Comprehensive Exams 1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oytocin !"itocin# to augment her contractions. $hich of the following is the most important aspect of nursing intervention at this time% A. Timing and recording &. (. "reparing for an ). (hec*ing the perineum for bulging.
length emergency
of
contractions. 'onitoring. cesarean birth.
2. A client client who hallucinates is not in touch with reality. +t is important for the nurse to, A. +solate the &. 'aintain (. Orient the client ). stablish a trusting relationship.
client a to
from other patients. safe environment. timeplaceand person.
3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. $hich of the following would the nurse give to the child% A. &. (. ). A glass of mil*
(ola /ellow (ool
with noncitrus cherry
ic e 0ello oolAid
. The physician ordered "henylephrine !4eoSynephrine# nasal spray to a 13yearold client. The nurse caring to the client provides instructions that the nasal spray must be used eactly as directed to prevent the development of, A. +ncreased &. (. ). Tinnitus and diplopia.
nasal 4asal &leeding
congestion. polyps. tendencies.
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should, A. "lace the client in a private &. $ear an 4 65 respirator when caring for the (. "ut on a gown every time when entering the ). )on a surgical mas* with a face shield when entering the room.
room. client. room.
7. $hich of the following is the most freuent cause of noncompliance to the medical treatment of openangle glaucoma% A. The freuent nausea and vomiting accompanying use of miotic drug. &. 9oss of mobility due to severe driving restrictions. (. )ecrea )ecreased sed light light and near nearvis vision ion accomm accommoda odatio tion n due to miotic miotic effect effectss of pilocar pilocarpin pine. e. ). The painful and insidious progression of this type of glaucoma. :. +n the morning shift- the nurse is ma*ing rounds in the nursing care units. The nurse enters in a client;s room and notes that the client;s tube has become disconnected from the "leurovac. $hat would be the initial nursing action% A. Apply pressure directly over &. (lamp the chest tube near (. (lamp the chest tube closer to ).
the the the
incision incision drainage
site. site. system.
8. $hich of the following complications during a breech birth the nurse needs to be alarmed% A. &. (. ). =mbilical cord prolapse.
Abruption (aput "athological
placenta. succedaneum. hyperbilirubinemia.
6. The nurse is caring to a client diagnosed with severe depression. $hich of the following nursing approach is important in depression% A. "rotect the client against harm &. "rovide the client with motor outlets for aggressive(.
ing preoccupation with elimination- nourishment- and sleep.
to hostile
others. feelings. contacts.
1?. A 3monthold client is in the pediatric unit. )uring assessment- the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not, A. &. "ic* (. ). @old the head up.
up
Sit and
hold
a
up. rattle. over.
11. The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not *nowthe physician or the client to whom the order pertains. The nurse should,
A. As* the the physi physici cian an to call call bac* bac* afte afterr the the nurse nurse has has read read the the hosp hospit ital al poli policy cy manua manual. l. &. Ta*e the telephone order. (.
? 2? 35
years years years
of of of
age. age. age.
1. The emergency department has shortage of staff. The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. $hat should the staff nurse epect under these conditions% A. The The floa floatt staf stafff nurs nursee will will be info inform rmed ed of the the situ situat atio ion n befo before re the the shif shiftt begi begins ns.. &. The staff nurse will be able to negotiate the assignments in the emergency department. (. (ross training will be available for the staff nurse. ). (lient assignments will be eually divided among the nurses. 15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is receiving digoin. $hich of the following uestions will be as*ed by the nurse to the parents of the child in order to assess the client;s c lient;s ris* ris* for digoin toicity% A. @as he been eposed to any childhood communicable diseases in the past 23 wee*s%B &. @as he been ta*ing diuretics at home%B (. )o any of his brothers and sisters have history of cardiac problems%B ). @as he been going to school regularly%B
17. The nurse noticed that the signed consent form has an error. The form states- Amputation of the right legB instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. $hat should the nurse do% A. (all the physician to reschedule &. (all the nearest relative to come in to sign (. (ross out the error and initial ). @ave the client sign another form.
the surgery. a new form. the form.
1:. The nurse in the nursing care unit chec*s the fluctuation in the waterseal compartment of a closed chest drainage system. The fluctuation has stopped- the nurse would, A. Cigorously strip the tube to dislodge a clot. &.
and Cision
Tinnitus vomiting problem
2?. $hich $hich of the follow following ing treatm treatment ent modali modality ty is appropr appropriat iatee for a client client with with paranoi paranoid d tendency% A. &. (. ). Family therapy.
Activity +ndividual Eroup
therapy. therapy. therapy.
21. The client with rheumatoid arthritis is for discharge. +n preparing the client for discharge on prednisone therapy- the the nurse should advise the client to,
A. $ear sunglasses if epose osed to bright light for an ete tended ded period of time. &. Ta*e oral preparations of prednisone before meals. (. @ave periodic complete blood counts while on the medication. ). 4ever stop or change the amount of the medication without medical advice. 22. A pregnant client tells the nurse that she is worried about having urinary freuency. $hat will be the most appropriate nursing response% A. Try Try using using egel egel !peri !perineal neal## eerci eercises ses and limiti limiting ng fluids fluids before before bedtim bedtime. e. +f you have have freuency freuency associated associated with feverfever- pain on voiding- or blood in the urine- call your doctorDnurse doctorDnurse midwife. &. "lacental progesterone causes irritability of the bladder sphincter. /our symptoms will go away after the baby comes.B (. "regnant women urinate freuently to get rid of fetal wastes. 9imit fluids to 19Ddaily.B ). Freuency is due to bladder irritation from concentrate urine and is normal in pregnancy. +ncrease your daily fluid inta*e to 39.B 23. $hich of the following will help the nurse determine that the epression of hostility is useful% A. pression of anger dissipates &. nergy from anger is used to accomplish what (. pression intimidates ). )egree of hostility is less than the provocation.
the needs to
energy. be done. others.
2. The nurse is providing an orientation regarding case management to the nursing students. $hic $hich h chara charact cter eris isti tics cs shoul should d the the nurs nursee incl includ udee in the the disc discus ussi sion on in under underst stan andi ding ng case case management% A. 'ain obGective is a written plan that combines disciplinespecific processes used to measure outcomes of care. &. 'ain purpose is to identify epected client- family and staff performance against the timeline for clients with the same diagnosis. (. 'ain focus is comprehensive coordination of client care- avoid unnecessary duplication of servicesimprove resource utili>ation and decrease cost. ). "rimary goal is to understand why predicted outcomes have not been met and the correction of identified problems. 25. 25. The The physi physici cian an orde orders rs a dose dose of +C phenyto phenytoin in to a chil child d clie client nt.. +n prep prepar arin ing g in the the administration of the drug- which nursing action is not correct% A. +nf +nfuse use the the phen pheny ytoin oin into nto a smal smalller vei vein to prev preven entt pur purple ple glov glovee synd syndrrome. ome. &. (hec* the phenytoin solution to be sure it is clear or light yellow in color- never cloudy. (. "lan to give phenytoin over 3?7? minutes- using an inline filter. ). Flush the +C tubing with normal saline before starting phenytoin.
27. The pregnant woman visits the clinic for chec* Hup. $hich assessment findings will help the nurse determine that the client is in 8wee* gestation% A. 9eopold &. Fundal (. "ositive radioimmunoassay ). Auscultation of fetal heart tones.
test
!<+A
maneuvers. height. test#.
2:. 2:. $hich hich of the the foll follow owin ing g nurs nursin ing g inte interv rven enti tion on is esse essent ntia iall for for the the clie client nt who who had had pneumonectomy% A. 'edicate for pain only wh e n &. (onnect the chest tube to waterseal (. 4otify the physician if the chest drainage eceeds ). ncourage deep breathing and coughing.
needed. drainage. 1??m9Dhr.
28. 28. The The nurs nursee is prov provid idin ing g a healt health h teac teachi hing ng to a grou group p of paren parents ts regar regardi ding ng (hla (hlamy mydi diaa trachomatis. The nurse is correct in the statement- (hlamydia trachomatis is not only an intracellular bacterium that causes neonatal conGunctivitis- but it also can ca use, A. )iscoloration of &. "neumonia (. Snuffles and ). (entral hearing defects in infancy.
baby in rhagades
and
adult the
in
the
teeth. newborn. newborn.
26. The nurse is assigned to care to a 1:yearold male client with a history of substance abuse. The client as*s the nurse- @ave you ever tried or used drugs%B The most correct response of the nurse would be, A. /esonce &. 4o+ (. $hy do you ). @ow will my answer help you%B
+ don;t want
to
tried thin* *now
grass.B so.B that%B
3?. $hich of the following describes a health care team with the principles of participative leadership% A. ach member of the team can independently ma*e decisions regarding the client;s care without necessarily consulting the other members. &. The physician ma*es most of the decisions regarding the client;s care. (. The team uses the epertise of its members to influence the decisions regarding the client;s care. ). 4urses decide nursing careI physicians decide medical and other treatment for the client.
31. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. $hich $hich hormon hormonee- normal normally ly secret secreted ed during during the postpar postpartum tum period period-- influe influences nces both both the mil* mil* eGection refle and uterine involution% A. &. (. ).
Oytocin. strogen. "rogesterone.
32. One staff nurse is assigned to a group of 5 patients for the 12hour shift. The nurse is responsible for the overall planning- giving and evaluating care during the entire shift. After the shift- same responsibility will be endorsed to the net nurse in charge. This describes nursing care delivered via the, A. &. (. ). Team method.
"rimary
nursing (ase Functional
method. method. method.
33. The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. $hile waiting for the ambulance- the nurse will anticipate emergency care to include assessment for, A. Eas &. (. ). Fluid volume ecess.
echange
impairment. @ypoglycemia. @yperthermia.
3. 'ost couples couples are using naturalB naturalB family planning methods. 'ost accidental pregnancies pregnancies in couples couples preferred preferred to use this this method method have have been been relate related d to unprot unprotect ected ed interc intercour ourse se before before ovul ovulat atio ion. n. $hich $hich of the the foll follow owin ing g fact factor or epl eplai ains ns why preg pregnan nancy cy may be achie achieve ved d by unprotected intercourse during the preovulatory period% A. &. (. ). Secretory endometrium.
Ovum Tubal Spermato>oal
viability. motility. viability.
35. An older adult client wa*es up at 2 o;cloc* o;cloc* in the morning and comes to the nurse;s nurse;s station station saying- + am having difficulty in sleeping.B $hat is the best nursing response to the client% A. +;ll give you a sleeping pill to &. "erhaps you;d li*e to sit here at (. $ould you li*e me to show ). $hat wo*e you up%B
help you get more sleep now.B the nurse;s station for a while.B you where the bathroom is%B
37. The nurse is ta*ing care of a multipara who is at 2 wee*s of gestation and in active laborher membra membranes nes ruptur ruptured ed sponta spontaneou neously sly 2 hours hours ago. ago. $hile $hile auscul auscultat tating ing for the point point of maimum intensity of fetal heart tones before applying an eternal fetal monitor- the nurse counts 1?? beats per minute. The immediate nursing action is to, A. Start oygen by mas* to reduce &. amine the woman for signs of a (. Turn the woman on her left side to increase ). Ta*e the woman;s radial radial pulse while still auscultating the F@<.
fetal distress. prolapsed cord. placental perfusion.
3:. The nurse must instruct a client with glaucoma to avoid ta*ing overthecounter medications li*e, A. &. (. ). Salicylates.
Antihistamines. 4SA+)s. Antacids.
38. A male client is brought to the emergency department due to motor vehicle accident. $hile monitoring the client- the nurse suspects increasing intracranial pressure when, A. (lie (lient nt is orie orient nted ed when when arou arouse sed d from from slee sleepp- and and goes goes bac* bac* to slee sleep p imme immedi diat atel ely y. &. &lood pressure is decreased from 17?D6? to 11?D:?. (. (lient refuses dinner because of anoreia. ). "ulse is increased from 8867 with occasional s*ipped beat. 36. The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. $hich of the following following statement by the nurse Gs correct% A. The The spou spouse se-- but not not the the rest rest of the the family family-- may may overr overrid idee the the advan advance ce dire direct ctiv ive. e.BB &. An advance directive is reuired for a do not resuscitateB order.B (. A durable power of attorney- a form of advance directive- may only be held by a blood relative.B ). The advance directive may be enforced even in the face of opposition by the spouse.B ?. A client diagnosed with schi>ophrenia is shouting and banging on the door leading to the outside- saying- + need to go to an appointment.B $hat is the appropriate nursing intervention% A. Tell the client that he cannot &. +gnore this (. scort the client going bac* ). As* the client to move away from the door.
bang
on
into
1. $hich of the following action is an accurate ac curate tracheal suctioning techniue%
the the
door. behavior. room.
A. 25 seconds of continuous suction during &. 2? seconds of continuous suction during (. 1? seconds of intermittent suction during ). 15 seconds of intermittent suction during catheter withdrawal.
catheter catheter catheter
insertion. insertion. withdrawal.
2. The client;s Gaw and chee*bone is sutured and wired. The nurse anticipates that the most important thing that must be ready at the bedside is, A. &. (. ). $ire cutters.
Suture Tracheostomy Suction
set. set. euipment.
3. A mother is in the third stage of labor. $hich of the following signs will help the nurse determine the signs of placental separation% A. The uterus &. The umbilical (. The fundus appears ). 'ucoid discharge is increased.
becomes cord
is at
the
globular. shortened. introitus.
. After therapy with the thrombolytic alteplase !t"A. - what observation will the nurse report to the physician% A. 3J &. (hange in (. ). @eart rate of 1??Dbpm.
level of Occasional
peripheral consciousness
and
pulses. headache. dysrhythmias.
5. A client who undergone left nephrectomy has a large flan* incision. $hich of the following nursing action will facilitate deep breathing and coughing% A. "ush fluid administration to loosen respiratory secretions. &. @ave the client lie on the unaffected side. (. 'aintain the client in high Fowler;s position. ). (oordinate breathing and coughing eercise with administration of analgesics. 7. The community nurse is teaching the group of mothers about the cervical cervical mucus method of natural family planning. $hich characteristics are typical of the cervical mucus during the fertileB period of the menstrual cycle% A. &. Thin(. ). /ellow and stic*y.
Absence clearThic*-
of good
ferning. spinnbar*eit. cloudy.
:. A client with ruptured appendi had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semiFowler;s position primarily to, A. Facilitate movement and reduce complications &. Fully aerate the (. Splint the ). "romote drainage and prevent subdiaphragmatic abscesses.
from
immobility. lungs. wound.
8. $hich of the following will best describe a managemen t function% A. $riting a letter to the editor of &. 4egotiating labor (. )irecting and evaluating nursing ). plaining medication side effects to a client.
a
nursing staff
Gournal. contracts. members.
6. The parents of an infant client as* the nurse to teach them how to administer (ortisporin eye drops. The nurse is correct in advising the parents to place the drops, A. +n the middle of the lower conGunctival &. )irectly onto the (. +n the outer canthus of ). +n the inner canthus of the infant;s eye.
sac
of the infant;s eye. infant;s sclera. the infant;s eye.
5?. The nurse is assessing on the client who is admitted due to vehicle accident. $hich of the following findings will help the nurse that there is internal bleeding% A. Fran* blood &. Thirst (. Abdominal ). (onfusion and altered of consciousness.
on and
the
clothing. restlessness. pain.
51. The nurse is completing an assessment to a newborn baby boy. The nurse observes that the s*in of the newborn is dry and fla*ing and there are several areas of an apparent macular rash. The nurse charts this as, A. &. (. ). 'ilia
+cterus 'ultiple rythema
neonatorum hemangiomas toicum
52. The client is brought to the emergency department because of serious vehicle accident. After an hour- the client has been declared brain dead. The nurse who has been with the client must now tal* to the family about organ donation. $hich of the following consideration is necessary% A. +nclude as many family &. Ta*e the family (. )iscuss life ). (larify the family;s understanding of brain death.
members to support
as the
possible. chapel. systems.
53. The nurse is teaching eercises that are good for pregnant women increasing tone and fitness and decreasing lower bac*ache. $hich of the following should the nurse eclude in the eercise program% A. Stand with legs apart and touch hands &. Ten minutes of wal*ing per day with (. Ten minutes of swimming or leg ). "elvic roc* eercise and suats sua ts three times a day.
to floor three times per day. an emphasis on good posture. *ic*ing in pool per day.
5. A client with obsessivecompulsive behavior is admitted in the psychiatric unit. The nurse ta*ing care of the client *nows that tha t the primary treatment goal is to, A. "rovide &. Support but (. "rohibit ). "oint out the behavior.
limit
the the
distraction. behavior. behavior.
55. After ileostomyileostomy- the nurse epects that the drainage appliance will be a pplied to the stoma, A. $hen the client is able to &. 2 hours laterwhen (. +n the operating room after ). After the ileostomy begins to function.
begin the the
selfcare swelling ileostomy
procedures. subsided. procedure.
57. A female client who has a 28day menstrual cycle as*s the community health nurse when she get pregnant during her cycle. c ycle. $hat will be the best nursing response% A. +t is impossible to determine the fertile period reliably. So it is best to assume that a woman is always fertile. &. +n a 28day cycle- ovulation occurs at or about day 1. The egg lives for about 2 hours and the sperm live for about :2 hours. The fertile period would be approimately between day 11 and da y 15. (. +n a 28 day cycle- ovulation ovulation occurs at or about day 1. The egg lives for about :2 hours and the sperm live for about 2 hours. h ours. The fertile period would be approimately between da y 13 and 1:. ). +n a 28day cycle- ovulation occurs 8 days before the net period or at about day 2?. The fertile period is between day 2? and the beginning of the net period.
5:. $hich of the following statement describes the role of a nurse as a client advocate% A. A nurse may override clients; wishes for their own good. &. A nur nurse has the mora oral obli bligat gation to preve event har harm and do well for clients. (. A nurse helps clients gain greater independe ndence nce and selfdetermi rminat nation. ). A nurse measures the ris* and a nd benefits of various health situations while factoring in cost. 58. A community health nurse is providing a health teaching to a woman infected with herpes simple 2. $hich of the following health teaching must the nurse include to reduce the chances of transmission of herpes simple 2% A. Abstain from intercourse until lesions &. Therapy is (. "enicillin is the drug of choice for ). The organism is associated with later development of h ydatidiform mole.
heal.B curative.B treatment.B
56. The nurse in the psychiatric ward informed the male client that he will be attending the 6,?? A' group therapy sessions. The client tells the nurse that he must wash his hands from 6,?? to 6,3? A' each day and therefore he cannot attend. $hich concept does the nursing staff need to *eep in mind in planning nursing intervention for this client% A. )epression underlines ritualistic behavior. &. Fear and tensio tensions ns are often often epres epressed sed in disgui disguised sed form form through through symboli symbolicc proces processes ses.. (.
+ntellectuali>ation. Suppression.
71. $hich of the following situations cannot be delegated by the registered nurse to the nursing assistant% A. A postoperative client wh o is stable needs &. (lient in soft restraint who is very agitated (. A confused elderly woman who needs assistance ).
to ambulate. and crying. with eating.
72. +n the admission care unit- which of the following client would the nurse give immediate attention%
A. A client who is 3 days postoperative with left calf &. A client who is postoperative hip pinning who is complaining of (. 4ew admitted client with chest ). A client with diabetes who has a glucoscan reading of 18?.
pain. pain. pain.
73. A couple see*s medical advice in the community health care unit. A couple has been unable to conceiveI the man is being evaluated for possible problems. The physician ordered semen analys analysis. is. $hich $hich of the follow following ing instr instruct uction ionss is correc correctt regard regarding ing collec collectio tion n of a sperm sperm specimen% A. (ollect a specimen at the clinic- place in iced container- and give to laboratory personnel immediately. &. (oll (ollect ect spec specim imen en afte afterr 8:2 8:2 hour hourss of absti abstine nence nce and and brin bring g to clin clinic ic with within in 2 hour hours. s. (. (ollect specimen in the morning after 2 hours of abstinence and bring to clinic immediately. ). (ollect specimen at night- refrigerate- and bring to clinic the net morning. 7. The physician ordered &etamethasone to a pregnant woman at 3 wee*s of gestation with sign of preterm labor. The nurse epects that the drug will, A. &. Suppress (. Stimulate the ).
Treat labor production
infection. contraction. surfactant.
of
75. A tracheostomy cuff is to be deflated- which of the following nursing intervention should be implemented before starting the procedures% A. Suction &. @ave (. ncourage ). )o a pulse oimetry reading.
the
trachea the
deep
and
mouth. available. coughing.
obdurator breathing and
77. A client client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that, A. Eloves are worn when handli dling the cli client;s tissueue- ecreti etions- and linen. &. &oth client and attending nurse must wear mas*s at all times. (. 4urse and visitors must wear mas*s until chemotherapy is begun. (lient is instructed in cough and tissue techniues. ). Full isolationI that is- caps and gowns are reuired during the period of contagion. 7:. A client with lung cancer is admitted in the nursing care unit. The husband wants to *now the condition of his wife. @ow should the nurse respond to the husband% A. &.
Find Suggest
out that
what he
information discuss it
he with
already his
has. wife.
(.
to
the
doctor.
78. A hospitali>ed client cannot find his hand*erchief and accuses other cient in the room and the nurse of stealing them. $hich is the most therapeutic approach to this client% A. )ivert the client;s &. 9isten without reinforcing the (. +nGect humor to defuse ). 9ogically point out that the client is Gumping to conclusions.
client;s the
attention. belief. intensity.
76. After a cystectomy and formation of an ileal conduit- the nurse provides instruction regarding prevention of lea*age of the pouch and bac*flow bac* flow of the urine. The nurse is correct to include in the instruction to empty the urine pouch, A. &. (. ). Once before bedtime.
very
3
hours. hour. day.
v e r y Twice
a
:?. $hich telephone call from a student;s mother should the school nurse ta*e care o f at once% A. A telephone call notifying the school nurse that the child; pediatrician has informed the moth mother er that that the the chil child d will will need need card cardia iacc repa repair ir surg surger ery y with within in the the net net few few wee* wee*s. s. &. A telephone call notifying the school nurse that the child;s pediatrician has informed the mother that the child has head lice. (. A telephone call notifying the school nurse that a child has a temperature of 1?2KF and a rash covering the trun* and upper etremities of the body. ). A tele teleph phon onee call call noti notify fyin ing g the the scho school ol nurs nursee that that a chil child d unde underw rwen entt an emer emerge genc ncy y appendectomy during the previous night. :1. $hich of the following signs and symptoms that reuire immediate attention and may indicate most serious complications during pregnancy% A. Severe abdominal pain or fluid discharge from the vagina. &. ce cess ssiive sali alivava- bum bumps ps arou around nd the areo areola laee- and and incr increa eassed vagi vagina nall mucus ucus.. (. Fatigue- nausea- and urinary freuency at any time during pregnancy. ). An*le edema- enlarging varicosities- and heartburn. :2. The nurse is assessing the newborn boy. Apgar scores are : and 6. The newborn becomes slightly cyanotic. $hat is the initial nursing action% A. levate his head to promote gravity drainage &. $rap him in another blan*etto reduce (. Stimulate him to cry-to increase ). Aspirate Aspirate his mouth and nose with bulb syringe.
of
secretions. heat loss. oygenation.
:3. The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs to have *nowledge of which psychodynamic principle% A. The symptoms of a somatoform disorder are an attempt to adGust to painful life situations or to cope with conflicting seualaggressiveor dependent feelings. &. The maGor fundamental mechanism is regression. (. The client;s symptoms are imaginary and the suffering is fa*ed. ). An etensive- prolonged study of the symptoms will be reassuring to the client- who see*s sympathy- attention attention and love. :. An infant is brought to the health care clinic for three immuni>ations at the same time. The nurse *nows that hepatitis &- )"T- and @aemophilus influen>ae type & immuni>ations should, A. &e drawn in the same syringe and given in one inGection. &. &e mied and inGect in the same sites. (. 4ot be mied and the nurse must give three inGections in three sites. ). &e mied and the nurse must give the inGection in three sites. :5. A female female client with cancer can cer has radium implants. The nurse wants to maintain the implants in the correct position. The nurse should position the client, A. Flat &. On the (. $ith the foot of ). $ith the head elevated 5degrees !semiFowler;s#. !semiFowler;s#.
in side the
bed
bed. only. elevated.
:7. The nurse wants to *now if the mother of a toddler understands the instructions regarding the administration of syrup of ipecac. $hich of the following statement will help the nurse to *now that the mother needs additional teaching% A. +;ll give the medicine if my child gets into some toilet bowl cleaner.B &. +;ll give the medicine if my child gets into some aspirin.B (. +;ll give the medicine if my child gets into some plant bulbs.B ). +;ll give the medicine if my child gets g ets into some vitamin pills.B ::. To assess if the cranial nerve C++ of the client was damaged- which changes would not be epected% A. )rooling and drooping &. +nability to open eyelids (. Sagging of the face on ). +nability to close eyelid on operative side.
of on the
the operative operative
mouth. side. side.
:8. The community health nurse ma*es a home visit to a family. )uring the visit- the nurse observes that the mother is beating her child. $hat is the priority nursing intervention in this situation%
A. Assess the child;s inGuries. &. e of &. "revent crystalline irritation (. e of ). +ncrease the hydrostatic pressure in the urinary tract.
to
eisting the eisting
stones. ureter. stones
81. The nurse is counseling a couple in their mid 3?;s who have been unable to conceive for about 7 months. They are concerned that one or both of them may be infertile. infertile. $hat is the best advice the nurse could give to the couple% A. it is no unusual to ta*e 712 months to get pregnant- especially when the partners are in their mid3?s. at welleerciseand avoid stress.B &. Start Start planning planning adoptio adoption. n. 'any couples couples get pregnan pregnantt when they are trying trying to adopt.B adopt.B (. (ons onsult a fertility speciali alist and start testing before you get any older.B ). @ave se as often as you can- especially around the time of ovulation- to increase your chances of pregnanc y.B y.B 82. The nurse is caring for a cient who +s a retired nurse. A 2hour urine collection for (reatinine clearance is to be done. The client tells the nurse- + can;t remember what this test is for.B for.B The best response by the nurse nu rse is, A. +t provides a way to see if you are passing any protein in your urine.B &. +t tells how well the *idneys filter wastes from the blood.B (. +t tells if your renal insufficiency has affected your heart.B ). The test measures the number of particles the *idney filters.B
83. The nurse observes the female client in the psychiatric ward that she is having a hard time sleeping at night. The nurse as*s the client about it and the client says- + can;t sleep at night because of fear of dying.B $hat is the best initial nursing nursing response% A. +t must be frightening for you to feel that way. Tell me more about it.B &. )on;t worry- you won;t die. /ou are Gust here for some test.B (. $hy are you afraid of dying%B ). Try to sleep. /ou need the rest before tomorrow;s test.B 8. +n the hospital h ospital lobby- the registered nurse overhears a two staff members discussing about the health health condition condition of her client. $hat would be the appropriate appropriate action for the registered registered nurse to ta*e% A. 0oin in the conversationgiving her input about the case. &. +gnor nore them hem- bec becaus ause they have the right to discuss uss anyt nythin hing they want to. (. Tell them it is not appropriate to discuss such things. ).
cient client client
net net away
to to from
b e d. bed. bed.
87. The child client has undergone hip surgery and is in a spica cast. $hich of the following toy should be avoided to be in the child;s bed% A. &. (. ). 9egos.
A
toy stuffed
A
gun. animal. ball.
A
8:. The 9"4D9C4 as*s the registered nurse why oytocin !"itocin#- 1? units !+C or +'# must be given to a client after birth fo the fetus. The nurse is correct to eplain that o ytocin, A. 'inimi>es &. (. ). 'aintains uterine tone.
discomfort Suppresses "romotes
from
afterpains.B lactation. lactation.
88. The nurse in the nursing care unit is aware that one of the medical staff displays unli*ely behaviors li*e confusion- agitation- lethargy and un*empt appearance. This behavior has been reported to the nurse manager several times- but no changes observed. The nurse should,
A. (ont (ontin inue ue to repor reportt obse observ rvat atio ions ns of unus unusua uall behav behavio iorr unti untill the the probl problem em is reso resolv lved. ed. &. (onsider that the obligation to protect the patient from harm has been met by the prior reports and do nothing further. (. )iscuss the situation with friends who are also nurses to get ideas . ). Approach the partner of this medical staff member with these concerns. 86. 86. The The physi physici cian an order ordered ed tetr tetracy acycl clin inee "O id id to a chil child d clie client nt who who weig weight htss 2?*g. 2?*g. The The recommended "O tetracycline dose is 255? mgD*gDday. $hat is the maimum single dose that can be safely administered to this child% A. &. (. ). 125 mg
1 5?? 25?
g mg mg
6?. The nurse is completing an obstetric history of a woman in labor. $hich event in the obstetric history will help the nurse suspects dysfunctional labor in the current pregnanc y% A. Total time of ruptured membranes was 2 hours with the second birth. &. First labor lasting 2 hours. (. =terine fibroid noted at time of cesarean delivery. ). Second birth by cesarean for face presentation. 61. The nurse is planning to tal* to the client with an antisocial personality disorder. $hat would be the most therapeutic approach% A. "rovide &.
eternal the client;s opportunities to
controls. selfconcept. test reality.
62. 62. The The nurse nurse is teac teachi hing ng a group group of wome women n about about fert fertil ilit ity y awar awarene eness ss-- the the nurse nurse shoul should d emphasi>e that basal body temperature, A. (an be done with a mercury thermometer but no a digital one. &. The average temperature ta*en each morning. (. Should be recorded each morning before any activity. ). @as a lower degree of accuracy in predicting ovulation than the cervical mucus test. 63. The nursing applicant has given the chance to as* uestions during a Gob interview at a local hospital. $hat should be the most important uestion to as* that can increase chances of securing a Gob offer% A. &egin &egin with with uestio uestions ns about about client client care care assign assignmen mentsts- advancem advancement ent opportu opportunit nities ies-- and continuing education. &. )ecl )eclin inee to as* as* ues uesti tion onss- beca becaus usee that that is the the resp respon onsi sibi bili lity ty of the the inte interv rvie iewe werr.
(. As* as many uestions about the facility as possible. ). (larify information regarding salary- benefits- and wor*ing hours first- because this will help in deciding whether or not to ta*e the Gob. 6. The nurse advised the pregnant woman that smo*ing and alcohol should be avoided during pregnancy. The nurse ta*es into account that the developing fetus is most vulnerable to environment teratogens that cause malformation during, A. &. (. ). The second trimester.
The The The
entire third first
pregnancy. trimester. trimester.
65. A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing response would be, A. &. $here;s the bug% (. + don;t see a bug in ). /ou /ou must be seeing things.B
+;ll your
*ill bedbut
it you
for seem
Silence. you.B afraid.B
67. A pregnant client in late pregnancy is complaining co mplaining of groin pain that seems worse on the right side. $hich of the following is the most li*ely cause of it% A. &eginning &. (. ). Tension Tension on the round ligament.
of
labor. infection. (onstipation.
&ladder
6:. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct in imparting the idea that the Eood Samaritan law protects the nurse from a suit for malpractice when, A. The The nurs nursee stop stopss to rend render er emer emerge gency ncy aid aid and leave leavess befor beforee the ambu ambula lanc ncee arri arrives ves.. &. The nurse acts in an emergency at his or her place of employment. (. The The nurs nursee refu refuse sess to stop stop for for an emer emerge genc ncy y outs outsid idee of the the scop scopee of empl employ oyme ment nt.. ). The nurse is grossly negligent at the scene o f an emergency. 68. A woman is hospitali>ed with mild preeclampsia. The nurse is formulating a plan of care for this client- which nursing care is least li*ely to be done% A. )eeptendon reflees &. Cital signs and F@< and (. Absolute ). )aily weight.
once rhythm bed
h
per while
shift. awa*e. rest.
66. $hile feeding a newborn with an unrepaired cardiac defect- the nurse *eeps on assessing the condition of the client. The nurse notes that the newborn;s respiration is :2 breaths per minute. $hat would be the initial nursing action% A. &. (. ). 4otify the physician.
&urp Stop (ontinue
the the the
newborn. feeding. feeding.
1??. A client who undergone appendectomy 3 days ago is scheduled for discharge today. The nurse notes that the client is restless- pic*ing at bedclothes and saying- + am late on my appointment-B and calling the nurse by b y the wrong name. The nurse suspects, A. &. (. Toic ). )elirium tremens.
"anic 'edication reaction
to
an
reaction. overdose. antibiotic.
Answers & Rationale 1. A. The oytoci oytocicc effect effect of "itoci "itocin n increa increases ses the intens intensity ity and durati durations ons of contrac contractio tionsI nsI prolonged contractions will Geopardi>e the safetyof the fetus and necessitate discontinuing the drug. 2. &. +t is of paramount importance to prevent the client from hurting himself or herself or others. 3. &. After tonsillectomy- clear- cool liuids should be given. (itrus- carbonated- and hot or cold liuids should be avoided because they may irritate the throat. ardous- reducing the client;s ability to read read for for eten etended ded perio periods ds and ma*i ma*ing ng part partic icip ipat atio ion n in games games with with fast fastm movi oving ng obGec obGects ts impossible.
:. &. This stops the suc*ing of air through the tube and prevents the entry of contaminants. +n addition- clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube. 8. ). &ecause umbilical cord;s insertion site is born before the fetal head- the cord may be compressed by the aftercoming head in a breech birth. 6. &. +t is important to eternali>e the anger away from self. 1?. ). )evelop )evelopmen mentt normal normally ly procee proceeds ds cephalo cephalocaud caudally allyII so the first first maGor maGor develop developmen mental tal milestone that the infant achieves is the ability to hold the head up within the first 812 wee*s of life. +n hypothyroidism- the infant;s muscle tone would be poor and the infant would not be able to achieve this milestone. 11. ). Eet a senior nurse who *now s the policies- the client- and the doctor. Eenerally spea*inga nurse should not accept telephone orders. @owever- if it is necessary to ta*e one- follow the hospital;s policy regarding telephone orders. Failure F ailure to followhospital policy could be considered con sidered negligence. +n this case- the nurse was new and did not *now the hospital;s policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not ta*e the order unless A. no one else is available and &. it is an emergency situation. 12. (. The nurse is obligated to inform the nurse manager about changes in the condition of the client- which may change the decision made by the nurse manager. 13. A. "erinatal ris* factors for the development of )own syndrome include advanced maternal age- especially with the first pregnancy. 1. &. Assignments should be based on scope of practice and epertise. 15. &. The child who is concurrently ta*ing digoin and diuretics is at increased ris* for digoin toicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium- and the child should be encouraged to eat a highpotassium diet. +n addition- the child;s serum potassium level should be carefully monitored. 17. A. The responsible for an accurate informed consent is the physician. An eception to this answer would be a lifethreatening emergency- but there are no data to support another response. 1:. ). As*ing the client to cough and ta*e a deep breath will help determine if the chest tube is *in*ed or if the lungs has reepanded. 18. &. very event that eposes a client to harm should be recorded in an incident report- as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again.
16. ). One of the earliest signs of digoin toicity is &radycardia. For a toddler- any heart rate that that fall fallss belo below w the the norm norm of abou aboutt 1??1 1??12? 2? bpm bpm woul would d indi indicat catee &rady &radyca card rdia ia and and woul would d necessitate holding the medication and notifying the physician. 2?. &. This option is least threatening. 21. ). +n preparing the client for discharge that is receiving prednisone- the nurse should caution the client to !A. ta*e oral preparations after mealsI !&. remember that routine chec*s of vital signs- weight- and lab studies are criticalI !(. 4C< STO" O< (@A4E T@ A'O=4T OF ')+(AT+O4 $+T@O=T ')+(A9 A)C+(I !). store the medication in a lightresistant container. 22. A. "rogesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. $omen $omen should contact their doctors if they ehibit signs of infection. egel eercise will help strengthen the perineal musclesI limiting fluids at bedtime reduces the possibility of being awa*ened by the necessity of voiding. 23. &. This is the proper use of anger. ang er. 2. (. There are several models of case management- but the commonality is comprehensive coordination of care to better predict needs of highris* clients- decrease eacerbations and continually monitor progress overtime. 25. A. "henytoin should be infused or inGected into larger veins to avoid the discoloration *now as purple glove syndromeI infusing into a smaller vein is not appropriate. 27. (. Serum radioimmunoassay !<+A. is accurate within :days of conception. This test is specific for @(E- and accuracy is not compromised by confusion with 9@. 2:. ). Surgery and anesthesia can increase mucus production. )eep breathing and coughing are essential to prevent atelectasis and pneumonia in the client;s only remaining lung. 28. &. 4ewbor 4ewborns ns can get pneumo pneumonia nia !tachy !tachypnea pnea-- mild mild hypoi hypoiaa- coughcough- eosino eosinophi philiA liA.. and conGunctivitis from (hlamydia. 26. ). The client may perceive this as avoidance- but it is more important to redirect bac* to the client- especially in light of the manipulative behavior of drug abusers and adolescents. 3?. (. +t describes a democratic process in which all members have input in the client;s care. care. 31. A. (ontraction of the mil* ducts and letdown refle occur under the stimulation of oytocin released by the posterior pituitary gland. 32. &. +n case management- the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty.
33. A. Smo*e inhalation affects gas echange. 3. (. Sperm deposited during intercourse may remain viable for about 3 days. +f ovulation occurs during this period- conception may result. 35. &. This option shows acceptance !*ey concept# of this agetypical sleep pattern !that of wa*ing in the early morning#. 37. ). Ta*ing the mother;s pulse while listening to the F@< will differentiate between the maternal and fetal heart rates and rule out fetal &radycardia. 3:. A. Antihistamines Antihistamines cause pupil dilation and should be avoided with glaucoma. 38. A. This suggests that the level of consciousness is decreasing. 36. ). An advance directive is a form of informed consent- and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. +f the spouse does not hold the power of attorney- the decisions of the holder- even if opposed by the spouseare enforced. ?. (. Eentle but firm guidance and nonverbal direction is needed to intervene when a client with schi>ophrenic symptoms is being disruptive. 1. (. Suctioning is only done d one for 1? seconds- intermittently- as the catheter is being withdrawn. 2. ). The priority for this client is being able to establish an airway. 3. A. Signs of placental separation include a change in the shape of the uterus from ovoid to globular. . &. This could indicate intracranial bleeding. Alteplase is a thrombolytic en>yme that lyses thrombi and emboli. &leeding is an adverse effect. 'onitor clotting times and signs of any gastrointestinal or internal bleeding. 5. ). &ecause flan* incision in nephrectomy is directly below the diaphragm- deep breathing is painful. Additionally- there is a greater incisional pull p ull each time the person moves than there is with abdominal surgery. +ncisional pain following nephrectomy generally reuires analgesics administrat administration ion every 3 hours for 28 hours after surgery. surgery. ThereforeTherefore- turningturning- coughing coughing and deepbreathing eercises should be planned to maimi>e the analgesic effects. 7. &. =nder high estrogen levels- during the period surrounding ovulation- the cervical mucus becomes thin- clear- and elastic !spinnbar*eit#!spinnbar*eit#- facilitating sperm passage. :. ). After surgery for a ruptured appendi- the client should be placed in a semiFowler;s position to promote drainage and to prevent possible complications.
8. (. )irecting and evaluation of o f staff is a maGor responsibility of a nursing manager. 6. A. The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conGunctival sac. 5?. &. Thirst and restlessness indicate hypovolemia and hypoemia. +nternal bleeding is difficult to recogni>ed and evaluate because it is not apparent. 51. (. rythema toicum is the normaln ormal- nonpathological macular newborn rash. 52. ). The family needs to understand understand what brain death is before tal*ing about organ donation. donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed. 53. A. &ending from the waist in pregnancy tends to ma*e bac*ache worse. 5. &. Support and limit setting decrease aniety and provide eternal control. 55. (. The stoma drainage bag is applied in the operating room. )rainage from the ileostomy contains secretions that are rich in digestive en>ymes and highly irritating to the s*in. "rotection of the s*in from the effects of these en>ymes is begun at once. S*in eposed to these en>ymes even for a short time becomes reddened- painful and ecoriated. 57. &. +t is the most accurate statement of physiological facts for a 28day menstrual cycle, ovulation at day 1- egg life span 2 hours- sperm life span of :2 hours. Fertili>ation could occur from sperm deposited before ovulation. 5:. (. An advocate role encourage freedom of choice- includes spea*ing out for the client- and supports the client;s best interests. 58. A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting transmitting infection to one;s seual partner. 56. &. Aniety Aniety is generated generated by b y group therapy at 6,?? A'. The ritualisti ritualisticc behavioral behavioral defense of hand washing decreases aniety by b y avoiding group therapy. 7?. ). )enial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances- such as during natural disasters- it may in greater pathology in a woman with potential breast carcinoma. 71. &. The registered registered nurse cannot delegate the responsibil responsibility ity for assessment assessment and evaluation evaluation of clients. clients. The status status of the client client in restraint reuires reuires further assessment assessment to determine determine if there are additional causes for the behavior.
72. (. The client with chest chest pain pain may be having having a myocar myocardia diall infarc infarctio tionn- and immedia immediate te assessment and intervention is a priority. 73. &. +s correc correctt becaus becausee semen semen analys analysis is reuir reuires es that that a freshl freshly y mastur masturbat bated ed specim specimen en be obtained after a rest !abstinence# period of 8:2 hours. 7. (. &etamethasone- a form of o f cortisone- acts on the fetal lungs to produce surfactant. 75. A. Secretions may have pooled above the tracheostomy cuff. +f these are not suctioned before deflation- the secretions may be aspirated. 77. (. "roper handling of sputum is essential to allay droplet transference of bacilli in the air. (lients need to be taught to cover their nose and mouth with tissues when snee>ing or coughing. (hemotherapy generally renders the client noninfectious within days to a few wee*s- usually before cultures for tubercle bacilli are negative. =ntil chemical isolation is established- many institutions reuire the client to wear a mas* when visitors are in the room or when the nurse is in attendance. (lient should be in a wellventilated room- without air recirculation- to prevent air contamination. 7:. A. +t is best to establish baseline information first. 78. &. 9istening is probably the most effective response of the four choices. 76. A. =rine flow is continuous. The pouch has an outlet valve for easy drainage every 3 hours. !the pouch should be changed every 35 days- or sooner if the adhesive is loose#. :?. :?. (. A high high feve feverr acco accomp mpan anie ied d by a body body rash rash coul could d indi indica cate te that that the the chil child d has has a communicable disease and would have eposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection. :1. A. Severe abdominal pain may indicate complications of pregnancy such as abortion- ectopic pregnancy- or abruption placentaI fluid fluid discharge from the vagina may indicate premature rupture of the membrane. :2. ). Eentle aspiration of mucus helps maintain a patent airway- reuired for effective gas echange. :3. A. Somatoform disorders provide a way of coping with conflicts. :. (. +mmuni>ation should never be mied together in a syringe- thus necessitating three separate inGections in three sites. 4ote, some manufacturers ma*e a premied combination of immuni>ation that is safe and effective.
:5. A. (lients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal pac*ing. The client may roll to the side for meals but the upper body should not be raised more than 2? degrees. :7. A. Syrup of ipecac is not administered when the ingested substances is corrosive in nature. Toilet bowl cleaners- as a collective whole- are highly corrosive substances. +f the ingested substance burnedB the esophagus going down- it will burnB the esophagus coming bac* up when the child begins to vomit after administration of syrup of ipecac. ::. &. +nability to open eyelids e yelids on operative side is seen with cranial nerve +++ damage. :8. A. Assessment of physical inGuries !li*e bruises- lacerations- bleeding and fractures# is the first priority. :6. (. The nurse who is supervising others has a legal obligation to determine that they are compe compete tent nt to perf perfor orm m the the assi assignm gnment ent-- as well well as legal legal oblig obligat atio ion n to provi provide de adeu adeuat atee supervision. 8?. ). +ncreasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi. 81. A. +nfertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will eperience a longer time to get pregnant. 82. &. )eterm )etermini ining ng how well the *idney *idneyss filte filterr wastes wastes states states the purpose purpose of a (reati (reatinin ninee clearance test. 83. A. Ac*nowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings. 8. (. The behavior should be stopped. The first is to remind the staff that confidentiality maybe violated. 85. (. $ith a rightsided cerebrovascular accident the client would have leftsided hemiplegia or wea*ness. The client;s good side should be closest to the bed to facilitate the transfer. 87. ). 9egos are small plastic building bloc*s that could easily slip under the child;s cast and lead to a brea* in s*in integrity and even infection. "encils- bac*scratchers- and marbles are some other narrow or small items that could easily slip under the child;s cast and lead to a brea* in s*in integrity and infection. 8:. ). Oytocin !"itocin# is used to maintain uterine tone. 88. &. The submission of reports about incidents that epose clients to harm does not remove the obligation to report ongoing behavior as long as the ris* to the client continues.
86. (. The recommended dosage of tetracycline is 255?mgD*gDday. +f the child weighs 2?*g and the maimum dose is 5?mgD*g- this would indicate a total daily dose of 1???mg of tetracycline. +n this case- the child is being given this medication four times a day. Therefore the maimum single dose that can be given is 25?mg !1??? mg of tetracycline divided by four doses.# 6?. 6?. (. An abno abnorm rmal alit ity y in the the uter uterin inee musc muscle le could could reduc reducee the the effe effect ctiv ivene eness ss of uter uterin inee contractions and lengthen the duration of subseuent labors. 61. A. "ersonality disorders stem from a wea* superego- implying a lac* of adeua te controls. 62. (. The basal body temperature is the lowest body temperature of a healthy person that is ta*en immediately after wa*ing and before getting out of bed. The &&T usually varies from 37.2 K( to 37.3K( during menses and for about 5: days afterward. About the time of ovulation- a slig slight ht drop drop in temp temper erat atur uree may be seen seen-- afte afterr ovul ovulat atio ion n in conc concer ertt with with the the incr increa easi sing ng progesterone levels of the early luteal phase- the &&T rises ?.2?. K(. This elevation remains until 23 days before menstruation- or if pregnancy has occurred. 63. A. This choice implies concern for client care and selfimprovement. 6. (. The first trimester is the period of organogenesis- that is- cell differentiation into the various organs- tissues- and structures. 65. (. This response does not contradict the client;s perception- is honest- and shows empathy. 67. ). Tension on round ligament occurs because of the erect human posture and pressure eerted by the growing fetus. 6:. ). The Eood Samaritan 9aw does not impose a duty to stop at the scene of an emergency outside of the scope of employment- therefore nurses who do not stop are not liable for suit. 68. (. Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia- she will most probably have bathroom privileges. 66. &. A normal respiratory rate for a newborn is 3?? breaths per minute. 1??. 1??. ). The behavior behavior descri described bed is li*ely li*ely to be symptom symptomss of deliri delirium um tremen tremenss- or alcoho alcoholl withdrawal !often unsuspected on a surgical unit.#
