate well covered to prevent cold stress
c.
maintain the neonate’s position for > hours at a time
d.
place an opaque mask over the neonate’s eyes
-ationale* orrect answer* % An opaque mask is placed over the neonate’s eyes to prevent retinal damage from the lights. The mask should be removed for 2 minutes every = hours to assess for irritation or redness. 1=. Cn performing <-( the primary goal of the nurse is to a. b.
return the heart to normal rhythm maintain acidbase balance
c.
maintain circulation to vital organs
d.
correct fluid volume deficit
-ationale* orrect answer* The goal of <- is to maintain circulation to vital organs until more advanced forms of life support can be initiated. 1G. A client with a peripheral C; line is about to receive a blood transfusion of packed red blood cells due to anemia. The nurse administering the transfusion will a. b. c.
infuse the blood slowly over a period of to 3 hours initially infuse at a rapid rate and check pulse frequently obtain the client’s vital signs prior to the transfusion
pg. 78
d.
prime the tubing with a % solution prior to infusing blood
-ationale* orrect answer* The nurse must obtain baseline vital signs for this client )ust prior to starting the transfusion. Then the nurse will continue to monitor his vital signs as per protocol to evaluate for signs of a transfusion reaction. 25. The nurse is caring for an adult admitted to the coronary care unit with a myocardial infarction. %uring the second night in the 9( the client develops congestive heart failure. A #wan@anz catheter is inserted to monitor the client for left ventricular function because a. b.
Ct provides information about pulmonary resistance. Ct measures myocardial o6ygen consumption.
c.
Ct controls renal blood flow.
d.
Ct controls afterload.
-ationale* orrect answer* A The #wan@anz catheter measures pulmonary artery and capillary wedge pressures( which are good indicators of pulmonary pathology. The #wan@anz catheter does not measure myocardial o6ygen consumption and does not control renal blood flow. 21. Ers. :. is admitted to the cardiac care unit with a myocardial infraction. The morning after admission she and her husband tell the nurse that she must be home tonight to care for the children when Er. :. goes to work. The problem identified at this point would be a. An6iety
related to physical limitations.
b. Alteration
in cardiac output.
c.
Cnability of clientLfamily to understand disease process.
d.
#afety needs related to inability to cope.
-ationale* orrect answer* The nurse should assess b oth Er. and Ers. :.’s understanding of the disease and rehabilitation processes. They both e6hibit the need for information in order to be able to make rational decisions. 22. Es. F. is admitted to the coronary care unit to rule out a myocardial infarction. #he tells the nurse she is sure it is )ust angina and cannot understand what the difference is between angina and infarct pain. hich response is most appropriate for the nurse to make! a. Anginal b. Anginal
pain usually only lasts 4 minutes. pain produces clenching of the fists over the chest while acute EC pain does not.
c. Anginal
pain requires morphine for relief.
d. Anginal
pain radiates to the left arm while acute EC pain does not.
-ationale* orrect answer* A Anginal pain is of short duration. Ct is usually relieved by rest. The usual treatment for anginal pain is nitroglycerin. Anginal pain and the pain of an acute EC can both radiate to other locations 24. hich assessment finding in the elderly is caused by decreased vessel elasticity and increased peripheral resistance! a.
onfusion
b. An c. An d.
erratic pulse rate increase in blood pressure
ide +-# comple6es on the /@
-ationale* orrect answer* The blood pressure increases in response to the thickening of vessels and lessdistensible arteries and veins. There is also an impedance to blood flow and increased systemic vascular resistance( contributing to hypertension. onfusion could be caused by a decreased o6ygenation to the brain or by the interaction of multiple medications. An erratic pulse is not caused by decreased vessel elasticity and increased peripheral vascular resistance. An erratic pulse could be a sign of cardiac disease( a side effect of a prescribed medication( or a sign of the interaction of multiple medications. A wide +-# comple6 on an /@ is present in arrhythmias arising from the ventricles or in the presence of conduction defects of the ventricles.
pg. 79
2>. A nurse is caring for a client during the recovery phase following a myocardial infarction. A cardiac catheterization( using the femoral artery approach( is performed to assess the degree of coronary artery thrombosis. hich nursing action following the procedure is unsafe for the client! a.
b.
/ncouraging the client to increase fluid intake
c.
Cnstructing the client to move the toes when checking circulation
d.
-esuming prescribed precatheterization medications
-ationale* orrect answer* A Cmmediately following a cardiac catheterization with femoral artery approach( the client should not fle6 or hypere6tend the affected leg to avoid blood vessel occlusion or hemorrhage. 7luids are encouraged to assist in removing the contrast medium from the body. Asking the client to move their toes assess motion( which could be impaired if a hematoma or thrombus were developing. The precatheterization medications are needed to treat acute and chronic conditions. Y#ome facilities may require the E% to reorder all preprocedural medications. heck your facility policy , procedures.Z ?eywords for this question are unsafe and femoral artery approach. 2. A nurse admits a client transferred from the emergency room. The client( diagnosed with a myocardial infarction( is complaining of substernal chest pain( diaphoresis and nausea. The first action by the nurse should be a.
Drder an /?@
b. Administer
morphine sulphate
c.
#tart an C;
d.
Eeasure vital signs
-atio* The correct answer is* I %ecreasing the client’s pain is the most important priority at this time. As long as pain is present there is danger in e6tending the infarcted area. Eorphine will decrease the o6ygen demands of the heart and act as a mild diuretic as well. #meltzer( #.. and Iare( I.@. &255>'. Eedical surgical nursing. &15th edition'. '. $urse’s drug guide. 9pper #addle -iver( $ew :ersey*
pg. 80
-atio* correct answer* A A prudent diet would be high in potassium because digo6in and furosemide can both deplete potassium. The diet needs to be low in sodium to prevent additional fluid overload with heart failure. hicken( potato( and cantaloupe are all potassiumrich foodsH options 2(4( and > are higher in sodium. 2=. A client is prescribed sublingual nitroglycerine for the treatment of angina pectoris. hat response from the client indicates that the client understands this medication! a. Bill the physician give me a year’s supply of nitroglycerine tablets!” b. BC will carry my nitroglycerine tablets in the inside pocket of my )acket( so they are always close.” c. BC usually take three of my nitroglycerine tablets at the same time. C find that they work better that way.” d. BC have a small labeled case for a few nitroglycerine tablets that C carry with me when C go out.” -atio* answer* % $itroglycerine loses potency over time when e6posed to light and heat. They should be kept cool( dry( and in a dark container. lients should get a new bottle every 3 months( and store them in a cool placeH tablets should be taken minutes apart( taking more that one tablet at a time can actually decrease the effectiveness of the drug and may cause severe hypotension. 2G. A client is being evaluated for a possible myocardial infarction. The nurse performs a 12lead /@ for an episode of new chest pain. The nurse will monitor for which sign of acute myocardial Cn)ury! a. #T depression b. #T elevations c. $ew + wave d. $ew 9 wave -atio* answer* I #T elevations indicate immediate myocardial in)uryH #T depressions indicate myocardial ischemiaH a + wave forms several days after a myocardial infarctionH a 9 wave is a sign of hypokalemia. 45. The nurse is caring for a client with new onset atrial fibrillation. The nurse anticipates that which of the following is a possible treatment for this dysrhythmia when it first develops! a. /6ternal pacemaker application b. Cnsertion of automatic internal cardiac defibrillator &AC%' c. #ynchronized cardioversion d. %efibrillation -atio* answer* #ynchronized cardioversion is most effective with ne w Konset atrial fibrillation.
pg. 81
-atio* answer* The best first action is to assess the client’s level of consciousness and assess if the ventricular tachycardia is perfusing the body &I<( pulse'. ith pulseless ventricular tachycardia( immediate defibrillation is performed by an A"# certified nurse. Cf the client has a good I< and pulse( is awake and alert( the nurse may administer lidocaine as prescribed or( in some cases( administer a precordial thump. 44. The physician has diagnosed a myocardial infarction on the basis of /@ changes for a client in the emergency room. The nurse is assessing the client frequently( and notes that the client seems forgetful( making the nurse repeat the e6planations about the /@ and noninvasive blood pressure monitors. The nurse concludes that the client’s response is most likely due to which of the following reasons! a. The client is showing signs of Alzheimer’s disease. b. The client is showing signs of fear and an6iety. c. $urses in the emergency room are too busy to properly ed6plain the purpose of equipment. d. Eemory lapses are common with clients e6periencing myocardial infarctions. -atio* answer* I An6iety and fear are common responses to a diagnosis of myocardial infarction because of the possibility of death. This prevents the client and family from absorbing the detailed e6planations about the care being provided. Eemory lapses are not a common symptom of myocardial infarction( and there is not adequate information to determine that this memory lapse is associated with Alzheimer’s disease. $urses in the emergency room a re able to e6plain procedures well to their clients. 5 percent of people over the age of 5 develop varicose veins and a ma)or risk factor is standing for long periods of time at work. The other responses do not address these concerns. 4>. hen assessing a client( the nurse determines the capillary refill time to be 8 seconds. The nurse determines the client may be e6periencing* a. $ormal signs of aging b. Cmpending stroke c. %ecreased cardiac output d. Fypokalemia -atio* answer* Ilanching of the nailbed for more than 4 seconds after of pressure may be indicate reduced arterial capillary perfusion( which may be an indication of decreased cardiac output. The other options are incorrect for the time frame indicated or do not apply. 4. After the first dose of an antihypertensive agent( your client suddenly becomes hypotensive. Jou should position the client* a. Cn a semi7owler’s position b. Cn a sidelying position c. Cn Trendelburg position d. ith legs elevated 45 degrees -atio* answer* % /levating the legs increases venous return to the heart and will assist in raising the blood pressure. A semi7owler’s position could lower the blood pressure even further. A sidelying position will have no beneficial effect( and the Trendelburg position could impair respirations by causing upward pressure on the diaphragm( by gravity. 43. The nurse is planning to instruct a client on the side effect of nifedipine &
pg. 82
vasodilation. %izziness is a common side effect because of orthostatic hypotension. lients need to be taught to change position slowly to prevent falls. 48. The nurse e6plains to a client that the goal of anticoagulation therapy in a client with a deep vein thrombosis is to* a. 5. hat is the correct reference point that the nurse would use to measure a client’s central venous pressure &;<'! a. -ight side( midclavicular line where it intersects with the fifth intercostals space. b. Eidau6illary line at the level of the fifth intercostals space. c. "eft midsternal border at the level of the fourth intercostals space. d. Anterior aspect of the thoracic cavity( left side at the f ifth intercostals space. -atio* answer* I The level of the right artrium must be determined( and each successive reading must be determined from the same point of reference on the client. This area is also called the phlebostatic a6is. >1. hat is an important nursing action in the safe administration of heparin! a. heck the prothrombin time &
pg. 83
without aspirating or massaging the area. 2. hile discussing her diagnosis of hypertension( a client asks the nurse how long she is going to have to take of the medications that have been prescribed. Dn what principle is the nurse’s response based! a. The client will be scheduled for an appointment in 2 monthsH the doctor will decrease her medications at that time. b. As soon as her blood pressure &I<' returns to normal levels( the clients will be able to stop taking her medications. c. to maintain stable control of her I<( the client will have to take the medications indefinitely. d. The nurse cannot discuss the medications with the clientH the client will need to talk with the doctor. -atio* answer* $oncompliance with blood pressure medications is a common p roblem in the treatment of hypertension. The client must understand that the only way to keep her blood pressure under control is to discontinue taking her medications. #he is not going to be able to discontinue the medications unless there is significant change in her condition as a result of weight loss( an e6ercise program( and Lor decreased stress. >4. The nurse is caring for a client who is 3 hours post partum. hat nursing actions are directed toward the prevention of postpartum thrombophlebitis! a. /ncourage the early ambulation and increased fluid intake. b. Iathroom privileges only and elevates the lower e6tremities. c. Administer anticoagulants and evaluate the clotting factors. d. /ncourage her to breastfeed the infant as soon as possible. -atio* answer* A /arly ambulation is the most effective and safe way to prevent thrombophlebitis with any type of client. This promotes venous return and prevents venous stasis. Anticoagulants are not routinely given postpartum unless there is another pathological condition present. The legs should be elevated when the client is in a sitting position. >>. A client diagnosed with peripheral vascular disease is being discharged. hich of the client’s risk factors would be most important to discuss! a. Drthostatic hypotension b. Age c. #moking d. Fypoglycemia -atio* answer* #moking causes vasoconstriction( which increases the complications brought about by <;%. This is a modifiable risk factor that will assist in increasing circulation. Age cannot be modified. The diabetic client needs to maintain good control of diabetic clients needs to maintain good control of diabetes( but <;% is a complication of the disease process. Drthostatic hypotension is not a factor in this client. >. 7our hours after aorticfemoral bypass graft surgery( the nurse assesses the client and is unable to palpate pulses in the operative leg. The client complains of pain in the leg. hat is the first nursing action! a. Eassage the leg and apply warm towels. b. /levated the leg and recheck the pulse. c. all the physician immediately. d. Assist the client to ambulate. -atio* answer* Dcclusion to the aorticLfemoral bypass graft is considered an immediate medical emergency( and physician notification is imperative. $o other nursing options would alleviate the problem. Eassaging the leg and having the ambulate would be contraindicated. The nurse should not wait to call the physician if the pulses cannot be palpated and the client is e6periencing pain.
pg. 84
>3. The nurse is administering a fluid challenge to a client in hypovolemic shock. hat nursing assessment data are most important in determining whether the client is responding favorably to the fluid replacement! a. 9rine output increases from 2 mlLhr to >5 mlLhr. b. systolic I< increases from =5 mm Fg to G5 mm Fg. c. entral venous pressure increases from cm F2D to 8cm F2D. d. The 8. The client returns to his room after a thoracotomy. hat will the nursing assessment reveal if hypovolemia from e6cessive blood loss is p resent! a. ;< of cm F2D and urine output of 25 mlLhr. b. :ugular vein distention with the head elevated > degrees. c. hest tube drainage of 5 mlLhr in the first > hours. d. Cncreased I< and increased pulse pressure. -atio* answer* A A lowrange ;< reading and the decrease in urine output would be associated with hypovolemia caused by hemorrhage. The decrease in urine output is reflective of poor renal p erfusion. >=. A client with hypertension asks the nurse what type of e6ercise she should do each day. hat is the nurse’s best response! a. /6ercise for an hour( but only three times a week. b. alk on the treadmill for > minutes every morning. c. Iegin walkingH increase distance as you tolerate it. d. /6ercise only in the morningH stop when you get tired. -atio* answer* A complication of hypertension is congestive heart failure( which may be first seen as dyspnea on e6ertion. The client should e6ercise as tolerated and stop when she gets tired or begins to have shortness of breath( regardless of the amount of time she has already e6ercised. >G. The nurse is monitoring an C; infusion of sodium nitroprusside &$ipride'. 7ifteen minutes after the infusion is started( the client’s I< goes from 1G5L125 mm Fg to 125LG5 mm Fg. hat is a priority nursing action! a. -echeck the I< and call the doctor. b. %ecrease the infusion rate and recheck the I< in minutes. c. #top the medication and keep the Cv open with % . d. Assess the client’s tolerance of the current level of I<. -atio* answer* I $ipride is a very powerful( rapid vasodilator. The nurse should decrease the infusion first before the pressure drops further( then assess the client’s response to decreased rate. Cf the client’s urinary output remains adequate and there is no dizziness or neurological change( then the client is probably tolerating the blood pressure level. 5. The nurse is teaching a client with hypertension about his antihypertensive medications( furosemide &"asi6' and captopril &capotene'. hat is important to include in this teaching! a. #tand up slowly to decrease problem with dizziness. b. Cncrease fluid intake because of increased loss of body fluids. c. hen you begin to feel better( the doctor will decrease your medications. d. #tay out of the sunshine and make sure you ha ve adequate sodium intake. -atio* answer* A A common side effect of a combination of hypotensive and diuretic medications is postural hypotension. Ct
pg. 85
is important to teach the client how to deal with it. The client should not increase intake of fluids because the diuretics are being given to decrease e6cess fluid. The client should decrease intake of sodium. hen the client is feeling better( the medications are working. 1. The nurse is preparing a client for a cardiac catheterization. hat is the best e6planation regarding the purpose of a cardiac catheterization with coronary angiography! a. /valuate the e6ercise tolerance. b. #tudy the conduction system. c. /valuate coronary artery blood flow. d. Eeasure the pumping capacity of the heart. -atio* answer* Cn cardiac catheterization with angiography( contrast dye is in)ected into the coronary arteries( which allows visualization of the coronary arteries and provides information of their patency. /6ercise tolerance is a stress test( and an electrocardoagram &/?@' is a study of the conduction system. degree angle. b. rackling sounds over the lower lobes with client in an upright position. c. Iradycardia( restlessness( and an increase in respiratory rate. d. :ugular vein distension with the client supine and the head of the bed flat. -atio* answer* A :ugular vein distension with the client in a sitting position( or with a >degree head elevation( is indicative of an increase in the central venous pressure. Eany clients e6perience )ugular vein distension when in a supine position( and it is not indicative of an increase in central venous pressure. Adventitious breath sounds( bradycardia( restlessness( and tachypnea are not directly associated with increased )ugular vein distention but may occur if the client develops rightsided heart failure. 4. Cn discharge planning for the client with F7( the nurse discusses the importance of adequate rest. hat information is most important! a. A warm( quite room is necessary. b. Ied rest promotes venous return. c. A hospital bed is necessary. d. Adequate rest decreases cardiac workload. -atio* answer* % Cn order to decrease pulmonary congestion and dyspnea( it is desirable to decrease cardiac workload by encouraging adequate restH the client should not e6ert himself to the point of fatigue. Ied rest does promote venous return( but that is not the purpose of bed rest in the client with F7. >. The nurse is evaluating a client’s progress. hat information would be indicative of a cardiac compensatory mechanism! a. ;entricular dilation( hypertrophy( and tachycardia. b. Fepatomegaly( splenomegaly( and cardiac hypertrophy. c. Feadache( drowsiness( and confusion( d. Iradycardia( restlessness( and h yperventilation. -atio* answer* A ompensatory mechanisms assist the failing heart to maintain an adequate cardiac output and blood flow to the tissues. These changes will initially maintain the blood flow in clients with a decrease in cardiac output. Cncrease in cardiac rate and size wit ventricular dilation all increase the cardiac output. . The nurse is taking the history from a client with F7 caused b y hypertension. The nurse identifies what data as supportive of the client’s medical diagnosis! a. %yspnea after walking one block.
pg. 86
b. weight loss of 1 pounds over last 4 months. c. "ower e6tremity edema in the evenings. d. dizziness and fainting when rising too quickly. -atio* answer* A %yspnea on e6ertion is a classic sign of left ventricular problems( regardless of the precipitating cause. "ower e6tremity edema is also characteristic but not as much as the dyspnea. 3. hat would be the home care goal for a client who has bacterial endocarditis! a. To begin an e6ercise regimen as soon as possible. b. To monitor urinary output. c. To continue antibiotic therapy. d. To decrease activity until pulse stabilizes. -atio* answer* Antibiotics &usually administered by C;
bowel sounds
b.
breath sounds
c.
temperature
d.
urine output
-ationale* The correct answer is number* Jou are correctR This finding indicates potential infection so temperature is essential to evaluate before notification of the care provider. =. "actulose &hronulac' has been p rescribed for a client with advanced liver disease. hich of the following assessments would the nurse use to evaluate the effectiveness of this treatment! a. An
increase in appetite
b. A
decrease in fluid retention
c. A
decrease in lethargy
d. A
reduction in )aundice
-ationale* The correct answer is number* 4 %ue to physiological changes in the elderly( as well as conditions such as dehydration( hyperthermia( immobility and liver disease( the metabolism of drugs may decrease. As a result( drugs can accumulate to to6ic levels and cause serious adverse reactions. G. An adult is scheduled to undergo an e6ploratory laparotomy in one hour. The nurse has )ust received the order to administer his preoperative medication. hat assessment is essential for the nurse before administering the medication! a.
The client’s ability to cough and deep breathe.
b. Any
drug hypersensitivity or allergy.
c.
The client’s understanding of the surgical procedure.
d.
hether the client’s family is present and supportive.
-atio* orrect Answer I 1. Fis ability to cough and deep breathe should be assessed earlier so that further teaching can take place if needed. Dnce preoperative medications are administered( the client’s ability to retain information is impaired. 2. A complete drug hstor! on e"er! preoper#t"e clent s essent#l bec#use o$ potent#l re#ctons to drugs% &rug h!persenst"t! #nd #llergc re#ctons must be #ssessed be$ore preoper#t"e medc#tons #re #dmnstered% 4. The client’s understanding should be assessed earlier so the nurse can do further
pg. 87
teaching if indicated. This should be done before the operative consent is signed. >. hile it is optimal to have the family present( medication should be given as ordered so that the timing of the peak action is most beneficial to the client. 35. A client asks the nurse how she can she live without her gallbladder. Cn order to respond to this client( the nurse must have which understanding of the hepatobiliary system! a. The liver produces about 1555 m" of bile per day b. The gallbladder produces about G5 m" of bile per day c. The liver concentrates bile more than 15 times d. the gallbladder dilutes and release bile -atio* orrect answer* A The liver produces between 855 and 1555 m" of bile per day. The gallbladder stores and concentrates bile and then releases it when stimulated( but is not an essential structure. 31. The client is diagnosed with obstructive )aundice. The nurse should ask the client about which of this manifestation! a. lear( pale urine b. laycolored stools c. "actose intolerance d. Ankle edema -atio* orrect answer* I laycolored stools indicate that no bile is reaching the intestine and suggest obstructive )aundice. Dption A and are unrelated to the question. Dption % can be present due to cardio vascular disease or as an indirect consequence of portal hypertension with impaired venous return( but there is insufficient information in the question to support the opinion. 32. A client has )aundice. hich of the following comfort measures would be appropriate fort he nurse to implement! a. Dffer hot beverages frequently b. /ncourage taking a hot bath or shower c. ?eep the air temperature at appro6imately 3=S to 85S 7 d. #uggest the use of alcohol Kbased skin lotion -atio* orrect answer* :aundice frequently causes pruritis. omfort measures include keeping the air temperature cool &3=S to 85S 7' and the humidity at 45 to >5 percent. Tepid baths ¬ hot' with colloidal agents decrease itching &option b'. 9se of an emollient lotion is also helpful( but anything drying should be avoided &option %'. Fot beverages &option A' are of no benefit as a comfort measure for pruritus due to )aundice. 34. The client has )ust had a liver biopsy. hich of the following nursing action would be the priority after the biopsy! a. Eonitor pulse and blood pressure every 45 minutes until stable then hourly up to 2> hours b. Ambulate every > hours for the first day as long as the client van tolerate this c. Eeasure urine specific gravity every = hours for the ne6t >= hours d. Eaintain $ h ours postbiopsy -atio* orrect answer* A omplications of liver biopsy include hemorrhage or accidental penetration of biliary canniculi. The nurse should assess for for sign of hemorrhage &increased pulse( decreased blood pressure' every 45 minutes for the first few hours and then hourly 2> hours. The client should be monitored for every > hours and remain on bed rest for 2> hours. 3>. "actulose &ephulac' is ordered for the client with cirrhosis. hich of the following serum laboratory test should the nurse monitor to determine if the drug is h aving the desired effect! a. Albumin b. Ammonia
pg. 88
c. #odium d. "actate -atio* orrect answer* I "actulose &ephulac' is a disaccharide la6ative used to decrease the absorption of ammonia in the intestines( thereby lowering the serum ammonia and resulting in improvement in hepatic encephalopathy. 3. The client is admitted to the hospital for possible cholelithiasis. hile taking the history( the nurse notes that the client has which of the following risk factors for development of gallstones* a. Ilack race b. Fistory of hypertension c. Age of 48 years d. 9se of oral contraception -atio* orrect answer* % 7actors that increase the risk of gallstone formation include female gender( aging( use of oral contraceptives( pregnancy( and rapid weight loss( high cholesterol level( and diseases of the ileum. 33. A client with cirrhosis is admitted to the hospital. hich of the following assessments made by the nurse would indicate the development of portal hypertension! a. Fematemesis b. Asteri6is c. /levated blood pressure d. onfusion -atio* orrect answer* A Cn cirrhosis( the liver becomes fibrotic( which obstructs the venous blood flow through the liver. This increases the vascular pressure in the portal system( and causes congestion in the spleen and development of variscosities in the esophagus. Ileeding esophageal varices are a complication of portal hypertension and result in vomiting of blood and possible hemorrhage and death. 38. The nurse is doing discharge teaching for a client who has cirrhosis and ascites. hich of the following foods used by the client as snacks should the nurse instruct the client to avoid! a. hole wheat bread b. ookies c.
pg. 89
a. The client has immunity to hepatitis I b. The client has active hepatitis I c. The client has resolving hepatitis I d. The client has had the hepatitis I vaccine. -atio* correct answer* I FIsAg is hepatitis surface antigen and is usually present before symptoms manifest. Ct indicates acute disease. The other options are incorrect conclusions regarding this test results. 85. The client who has esophageal varies is receiving a vasopressin infusion. hich of these findings would indicate a complication of this therapy! a. hest pain b. Tinnitus c. 7lushed skin d. . The nurse teaches the client with gastroesophageal reflu6 disease &@/-%' about ways to minimize symptoms. hich of the following statements made by the client indicates that more teaching is needed!
pg. 90
a. BC will be sure to drink tea instead of coffee.” b. BC will take a walk after C eat.” c. BC will try to eat smaller mmeals more frequently.” d. BC will sleep with the head of the bed elevated about 12 inches.” -atio* correct answer* the client with @/-% is encourage to eat smaller( lowfat frequent meals and to avoid lying down after eating. lients are instructed to not eat for at least 2 nhours before bedtime and avoid foods that decrease lower esophageal sphincter pressure( such as anything containing caffeine &coffee( tea( cola( chocolate' 8. The client with a gastric ulcer is admitted to the hospital. The nurse should assess the client for intake of which of these substances that increases the risk of developing a gastric ulcer! a. Aspirin b. #picy food c. Acetaminophen &Tylenol' d. offee -atio* correct answer* % 7amotidine &
pg. 91
d. #toma is draining fluid -atio* correct answer* I A healthy stoma is red to reddishpink( moist( and shiny. A stoma that appears dark red( bluish( or black indicates ischemia or necrosis. This finding must be reported immediately because the viability of the tissue is at risk. Dption and % are of no concern immediately. =5. A client who had a Iillroth C procedure is beginning to eat solid foods. The nurse should assess the client for the development of dumping s yndrome by determining the presence of which of the following! a. Iradychardia b. %iarrhea c. %yspnea d. oughing -atio* correct answer* I #ymptoms of dumping syndrome can occur within minutes to 4 hours after eating and include nausea( vomiting( tachycardia( diaphoresis( abdominal pain( syncope( and hyperactive bowel sounds. =1. The nurse is planning care for the client scheduled for gastroduodenoscopy and a barium swallows. hat will the nursing plan include! a. Anticipating the client will receive a lowresidue diet in the evening and then receive nothing by mouth &$ hours the test. c. /6plaining to the client that he will receive nothing by mouth &$ hours after the test to make sure his stomach can tolerate his food. d. %iscussing the general anesthesia and e6plaining that he will wake up in the recovery room. -atio* answer* A $. The nurse knows that a conclusive diagnosis of pyloric stenosis will be made by what test! a. A flat plate of the abdomen b. A colonoscopy. c. An altered electrolyte balance.
pg. 92
d. An upper @C series. -atio* answer* % An upper gastrointestinal series will indicate delayed gastric empty and an elongated pyloric channel. =. A client is admitted with duodenal ulcers. hat will the nurse anticipate the history to include! a. -ecent weight loss. b. Cncreasing indigestion after meals. c. Awakening with pain at night. d. /pisodes of vomiting. -atio* answer* %uodenal ulcers are characterized by high gastric acid secretion and rapid gastric emptying. 7ood buffers the effect of the acid. Therefore pain increases when the stomach is empty. =3. The nurse is conducting discharge d ietary teaching for a client with diverticulosis who is recovering from an acute episode of diverticulosis. The nurse would determine that the client understood his dietary teaching by which statement! a. BC will need to increase my intake of protein and comple6 carbohydrates to increase healing.” b. B
pg. 93
a. Figh levels of to6in e6posure. b. #ystemic changes in melanin production. c. inches d. > to 3 inches -atio* answer* Three to four inches is required for an adult to clear the rectal sphincter. G4. The nurse is caring for a client with chronic hepatitis I &FI;'. hat will the teaching plan for this client include! a. Avoid se6ual activity b. -eport any claycolored stools c. /at a highprotein diet d. . hich position is best for the client who has undergone abdominal cholecystectomy! a. #idelying position( to p revent aspiration b. #emi7owler’s position( to facilitate breathing c. #upine( to decrease strain on the incision line. d.
pg. 94
gloves are not indicated for assessment. G3. hile talking with a client with a diagnosis of endstage liver disease( the nurse noticed the client was unable to stay awake and seemed to fall asleep in the middle of a sentence. The nurse recognizes these symptoms to be indicative of what condition! a. Fyperglycemia b. Cncreased bile production c. Cncreased blood ammonia levels. d. Fypocalcemia -atio* answer* Cn endstage liver disease( the liver cannot break down ammonia byproducts of protein metabolism. The increased ammonia levels in the serum cross the bloodbrain barrier( causing uncontrolled drowsiness and confusion. G8. hat is the name of the accumulation of fluid in the peritoneal cavity in individual liver disease! a.
pg. 95
Accurate intake and output measurements are essential for clients receiving diuretics. diuretics. Fypokalemia( Fypokalemia( not hyperkalemia( is a frequent occurrence with diuretic therapy( and hypovolemia is a much greater risk with an increased urine output. lients should be weighed daily.
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NURSING PRACTICE TEST V 1. hich of the following responses by the nurse is the best e6ample of clarifying! a. BTell BTell me about what you were thinking before you went to talk to him.” b. Bhen did you first notice these feelings.” c. BCnstead of talking about your mother( C want to know how you feel.” d. BC’m having difficulty understanding. ould you e6plain that to me!” Answer% & Dption % is seeking clarification after the nurse was unable to understand the client. Dption A is e6ploring( option b is placing event in time or sequence( and option is focusing. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 23 2. An emergency psychiatric client presents with hyperthermia and une6plained loss of appetite. The nurse concludes that these symptoms are consistent with trauma to which area of the brain! a. Thalamus b. Fypothalamus c. erebrum d. erebellum Answer: B The hypothalamus is located in the deincephalon and Cs responsible for regulating temperature( appetite( and the integration of the autonomic nervous system. The thalamus &option A' is also located in the diencephalons( and is functions are concerned primarily with sensation. The cerebrum’s &option ' primary functions include higherorder thinking( abstract reasoning( visual functions( )udgment( memory( and sensory function. The cerebellum &option % ' is primarily responsible for balance and coordination. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 28 4. A client who is unable to cope with the sudden loss of a )ob and who is feeling confused and unable to make decisions is to be e6periencing which of the following! a. Adventitious crisis. b. Eaturational crisis c. #ituational crisis d. #ocial crisis Answer: C A situational crisis crisis is one that is often sudden and unavoidable. unavoidable. The stressful stressful event threatens threatens a person’s physical( emotional( or social integrity. An An adventitious crisis &option A' occurs from an accidental or sporadic event. A maturational maturational crisis &option I' occurs because of the situation occurring from the maturing process( such as in the adolescents or older adults. A social social crisis &option %' is a crisis that occurs within a social conte6t. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page >. >. Cn assessing a client in crisis( it is important for the nurse to first assist the client to identify* a. The client’s feeling b. The realistic nature of the event. c. Dthers who might be affected by the event d. An immediate action plan Answer: A Ct is helpful for the client to identify the feelings he or she has about the crisis in order to feel validated and begin work on the problem. The realistic nature of the event &option I'( others impacted by the events &option '( and a plan of action &option %' all are important ne6t steps once the client has identified hi or her own feelings. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page >. . hen working with the client in crisis( which of the following is the most important! a. Dbtaining a complete assessment of the client’s past history
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b. -emaining focused on the immediate problem c. %etermining whether the client may have had a part in the emergence of the crisis. d. Assisting Assisting the client to identify what is similar about crisis to other crises in the client’s life. Answer: B The nurse must remain focused on the immediate problem as there is not enough time and no need to delve into the complete past history &option A'. The client’s role in the current crisis &option ' is not relevant at this time( although it may be more important in learning to prevent future crisis situations. Assisting Assisting the client to identify that is similar about this crisis to other crisis &option %' may be a usual ne6t step. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page > 3. A 24yearold client who’s life partner died recently from complications of AC%# has )ust found out that he is FC; positive. Fe has been referred to the outpatient crisis unit from his doctor’s office because he Bshut down Bafter finding out his FC; status. The nurse meets with the client( provides comfort measures( and begins the assessment. An immediate priority is to evaluate if the client* a. Cs at risk for selfdirected violence b. Fas an altered thought process c. Fas a psychiatric provider d. Fas a fear of dying Answer: A hile some clients will not talk about thoughts of self harm( they will usually talk about suicidal thoughts when asked. #afety is priority and suicidal clients should not be left alone. Altered Altered thought process &option I' ( psychiatric providers &option ' and feeling toward dying &option %' are important assessment areas after the client’s safety has been ensured. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page >3. 8. A 2yearold 2yearold client who was admitted to the hospital days ago with ma)or depression and suicidal ideations is now preparing for discharge. hich of the following statements for the client demonstrates she has met one of her outcomeLevaluation measures” Bhen C go home* a. C’ll finally get some sleep b. C’ll be able to take care of my plants again.” c. C have a list of people that C can call if C start to feel poorly.” d. C’ll cook for myself.” Answer: C Dne desired outcome is for the client to have enhanced social support. The client should be sleeping better by discharge &option 1'. Taking Taking care of h er plants &option I' and cooking for herself &option %' do not n ecessarily indicate the client’s level of recovery. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page >8. =. A 4yearold 4yearold client has been diagnosed with attention deficitL hyperactivity disorder &A%F%'. hich medication is most likely to be prescribed! a. Amitriptyline &/lavil' b.
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following must be present in order to be diagnosed with ma)or depression! a. #uicidal thoughts or plans of suicide reported over at least the last 2 weeks b. Fistory of one depressive episode within the last 2 years c. "oss of appetite for more than 4 days d. "oss of interest in previously en)oyed activities. Answer: & %#EC;T- states that depressed mood or loss of interest in previously en)oyed activities must be present in order to qualify for a diagnosis of ma)or depression. Although each of the other options may be present with depression( these criteria must be met first. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page G4 15. The nurse should consider the irregularities in which of the following body systems before an accurate diagnosis of mood disorder can be assigned! a. Cntegumentary b. ardiovascular c. -espiratory d. /ndocrine Answer% & Any client who is being evaluated for a mood disorder should have a workup to rule out the possibility of a pathophysiologic disorder being overlooked. The body systems listed in options A( I( and would not have actual irregularities that would indicate the same signs and symptoms as mood disorders. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page G4 11. %uring an assessment interview the client tells the nurse( BC can’t stop worrying about my makeup. C can’t go anywhere or do anything unless my makeup is fresh and p erfect. C wash my face and put on fresh makeup at least once and sometimes twice an hour. BThis behavior is most likely a sign of a &n'* a. Acute stress disorder b. @eneralized an6iety disorder c. Dbsessivecompulsive disorder d. . 14. The most appropriate nursing diagnosis for a client with a somatoform disorder is* a. Altered role performance
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b. ?nowledge deficit* medication. c. Figh risk for violence( selfdirected d. Acute trauma reaction Answer: A #omatoform disorders result in altered role performance because the illness interferes with the usual responsibilities in life. There is not enough data to support knowledge deficit or risk for selfdirected violence. Acute trauma reaction does not e6ist. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 14. 1>. A female client with a 1year history of somatization disorder is to be discharged from her first psychiatric hospitalization. hich statement would indicate that nursing care has been effective! a. BC need to make sure that all of my medications are sent home with me.” b. BC see now that when C get stressed( my Obody speaks for me.” c. BEy family is good to me when C am sick like this.” d. BThere are so many illness that you nurses simply do not know about.” Answer: B The client’s statement indicates accurate awareness of mindbody interaction. #he does not suggest the symptoms are something to medicate( nor does she persist in identifying her illness as physical in origin( both of which are characteristic of somatization disorder. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 14. 1. The best initial approach to take with a self accusatory( guilt ridden client would be to* a. ontradict the client’s persecutory delusions b. Accept the client’s statements as the client’s beliefs. c. Eedicate the client when these thoughts are e6pressed. d. -edirect the client whenever a negative topic is mentioned ANS'ER: B The nurse must accept the client’s statement and beliefs as real to the client to develop trust and move into a therapeutic relationship. A K lients can’t be argued out of delusions K These feelings and thoughts are constantH this would result in an overdose. % K -edirecting the client’s conversation whenever negative topics are brought up adds to the client’s feelings that negative thoughts are correct. +9/#TCD$ U 88 p. 23= 13. A client treated for hypochondriasis has an upsetting phone conversation with her husband and subsequently requests an analgesic. BEy head is killing me( and C know there is a tumor in there somewhere or it wouldn’t hurt like this. BThe nurse’s best response is* a. BJou have no brain tumor. Ct is )ust your anger towards your husband.” b. BC’ll get your vital signs and then call your doctor if they are abnormal.” c. BJou must try not to rely on the pain pills so much since they are addictive.” d. BC’ll get your medication and then let’s talk about what )ust happened.” Answer: & The nurse should provide physical care for the client in a matteroffact manner and( at the same time( should help the client note how symptoms increase at the time of stress and can be a way of coping with stress. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 14. 18. A client with a somatization disorder has been attending group therapy. hich statement indicates that care has been effective! a. BC think C’d better get some pain pills. Ey back hurts from sitting in group.” a. BThe other women in the group have mental problemsR” b. BC haven’t said much( but C get a lot out of listening.” c. BC feel better physically )ust from getting a chance to talk.”
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Answer: & =. 1G. A client recently released from prison for embezzlement has a history of blaming others for his problems and becoming defensive and angry when criticized. Fe has e6pressed no remorse for his actions nor any response to his conviction. Fe claims his actions were )ustified since his employer did not treat him fairly. Fe is displaying characteristics of which personality disorder! a. $arcissistic a. Fistrionic b. Antisocial c. Iorderline Answer: C The described behavior reflects %#EC; diagnostic criteria for antisocial personality disorder. Fis behavior is not characteristic of individuals diagnosed with narcissistic( histrionic( or borderline personality disorder. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 138. 25. A 4yearold client is being interviewed by the nurse. The client’s history indicates that she has few friends( fears criticism and re)ection from others( and withholds information about her thoughts and feelings because she anticipates a negative reaction. Iased on the data( the nurse suspects that the client may have which of the following personality disorder! a. #chizotypal b.
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Answer: C Cndividuals diagnosed with antisocial personality disorder display decreased impulse control( can be irritable and aggressive( and lack remorse or their action. -ecognizing the potential risk for violence and maintaining client safety is the first priority of nursing care. The other nursing diagnoses do not reflect the behavioral pattern associated with individuals diagnosed with antisocial personality disorder. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 138. 22. The client diagnosed with borderline personality disorder tends to label certain persons on the staff as being good or bad. This behavior is an e6ample of* a. #econdary gain a. Acting out b. . A client with a diagnosis of schizophrenia is speaking in a group by putting rhyming words that have no meaning together. This speech pattern is known as* a. /chopra6ia a. /cholalia b. lang association c. $eologism Answer: C lang associations are association disturbances in which schizophrenic clients rhyme words in a sentence that make no sense. /chopra6ia is meaningless imitation of motions made by others &option A'. /cholalia is involuntary parrotlike repetition of words spoken by others &option I'. $eologism is the coining of a new word that is meaningless to anyone but the client &option %'. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 1=. 2. The nurse administering atypical antipsychotic medication is aware that they have been defined as having which of the following characteristics! a. Figh risk for tardive dyskinesia b. Einimal to no risk for e6trapyramidal effects c. /ffective in treating only positive symptoms of schizophrenia d. /ffective in treating only negative symptoms of schizophrenia. Answer: B Atypical antipsychotic medications are helpful in treating both negative &option %' and positive &option ' symptoms of schizophrenia. This class of medications has minimal to no risk for
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e6trapyramidal side effects( which includes tardive dyskinesia &option A'. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 1=. 23. A client taking antipsychotic medications for treatment of schizophrenia complains to the nu rse of feeling nervous. The nurse notices that the client is pacing the long hallway and is unable to remain still even when other clients are talking with him. This client is most likely e6periencing* a. Akathisia b. Akinesia c. %ystonia d. Tardive dyskinesia Answer: A Akathisia is an e6trapyramidal side effect of antipsychotic medications that may manifest as sub)ective and ob)ective restlessness. Akinesia &option I'( dystonia &option '( and tardive dyskinesia &option %' are also e6trapyramidal side effects of antipsychotic medications( but are not characteristic of this client’s symptoms. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 1=. 28. hat nursing diagnosis is most likely to be associated with a client diagnosed as having schizophrenia( disorganized type! a. Cmpaired verbal communication a. #leep pattern disturbance b. #ocial isolation c. #elfcare deficit Answer: A #chizophrenia( disorganized type( is characterized by disorganized speech patterns. Dther manifestations of this diagnosis include disorganized behavior and inappropriate affect. #leep pattern disturbance &option I'( #ocial isolation &option '( and #elfcare deficit &option %' are possible( but not classic for disorganized schizophrenia. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 138. 2=. hich of the following is considered to be a positive symptom associated with schizophrenia! a. Alogia b. Avolition c. #ocial withdrawal d. "oose association Answer: & "oose associations are considered to be a positive symptom associated with schizophrenia because they indicate a distortion or e6cess of normal functioning. Alogia &option A'( avolition &option I'( and social withdrawal &option ' are considered negative s ymptoms of schizophrenia. $egative symptoms indicate a loss or lack of normal functioning. $egative symptoms develop over time and hinder the client’s ability to endure life tasks. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 1=3. 2G. 7amily members have noticed that during the bath( a client tries to chew on a bar of soap. hich term best describes this behavior! a. Fyperactivity a. Fyperamorphosis b. Fyperorality c. Fyperemesis Answer: C %uring stage 2 of Alzheimer’s disease( clients have a need to place ob)ects in the mouth so they can taste or chew them( causing a health hazard. This behavior is called hyperorality. Fyperactivity is behavior characterized by decreased attention span( increased impulsivity( and emotional lability. Fyperamorphosis is the need to compulsively touch and e6amine every ob)ect
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in the environment. Fyperemesis is characterized by e6cessive vomiting. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 253. 45. The nurse administering which of the following medications to a client realizes that it increases the availability of acetylcholine in the synapse and leads to the recovery of some mental functioning for the clients with dementia! a. 7luo6etine &
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d. . A client comes to day treatment into6icated but says he is not. The nurse’s evaluation of his symptomatology reveals* a. %enial b. -eaction formation c. Transference d. ountertransference Answer: A Ct would not be unusual for a client who has severe addiction to come to da y treatment into6icated and deny it. %enial would cause a client to insist he or she is n ot into6icated or doesn’t have a problem with alcoholism despite concrete evidence of the problem. -eaction formation is a defense mechanism that causes people to act e6actly opposite to the way they feel &option I'. Transference is the unconscious process of displacing feelings for significant people in the past unto the nurse in the recent relationship &option '. ountertransference is the nurse’s emotional reaction to client base on feelings of significant people in the nu rse’s past &option %'. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 245. 4. The nurse working in obstetrics is reinforcing the physician health teaching about the risks of using substances during pregnancy. The client states that she only drinks a little beer and wine and would never use any dangerous drugs. The nurse then assess for use of which drug that causes the most physical( cognitive( and growth and developmental problems to the fetus! a. Ienzodiazepines b. Fallucinogens c. Alcohol d. ocaine Answer: C Alcohol use during pregnancy causes dysmorphic prenatal and postnatal difficulties and $# dysfunction. Dther substances cause significant health concerns as well( but not quite as many different kinds of problems &option( I and %'. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 241. 43. A young female presents for her school checkup. #he denies any medical problem or taking any medications( but she does acknowledge daily la6ative use. As the school nurse( what other symptoms or problems would you e6pect to find! a. Feadaches b. Altered sleep patterns c. Abnormal eating patterns d. Cntermittent chest pain. Answer: C "a6ative abuse is a method used to control weight by anore6ic and bulimics. /ating disorder clients may have cardiac rhythm disturbances but not necessarily chest pain &option %'( headaches &option A'( or altered sleep &option I' as a result of their disordered eating. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 242. 48. A nursing educator is teaching a group of community health nurses on moderating alcohol use. The nurse educator evaluates the group’s understanding of Bharm reduction” if the group is able to identify which group is not appropriate for Bharm reduction”!
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a. Cndividuals with tolerance b. Cndividuals with alcohol skills c. Cndividuals unable to control use d. Cndividuals with highdose use Answer: C lients who are unable to control their use or are unable to learn strategies to reduce intake andLor harm caused by their use( are not a good candidates for this approach. 5. A nurse is teaching a class on domestic violence to high school students. hich of the following statements by a student would indicate to the nurse that further teaching is needed! a. B;iolence often begins in a dating relationship.” b. BThe abuser will often apologize and promise to stop.” c. BCf you are educated and have money( abuse does not happen.” d. BAbusers are often e6cessively )ealous and possessive.” Answer: C /ducation and money do not make persons immune from violence. Ct crosses all socioeconomic lines. ;iolence does often begin in dating relationship &option A'H abusers do apologize and promise to stop &option I'H abusers are often e6cessively )ealous and possessive &option %'. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 23. >1. A 1yearold female student comes into the school nurse’s office asking to be tested for
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Ypregnancy. #he confides to the nurse that her boyfriend forced her to have se6 against her will. The most appropriate intervention by the nurse would be* a. Administer a pregnancy test. b. %o teaching on safe se6. c. %o teaching on birth control method. d. Cdentify the student’s immediate concerns. Answer: & The client has been raped and nurse needs to respond to the client’s immediate concerns. Testing &option A ' and teaching &option I and ' are secondary interventions. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 23. >2. An adult survivor of child abuse state( Bhy couldn’t C make him stop the abuse! Cf C were a stronger person( C would have been able to make him stop. Eaybe it was my fault he abused me.” Iased on this data( which would be the most appropriate nursing diagnosis! a. Cneffective family coping b. #ocial isolation c. hronic low selfesteem d. An6iety Answer: C Cnappropriate selfblame and feelings that a child could have stopped an adult’s abuse indicate a low selfesteem. Dption A( I( and % are possible diagnoses for adult survivors of abuseH there is not enough evidence supporting these diagnoses. Eore data would be needed. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 28. >4. The nurse is assessing a normal appearing 3yearold brought to the /mergency %epartment by the mother( who reports that the child vomits every time she eats. The child’s history reveals no positive findings as well as several previous similar visits. The mother is very concerned and insists that the child be admitted for a full @C workup. The nurse reports this as possible* a. An6iety disorder b. Iulimia nervosa c. Eunchausen’s syndrome by pro6y. d. #evere food allergies. Answer: C Eunchausen’s #yndrome by >. Cn counseling parents who have recently lost a child to death( it is important for the nurse to have already dealt with personal feelings about death( grief( and loss in children. This selfawareness would* a. Assist the nurse in helping the parents to e6press their grief fully. b.
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and difficult feelings. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 288. >. An AfricanAmerican family gathered around their dying grandmother’s bed refuses to allow a feeding tube to be removed and to stop feeding her( even after the healthcare team has stated that there was nothing else to be done. The nurse understands the family’s resistance to removal of the feeding tube is most likely caused by* a. The refusal to accept the finality of death b. Their need to try e very possible solution c. Their spiritual and cultural beliefs d. Their distrust of the healthcare system Answer: C #piritual beliefs and practices greatly influence both a person’s and family’s reaction to death and subsequent behavior. Although option A and I are correct( option is more correct because their spiritual and cultural beliefs dictate these behaviors. The family may or may not trust the healthcare system. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 288. >3. Dutcome criteria for successful counseling for the loss of a client’s spouse would include the client’s ability to* a. Avoid feelings about the spouse’s d eath b. Cmmediately memorialize the spouse c. Attend grief support groups d. Avoid sharing loss with significant others. Answer: C A ma)or outcome of grief counseling is to assist the client in sharing his or her loss and to accept support from others. Ct is critical for the spouse to share the feelings of loss and grief with others. Ct is too early to memorialize the spouseH the client must grieve the loss of client first. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 28=. >8. The nurse working with terminally ill clients understands that culture influences a client and family’s reaction to grief( loss( and death by* a. Cgnoring inappropriate grieving behaviors b. Tolerating any e6pression of grief or loss c. /stablishing symbolic rituals d. #upporting all individual responses. Answer: C ulture dictates acceptable customs and rituals used in the e6pression of grief( as well as( delineate the appropriate e6pression of feelings and behaviors. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 28=. >=. hen questioned by a client about what an advance directive or living will is( the nurse should respond that it states* a. hat treatment should be provided or omitted if the client becomes incapacitated b. The practitioners who are allowed to provide care at the end of life c. The caregiver’s role in providing care at the end of life d. The inheritance requirements for those relatives who are living. Answer: A Advance directives is a general term that refers to a client’s written instructions about future medical care( in the event that the client becomes unable to speak or is incapacitated. #pecific instructions about what medical treatment the client chooses to omit or refuse &e.g. ;entilator support' in the event that the client is unable to make those decisions is also included. The other options are not part of an advance directive. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 28=.
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>G. hen planning care for the client diagnosed with a chronic medical illness( the nurse can anticipate the client needing assistance with issues related to what area! a. Anger b. Anore6ia c. Apathy d. /uphoria Answer: A Dption A( anger( is included in the stages of grief as clients grieve for what has been lost. Although clients may e6perience multiple emotional feelings in response to diagnosis of life K changing medical illness( anger is one of the most common emotional responses because of the sudden and often dramatic change in lifestyle. Dption I and might occur but are not considered primary responses. Dption % is inappropriate and typically does not occur. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 2G>. 5. hat is an e6pected outcome related to increasing the level of social support for the terminally ill client! a. Cncreased number of friends b. Cncreased independence c. /6pression of emotion d. /6pression of hope Answer: C The client’s engagement with social supports woul hopefully results in increased ability to e6press emotions with others. Dption A does not necessarily indicate a strong level of social support. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 2G>. 1. A client e6pressed feelings of hopelessness and helplessness about her husband’s illness and her inability to care for him. Df the following issues( which would be the be st for the client to focus on first! a. Fer husbands present illness b. Fer past losses of significant others c. Fer loneliness and isolation in her new surroundings d. Fer future loss of her husband Answer: B The nurse should help the client identify her coping strategies and her e6perience with past losses in order to identify the client’s strengths and past coping strategies. This helps the client draw on e6periences of the past to help her cope and look at events rationally. 7ocusing on the client’s husband’s current illness &option A' will only keep the client struck in hopelessness and helplessness. 7ocusing on loneliness and desolation &option ' and the future loss of her husband &option %' may be appropriate( but the nurse and client need to first e6amine how the client has coped with the past losses. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 28. 2. hile assessing the defense mechanisms used by the client( the nurse recognizes the client’s use of defense mechanisms as adaptive when the* a. Eechanism used decreases an6iety b. lient seeks isolation to avoid stress. c. An6iety is e6pressed in behaviors d. lient can identify the stressor Answer: A The purpose of defense mechanism is to reduce an6iety levels and allow the client to function adequately. #eeking isolation to avoid stress &option I' is an unhealthy adaptive strategy. An6iety is e6pressed in behavior &option 'H however( that behavior can be harmful to clients or others. -ecognition of a stressor &option %' is important but may not be used in the client’s adaptive use
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of defense mechanism. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 28. 4. A nurse who practices subtle stereotyping or countertransference can e6pect the cultural assessment to* a. Ie sensitive to the unmet needs of the culture b. Ie open and honest( reflecting the client’s concerns c. -einforce the nurse’s pre)udices about the culture d. 7acilitate the treatment process. Answer: C #tereotyping arises out of negative biasesH stereotypes are images frozen in time that cause us to see what we e6pect to see( even when the facts differ from our e6pectations. ountertransference is the nurse’s emotional reaction to a client based on feelings for significant people in the nurse’s past. These would only reinforce the nurse’s pre)udices about the culture and cause the nurse to be insensitive( not sensitive( to the client’s need &option A'. hen governed by stereotyping or countertransference( the nurse is unable to be open and honest &option I' and unable to facilitate effective treatment &option % '. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 2=. >. The nurse should do which of the following as a primary nursing strategy for dealing effectively with the spiritual needs of clients! a. -efer clients to appropriate clergy b. larify own spiritual beliefs and values c. 9se a spiritual assessment tool. d. %iscuss own religiosity with the client. Answer: B The first priority of nurses in assisting clients to manage any area of their lives is to understand themselves and clarify their own spiritual beliefs and values. -eferring clients to appropriate clergy &option A' may be an effective intervention( but the nurse has adequate skills in meeting many spiritual needs of the clients. 9se of a spiritual assessment tool &option ' is important but should be used after the nurse has done selfe6ploration. %iscussing the nurse’s own religious beliefs &option %' is inappropriate and pro)ects the nurse’s own religious beliefs onto the client. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 2=. . Among the following symptoms reported by a grieving older adult( which should concern the nurse the most! a. Dccasional shortness of breath b. /6pressed thoughts of being better off dead c. @uilt about what was done at the time of a loved one’s death d. A morbid preoccupation with worthlessness Answer: B An older adult who e6presses thoughts of death has priority over other choices safety is always a priority. /veryone e6periences grief differently. Dlder adults often normally e6perience grief somatically &option A'. @uilt about actions or lack of action at the time of a loved one’s death &option ' is not uncommon. A morbid preoccupation with worthlessness &option %' is a concern( but safety takes priority. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 2=. 3.
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Answer: A Iehavior modification is quite effective with children and adolescents. The child is told what is e6pected( what is not acceptable( and consequences for undesirable behaviors. Dpen communication is effective( but a fle6ible approach may be confusing to the child &option I'. Dpen e6pression of feelings &option ' and assertiveness training &option %' are useful techniquesH however( they are more effective within a contrived environment. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 35. 8. The nurse assesses for which of the following common an6iety disorders among children! a. Dbsessivecompulsive disorder b. #imple phobia c. #eparation an6iety disorder d.
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disorder &A%F%'. An6iety &option A'( sleepwalking &Dption I'( and mania &option %' do not appear to be genetically transmitted for children. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 31. 31. hen assessing an apparently an6ious client( questions about an6iety should be* a. Abstract and nonthreatening b. Avoided until the an6iety disappears c. Avoided until the client brings u p the sub)ect d. #pecific and direct Answer: C Iecause of shame( clients should be reluctant to talk about an6iety. +uestions should be specific( direct( and individualized to the client. Dption A is incorrect because when a client is e6periencing an6iety abstract thinking and questions should be avoided. Dption I and are incorrect because the nurse should ask direct questions about the client’s an6iety. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 118. 32. hich of the following nursing diagnoses has the highest priority for an an6ious client! a. %efensive coping b. Cneffective denial c. -isk for loneliness d. -isk for selfdirected violence Answer: & #afety needs generally have a higher priority than psychosocial needs. Dption A( I( and are applicable nursing diagnoses for an6ious clients( but safety has the highest priority. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 118. 34. The best goal for a client learning a rela6ation technique is that the client will* a. onfront the source of the an6iety b. /6perience an6iety without feeling overwhelmed c. ?eep a )ournal as a selfmonitoring technique d. #uppress an6ious feelings Answer: B The goal of teaching calming techniques is to assist the client to learn to e6perience an6iety without feeling threatened and overwhelmed. -ela6ation therapy does not assist a client to confront sources of an6iety. "ikewise( keeping a )ournal is a selfmonitoring technique but is not used to measure the outcome of rela6ation. The goal is not to suppress feelings but to make them more manageable. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 118. 3>. The longterm goal( BThe client will learn new ways of coping with an6iety(” is most appropriate at which level of an6iety! a. Eild b. Eoderate c. #evere d.
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d. Cnvolve the client in a physical activity Answer: A To promote safety( nurses should stay with e6tremely an6ious clients. %uring a panic attack a client is unable to focus on teaching. G. 38. A client client is brought to the emergency room after a brutal physical assault. Although Although oriented and coherent( she cannot remember the assault o r events surrounding it. The priority intervention is to provide* a. 7requent reality orientation b. G. 3=. A client with %issociative Cdentity %isorder &%C%' suddenly begins to speak with a child’s vocabulary and voice. hich of the following is the most therapeutic response by the nurse! a. BJou must be feeling very needy.” b. BFere are some toys you might en)oy.” c. Ban you tell me what is happening!” d. BThis behavior keeps you from working on your problems.” Answer: C #witching often occurs with increases in an6iety. Asking Asking the client to e6plain more will help the nurse understand what is happening on a system level( and why the child alter was emergent. Dption A and % will increase an6iety. Dption I( although helpful( may not provide therapeutic outcome. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 1>G. 3G. The priority nursing diagnosis for a client e6periencing amnesia is* a. Figh risk for selfdirected violence b. G.
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85. A client reports episodic depersonalization e6periences. hich of the following is an appropriate goal of care! a. The client will describe three stress management techniques by day 2. b. The client will report no suicidal thoughts by week 1 c. The client will create a chart of all personalities by week 1 d. The client will state five personal strengths by day 2. Answer: A -educing an6iety through the use of stress management techniques will prevent depersonalization that is a reaction to high levels of an6iety. There There is no data to support suicidal thoughts or multiple identities. Cmproving selfconcept is helpful( but is not a priority when an6iety leads to dissociation. #ource* -eview and -ationale #eries for nursing Eental Fealth by Fogan and #mith page 118. 81. A nurse nurse employed in managed care system collaboration with the treatment team in monitoring a client’s progress from psychiatric inpatient care to a communityassisted living program. The role of the nurse can best be described as* a. Advanced practice nurse b. ase manager c. $urse manager d. #taff nurse Answer: B Cn a managed care system( the case manager is responsible for monitoring and ensuring of care( therefore collaborating with the treatment team. Although they provide different levels of care( both the staff nurse and the advanced practice primary care. A staff nurse involves supervision of other nursing personnel. #ource* "ippincott’s -eview #eries( Eental Fealth and
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edition( page 18. 8>. A nurse nurse is interacting with a client from a different cultural background. hich of the following implementations would the nurse use to provide sensitive care! a. onfronting issues of noncompliance b. 9se of therapeutic silence c. 9se of therapeutic touch d. ;alidation of communication Answer: & Ct is important for the nurse to frequently validate nurseclient communication to prevent cultural misunderstandings. onfronting noncompliance is inappropriate( because the nurse’s interpretation of this situation may be quite different from the client’s perspective. Therapeutic Therapeutic silence is importanceH however( validating communication will ensure culturally sensitive care. Touch Touch must be used in a cautious manner when trying to understand a client’s probable response. Touch Touch is not appropriate for all clients. #ource* "ippincott’s -eview #eries( Eental Fealth and . 88. The nurse would select which of the following approaches in order to best respond to a client in crisis! a. Iehavior approach b. Iehavior approach
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c. . 8=. hich of the following best describes the role of the nurse as a member of a crisis intervention team! a. Assistive role b. ollaborative role c. /ducative role d. Eanagerial role Answer: B The nurse works as a member of a health team and therefore needs to collaborate with other professionals in helping the individual resolve the crisis. The nurse may assist the client and may also teach the clientH however( the question is asking for the nurse’s role as a team member. The nurse may or may not be in a managerial role on the team. #ource* "ippincott’s -eview #eries( Eental Fealth and . 8G. hich of the following symptoms common in individuals e6periencing a crisis would a nu rse e6pect to assess! a. 7eeling of depersonalization( loose association( flat affect b. "ack of regard to social norms( apathy( hallucinations c. Eood swings( feeling of boundless energy( grandiose beliefs d. #omatic complaints( difficulty performing roles in life( poor concentration Answer: & The client who is in crisis has difficulty performing usual role in life because of the acute distress e6perienced. #omatic symptoms and poor concentration are also common because of the influence of the physiologic stress response. All of the remaining symptoms would commonly occur with the onset of a mental illness. They are not typical of the response of an individual to a crisis. #ource* "ippincott’s -eview #eries( Eental Fealth and
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=1. hen evaluating an imminent suicide risk( which of the following information given by the client would be most significant! a. At least a 2yaer history of feeling depressed more days than not b. %ivorced from spouse 3 months ago c. 7eeling loss of energy and appetite d. -eference to suicide as best solution to identified problems Answer: & An individual who talks about suicide as a solution to problems is at high risk. #uicide threats need to be taken seriously( because this individual does not see any other viable solutions to problems in living. All of the factors in the other answer choices would increase the client’s risk for depressionH however( actual statements about intent for suicide a re red flags for the nurse of imminent danger. #ource* "ippincott’s -eview #eries( Eental Fealth and . The husband of a client who has recently lost her )ob tells the clinic nurse that the client’s moods are constantly changing from e6tremely crying. As past of an immediate assessment of the family situation( the nurse should question the husband and wife about which of the following!
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a. The client’s academic and work history b. The specific history of psychopathology in client’s family c. The client’s specific symptoms( the duration of the symptoms( and the impact of the symptoms on the family d. The quality of couple’s marital relationship. Answer: C Assessment of the current family situation would include identifying the client’s symptoms( duration of symptoms( and unique impact on this particular family The assessment data related to answer choices &option A' and &option I' would be important( but the immediate assessment would be more specific to the current family crisis. The quality of marital relationship would be one aspect of the entire family situation. #ource* "ippincott’s -eview #eries( Eental Fealth and 3. =8. hen interacting with a mother and father who are divorcing( the nurse notes that the ma)or theme of parental disagreement is the b ehavior of their 14yearold daughter is irresponsible and
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lacks respect for his authority( whereas the mother cites the belief that a strict( authoritarian father rules the daughter. hich of the following family systems concepts is this situation an e6ample of! a. %ifferentiation of child b. /nmeshed relationship of parents c. #kewed relationship of parents d. Triangulation of child Answer: & The concept of triangles in a family system refers to the emotional configuration involving three family members or two members and an issue. Cn this situation( the conflict between the spouses is handled by deflecting attention away from the spouses and onto the child. %ifferentiation is the process of developing autonomy within the family system. /nmeshed relationship between spouses refers to overinvolvement with the e6pectation that everyone in the family think and act alike. A skewed relationship between spouses refers to one spouse who is dysfunctional and therefore roles are imbalanced. #ource* "ippincott’s -eview #eries( Eental Fealth and 3. ==. The parents of a client with schizophrenia e6press feelings of responsibility and blame for the client’s problem. hich of the following would the nurse providing family education do! a. Acknowledge parents’ responsibility b. /6plain the biologic nature of schizophrenia c. 3. =G. The school nurse is conducting a class on parentchild relationships to encourage functional family development. hich of the following things would the nurse teach the class about family resolution of conflict situations! a. hildren need to be encouraged to accept parental advice b. onflict generally does not arise in functional families’ c. %iscussion of conflict in a clear( direct way is important d. #olutions to conflicts should be provided by a neutral party. Answer: C Cn families( the ability to discuss difficult issues openly among members reflects healthy behavior. ommunication needs to be reciprocal between parents and children. Fealthy( functional families are defined not by the absence of conflict but by the manner in which it is handled. The family needs to work out solutions( not have solutions provided by another #ource* "ippincott’s -eview #eries( Eental Fealth and 8. G5. A 1Gyearold client admitted to a psychiatric inpatient facility for treatment of ma)or depression. The nurse learns that the client’s father has been on total disability for 4 months since an accident
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and that the mother has recently e6perienced relapse of a chronic alcohol problem. The nursing diagnosis established is 7amily coping* ineffective compromised related to situation stressors. hich of the following is the most appropriate goal &outcome criterion' for intervention! a. /stablish independence of the client from the family system b. /nsure the mother’s compliance with alcohol treatment c. Cdentify ownership of problem as belonging to parents. d. 9se family and e6ternal resources to cope with problems. Answer: & There are several problems currently facing this family( including the father’s disability( the mother’s relapse( and the child’s hospitalization. Eobilizing and using resources from both inside the family &strengths' and outside the family &support s ystems' will constitute the most appropriate outcome for the nursing diagnosis. Autonomy or differentiation of self takes place within the family system and does not mean that independence from the family system occurs. /nsuring the mother’s compliance with alcohol treatment and identifying ownership of the problem as belonging to the parents are incorrect responses( because each member of the family is involved in the current problems. #ource* "ippincott’s -eview #eries( Eental Fealth and 3. G1. A client with benign essential hypertension has been referred for biofeedback training. hich of the following criteria would the nurse use to evaluate the client’s success with this method! a. The client states that his stress level is under control. b. The client’s blood pressure is normal while on a decreased dose of antihypertensive medication c. The client uses rela6ation methods on a regular basis. d. The client follows recommended diet and medication plan without deviation. Answer: B #uccessful use of biofeedback enables the client to modify physiologic responses to stress( including blood pressure. A decreased need for an antihypertensive medication is an ob)ective measurement of effectiveness. Although answer choices A and are outcomes of stress management( they are not specific for biofeedback. Answer choice % would be a successful outcome of the medical treatment program. #ource* "ippincott’s -eview #eries( Eental Fealth and
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b. To maintain focus on importance of nutrition c. To prevent purging behaviors d. To reinforce behavioral contact Answer: C The client may e6perience increased an6iety during treatment and therefore may resume behaviors designed to prevent weight gain( such as vomiting or e6cessive e6ercise. Although the other answer choices are important areas for nursing intervention( they do not provide the rationale for remaining with a client for one hour after eating. #ource* "ippincott’s -eview #eries( Eental Fealth and . The initial treatment priority for a client hospitalized for anore6ia nervosa on a special eating disorder unit is a. To determine current body image b. To identify family interaction pattern c. To initiate refeeding program d. To promote client independence Answer: C The physical need to reestablish nearnormal weight takes p riority because of the physiologic( lifethreatening consequences of anore6ia. The other answer choices are all important aspects of treatment( but they are not the highest priority in initial treatment. #ource* "ippincott’s -eview #eries( Eental Fealth and p. 232 G8. %uring an interview with the parents of an adolescent female( the nurse notices that her father
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continually defends and makes e6cuses for all his daughter’s actions whereas her mother seems to feel her daughter is )ust lazy and that there is nothing wrong with her that she couldn’t change with some effort. The nurse recognizes that the dynamic used by the family is known as* a. oalition b. -esignation c. #capegoating d. -eaction 7ormation ANS'ER: A The father is siding with his daughter and supports her whereas the mother accuses her of negative behaviorH this is an e6ample of a coalition or allianceH both the mother and the father maybe in denial. I. -esignation is evident when someone gives up. K #capegoating is when an individual is labeled or blamed by other family members as the cause of the family’s problems % K -eaction formation is a defense mechanism that causes individuals to overtly behave in a manner that is e6actly opposite to what they really feel in an attempt to conceal unacceptable feelings. #D9-/* ED#IJ’s -/;C/ +9/#TCD$# 7D- TF/ $"/0 -$ /0AEC$ATCD$ IJ #A0TD$( 5 p. 23 GG. The psychotherapeutic theory that uses hypnosis( dream interpretation( and free association as methods to release repressed feelings is the* a. Iehaviorist Eodel b.
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