1.A 60-year-old male client comes into the emergency department with complaints of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infraction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given intravenously. The nurse should first: a. Administer the morphine b. Obtain a 12-lead ECG c. Obtain the blood work d. Order the chest radiograph Ans: A – although obtaining the ECG, chest radiograph, radiograph, and blood work are all important, important, the nurse’s priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is priority action. 2. When administering a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of the drug is to: a. Help keep him well hydrated b. Dissolve clots that he may have c. Prevent kidney failure d. Treat potential cardiac dysrhythmias Ans: B – thrombolytic drugs are administered administered within the first 6 hours after of myocardial infarction to lyse clots and reduce the extent of myocardial damage. 3. If the client who has admitted for MI develops cardiogenic shock, which characteristic signs should the nurse expect to observe? a. Oliguria b. Bradycardia c. Elevated blood pressure d. Fever Ans: A – oliguria occurs during cardiogenic shock because there there is reduced blood flow to the kidneys. Typically Typically signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decrease urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. 4. The physician orders continuous intravenous nitroglycerin infusion for the client with MI. essential nursing action include which of the following? a. Obtaining an infusion pump for the medication b. Monitoring blood pressure every 4 hours c. Monitoring urine output hourly d. Obtaining serum potassium levels daily Ans: A – intravenous nitroglycerin infusion requires requires an infusion pump for precise control of the medication. medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is n ot associated with nitroglycerin infusion. 5. When teaching the client with MI, the nurse explains that the pain associated with MI is caused by: a. Left ventricular overload b. Impending circulatory collapse c. Extracellular electrolyte imbalances d. Insufficient oxygen reaching the heart muscle Ans: D – an MI interferes with or blocks circulation circulation to the heart muscle. Decreased blood supply to the heart muscle causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of oxygen to the cardiac muscle results in ischemic pain or angina. 6. Aspirin is administered to the client experiencing an MI because of its: a. Antipyretic action b. Antithrombotic action c. Antiplatelet action d. Analgesic action Ans: B – aspirin does have antipyretic, antiplatelet, antiplatelet, and analgesic actions, but the primary primary reason aspirin is administered to the client experiencing an MI is its antithrombotic action. In clinical trials, the antithrombotic action of aspirin has been thought to account for improved outcomes in clients with MI. 7. While caring for a client who has sustained an MI, the nurse notes eight PVCs in 1 minute on the cardiac monitor. The client is receiving an intravenous infusion of 5% dextrose in water and oxygen at 2 L/minute. The nurse’s first course of action should be to: a. Increase the intravenous infusion rate b. Notify the physician promptly c. Increase the oxygen concentration d. Administer a prescribed analgesic Ans: B – PVCs are often a precursor of life-threatening dysrhythmias, dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not n ot considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the physician should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the intravenous infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse’s first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability. 8. Which of the following is an expected outcome for a client on the second day of hospitalization after an MI? The client:
a. Has minimal chest pain b. Can identify risk factors for MI c. Agrees to participate in a cardiac rehabilitation program d. Can perform personal self-care activities without pain Ans: D – by day 2 of hospitalization after an an MI, clients are expected to be able to to perform personal care without chest pain. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to be able to agree to participate in a cardiac rehabilitation program. 9. When teaching a client about the expected outcomes after intravenous administration of furosemide, the nurse would include which outcome? a. Increased blood pressure b. Increased urine output c. Decreased pain d. Decreased PVCs Ans: B – furosemide is a loop diuretic acts acts to increase urine output. Furosemide does not increase increase blood pressure, decrease pain, or decrease dysrhythmias. 10. After an MI, the hospitalized client is taught to move the legs about while resting in bed. This type of exercise is recommended primarily to help: a. Prepare the client for ambulation b. Promote urinary and intestinal elimination c. Prevent thrombophlebitis and blood clot formation d. Decrease the likelihood of decubitus ulcer formation Ans: C – although this type of exercise may may decrease the likelihood of heel decubitus ulcer form formation, it is taught to the MI client to prevent thrombophlebitis and blood clot formation. Movement of the lower extremities provides muscular action and aids venous return. As a result, the activity helps prevent stasis of blood, which predisposes the client to thrombophlebitis and blood clot formation. This type of exercise is not associated with promoting urinary and intestinal elimination. 11. Which of the following reflects the principle on which a client’s diet will most likely be based during the acute phase of MI? a. Liquids as desired b. Small, easily digested meals c. Three regular meals per day d. Nothing by mouth Ans: B – recommended dietary principles principles in the acute phase of MI include avoiding large large meals because small, easily digested foods are better tolerated. Fluids are given according to the client’s needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable. 12. Of the following controllable risk factors for coronary artery disease (CAD) appears most closely linked to the development of the disease? a. Age b. Medication usage c. High cholesterol levels d. Gender Ans: C – high cholesterol levels are considered a controllable risk factor for CAD CAD and appear most clearly linked to to the development of the disease. High cholesterol levels can be modified through diet, exercise, and medication. Age and gender are uncontrollable risk risk factors for CAD. Medication usage is not considered a risk factor for CAD. CAD. 13. Which of the following is an uncontrollable risk factor that has been linked to the development of CAD? a. Exercise b. Obesity c. Stress d. Heredity Ans: D – heredity has been linked to CAD and is an uncontrollable uncontrollable risk factor. Exercise, obesity, obesity, and stress are controllable risk factor for CAD. 14. If a client displays risk factors for CAD such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, technique of behavior modification may be used to help the client change behavior. The nurse can best reinforce new adaptive behaviors by: a. Explaining how the old behavior leads to poor health b. Withholding praise until the new behavior is well established c. Rewarding the client whenever the acceptable behavior is performed d. Instilling mild fear into the client to extinguish the behavior Ans: C – a basic principle of behavior modification modification is that behavior that is learned learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward. 15. Alteplase recombinant. Or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of MI to: a. Control chest pain b. Reduce coronary artery vasospasm c. Control the dysrhythmias associated with MI d. Revascularize the blocked coronary artery Ans: D – the thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary coronary artery. The drug is most effective when administered within the first 6 hours after onset.
16. After the administration of t-PA, the nurse understands that a nursing assessment priority is to: a. Observe the client for chest pain b. Monitor for fever c. Monitor the 12-lead ECG every 4 hours d. Monitor breath sounds Ans: A – although monitoring the 12-lead ECG and monitoring monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority, because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever. 17. When monitoring a client who is receiving t-PA, the nu rse understands it is important to monitor vital signs and have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? a. Cardiac dysrhythmias b. Hypertension c. Seizure d. Hypothermia Ans: A – cardiac dysrhythmias are commonly observed observed with administration of t-PA. Cardiac Cardiac dysrhythmias associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue. 18. Contraindication to the administration of t-PA include which of the following? a. Age greater than 60 years b. History of cerebral hemorrhage c. History of heart failure d. Cigarette smoking Ans: B – a past history of cerebral cerebral hemorrhage is a contraindication to administration administration of t-PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications. 19. A client has driven himself into the emergency room. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse’s next action would be to: a. Call for the doctor b. Start an intravenous line c. Obtain a portable chest radiograph d. Draw blood for laboratory studies Ans: B – advanced cardiac life support support recommends that at least one or two intravenous intravenous lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the intravenous line. 20. Crackles heard on lung auscultation indicate which of the following? a. Cyanosis b. Bronchospasm c. Airway narrowing d. Fluid-filled alveoli Ans: D – crackles are auscultated over fluid-filled fluid-filled alveoli. Crackles heard heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing n arrowing generally are associated with wheezing sounds. 21. A 68-year-old female client on day 2 after hip surgery has no cardiac history but starts to complain of chest heaviness. The first nursing action should be to: a. Inquire about the onset, duration, severity, and precipitating factors of the heaviness b. Administer oxygen via nasal cannula c. Offer pain medication for the chest heaviness d. Inform the physician of the chest heaviness Ans: A – further assessments is needed in this situation. situation. It is premature to initiate initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician. 22. The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? a. Cancer b. Hypertension c. Liver disease d. Myocardial damage Ans: D – detection of myoglobin is one diagnostic tool to determine determine whether myocardial damage damage has occurred. Myoglobin is generally detected about 1 hour after a heart attack is experienced and peaks within 4 to 6 hours after physician. 23. An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: a. Left ventricular atrophy b. Irregular heart beats c. Peripheral vascular occlusion
d. Pacemaker placement Ans: A – in older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden able to respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult’s lifestyle. Peripheral vascular occlusion of pacemaker placement should not affect response to stress. The Client With Heart Failure 24. A 69-year-old woman has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema. On admission of this client, which of the following should be assessed first? a. Blood pressure b. Skin breakdown c. Serum potassium d. Urine output Ans: A – it is a priority to assess the blood pressure first, because people with pulmonary edema typically experience severe hypertension that requires early intervention. 25. In which of the following should the nurse place a client with suspected heart failure? a. Semi-sitting (Low Fowler’s position) b. Lying on the right side (Sims’ position) c. Sitting almost upright (High Fowler’s position) d. Lying on the back with the head lowered (Trendelenburg position) Ans: C – sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler’s position would be used if the client could not tolerate high Fowler’s position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate the Trendelenburg position. 26. Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema? a. Risk for infection related to line placements b. Impaired skin integrity related to pressure c. Activity intolerance related to imbalance between oxygen supply and demand d. Constipation related to immobility Ans: C – activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. The client could be at risk for infection related to line placements or impaired skin integrity related to pressure. However, these are not the priority nursing diagnoses for the client with heart failure and pulmonary edema, nor is constipation related to immobility. 27. The major goal of therapy for a client with heart failure and pulmonary edema would be to: a. Increase cardiac output b. Improve respiratory edema c. Decrease peripheral edema d. Enhance comfort Ans: A – increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema. 28. Digoxin is administered intravenously to a client with heart failure, primarily because the drug acts to: a. Dilate coronary arteries b. Increase myocardial contractility c. Decrease cardiac dysrhythmias d. Decrease electrical conductivity in the heart Ans: B – digoxin is cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat dysrhythmias and does decrease the electrical conductivity of the myocardium, this is not the primary reason for its use in clients with heart failure and pulmonary edema. 29. Captopril, an antigiotensin-converting enzyme (ACE) inhibitor, may be administered to a client with heart failure because it acts as a: a. Vasopressor b. Volume expander c. Vasodilator d. Potassium-sparing diuretic Ans: C- ACE inhibitors have become the vasodilators of choice in the client with mild to severe congestive heart failure. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure. 30. Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug’s desired effect? a. 5 to 10 minutes
b. 30 to 60 minutes c. 2 to 4 hours d. 6 to 8 hours Ans: A – after intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously. 31. The nurse teaches a client with heart failure to take oral Furosemide in the morning. The primary reason for this is to help: a. Prevent electrolyte imbalances b. Retard rapid drug absorption c. Excrete excessive fluids accumulated during the night d. Prevent sleep disturbances during the night Ans: D – when diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client’s sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night. 32. Clients with heart failure are prone to atrial fibrillation. During physical assessment, the nurse would suspect atrial fibrillation when palpation of the radial pulse reveals: a. Two regular beats followed by one irregular b. An irregular pulse rhythm c. Pulse rate below 60 bpm d. A weak, thready pulse Ans: B – characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the physician. A weak, thready pulse is characteristic of a client in shock. 33. When teaching the client about complications of atrial fibrillation, the nurse understands that the complications can be caused by: a. Stasis of blood in the atria b. Increased cardiac output c. Decreased pulse rate d. Elevated blood pressure Ans: A – atrial fibrillation occurs when the sinoatrial node no longer functions as the heart’s pacemaker and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed, atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not associated with increased cardiac output, elevated blood pressure, or decreased pulse rate; rather, it is associated with an increased pulse rate. 34. The nurse should teach the client that signs of digitalis toxicity include which of the following? a. Skin rash over the chest and back b. Increased appetite c. Visual disturbances such as seeing yellow spots d. Elevated blood pressure Ans: C – colored vision and seeing yellow spots are symptoms of digitalis toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digitalis toxicity. Additional signs of toxicity include dysrhythmias, such as atrial fibrillation or bradycardia. Skin rash, increased appetite, and elevated blood pressure are not associated with digitalis toxicity. 35. The nurse should be especially alert for signs and symptoms of digitalis toxicity if serum levels indicate that the client has a: a. Low sodium level b. High glucose level c. High calcium level d. Low potassium level Ans: D – a low serum potassium level (hypokalemia) predisposes the client to digitalis toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. 36. Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-g sodium diet? a. Apples b. Tomato juice c. Whole wheat bread d. Beef tenderloin Ans: B – canned foods and juices, such as tomato juice, are typically high in sodium and should be avoided in a sodium-restricted diet, canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice. 37. To help maintain a normal blood serum level of potassium, the client receiving a loop diuretic should be encouraged to eat such foods as bananas, orange juice, and, a. Spinach b. Skimmed milk c. Baked chicken d. Brown rice
Ans: A – foods rich in potassium include bananas, orange juice, and green leafy vegetables such as spinach. Honeydew melon, cantaloupe, and watermelons are also rich in potassium. Other good sources of potassium are grapefruit juice, nectarines, potatoes, dried prunes, raisins, and figs. Skimmed milk, baked chicken, and brown rice are not considered high in potassium. 38. The nurse finds the apical impulses below the fifth intercostals space. The nurse suspects a. Left atrial enlargement b. Left ventricular enlargement c. Right atrial enlargement d. Right ventricular enlargement Ans: B - a normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fifth intercostals space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostals space or lateral to the midclavicular line may indicate left ventricular enlargement. 39. The nurse is admitting a 69-year old man to the clinical unit. The client has a history of left ventricular enlargement. During the assessment the nurse notes +3 pitting edema of the ankles bilaterally. The client does not have chest pain. The nurse observes that the client does have dyspnea at rest. The nurse infers that the client may have a. Arteriosclerosis b. Congestive heart failure c. Chronic bronchitis d. Acute myocardial infarction Ans: B – peripheral edema is a symptom of congestive heart failure. Congestive heart failure results when the heart chronically pumps against increased resistance or is unable to contract forcefully to pump the blood out into the systemic circulation. As a result, the ventricles become overfilled and there is an accumulation of volume within the closed system. The client’s symptoms do not indicate arteriosclerosis, chronic bronchitis, or acute MI. 40. The nurse’s discharge teaching plan for the client with congestive heart failure would stress the significance of which of the following? a. Maintaining a high-fiber diet b. Walking 2 miles every day c. Obtaining daily weights at the same time each day d. Remaining sedentary for most of the day Ans: C – Congestive heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 pounds or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet id beneficial, but it is not relevant to the teaching needs of the client with congestive heart failure. Prescribing an exercise program for the client, such as walking 2 miles everyday, would not be appropriate at discharge. The client’s exercise program would need to be planned in consultation with the physician and based on his history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not pre-lifestyle should not be recommended. 41. A 70-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the client, the nurse would most likely learn that the client’s childhood health history included: a. Chicken pox b. Poliomyelitis c. Rheumatic fever d. Meningitis Ans: C – Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis. Chicken pox, poliomyelitis, and meningitis are not associated with mitral stenosis. 42. A client experiences some initial signs of excitation after having an intravenous infusion of lidocaine hydrochloride started. The nurse would assess that the client is demonstrating a typical adverse reaction to lidocaine hydrochloride when the client complains of: a. Palpitations b. Tinnitus c. Urinary frequency d. Lethargy Ans: B – Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, convulsions, and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine hydrochloride. 43. A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted. The physician orders pulmonary capillary wedge pressures. The purpose of this is to help assess the: a. Degree of coronary artery stenosis b. Peripheral arterial pressure c. Pressure from fluid within the left ventricle d. Oxygen and carbon dioxide concentrations in the blood Ans: C – the pulmonary artery pressures are used to assess the heart’s ability to receive and pump blood. The pulmonary capillary wedge pressure reflects the left ventricular end-diastolic pressure and guides the physician in determining fluid management for the client. The degree of coronary artery stenosis is assessed during a cardiac
catheterization. The peripheral arterial pressure is assessed with an arterial line. The oxygen and carbon dioxide concentrations in the arterial blood can be measured by an arterial blood gas determination. 44. Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation? a. Exertional dyspnea b. Confusion c. Elevated creatine phosphokinase concentration d. Chest pain Ans: A – weight gain due to fluid retention and worsening heart failure cause exertional dyspnea in clients with mitral regurgitation. The rise in left atrial pressure that accompanies mitral valve disease is transmitted backward to the pulmonary veins, capillaries, and arterioles and eventually to he right ventricle. Signs and symptoms of pulmonary and systemic venous congestion follow. Confusion, elevated creatine phosphokinase concentration, and chest pain are not typically associated with mitral regurgitation. 45. The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the: a. Aorta b. Right atrium c. Superior vena cava d. Pulmonary circulation Ans: D – when mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure. functioning of the aorta, right atrium, and superior vena cava is not immediately influenced by mitral stenosis. 46. Because a client has mitral stenosis and is a prospective valve recipient, the nurse preoperatively assesses the client’s past compliance with medical regimens. Lack of compliance with which of the following regimens would pose the greatest health hazard to this client? a. Medication therapy b. Diet modification c. Activity restrictions d. Dental care Ans: A – preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprostheses are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does. 47. In preparing the client and the family for a postoperative stay in the intensive care unit after open heart surgery, the nurse should explain that: a. The client will remain in the intensive care unit for 5 days b. The client will sleep most of the time while in the intensive care unit c. Noise and activity within the intensive care unit are minimal d. The client will receive medication to relieve pain Ans: D – management of postoperative pain is priority for the client after surgery, including valve replacement surgery, according to the Agency for Health Care Policy and Research. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the intensive care unit as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery. 48. A client who has undergone a mitral valve replacement experiences persistent bleeding from the surgical incision during the early postoperative period. Which of the following pharmaceutical agents should the nurse be prepared to administer to this client? a. Vitamin C b. Protamine sulfate c. Quinidine sulfate d. Warfarin sodium (Coumadin) Ans: B – protamine sulfate is used to help combat persistent bleeding in a client who has had open heart surgery. Vitamin C and quinidine sulfate do not influence blood clotting. Warfarin sodium is an anticoagulant, as is heparin, and these two agents would tend to cause the client to bleed even more. 49. The most effective measure the nurse can use to prevent wound infection when changing a client’s dressing after coronary artery bypass surgery is to: a. Observe careful handwashing procedures b. Cleanse the incisional area with an antiseptic c. Use prepackaged sterile dressings to cover the incision d. Place soiled dressings in a waterproof bag before disposing of them Ans: A – many factors help prevent wound infections, including washing hands carefully, using the sterile prepackaged supplies and equipment, cleansing the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful handwashing is also important in helping reduce other infections often acquired in hospitals, such as urinary tract and respiratory system infections.
50. For a client who excretes excessive amounts of calcium during the postoperative period after open surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion? a. Ensure a liberal fluid intake b. Provide an alkaline-ash diet c. Prevent constipation d. Enrich the client’s diet with dairy products Ans: A – in an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi. 51. The nurse teaches the client who is receiving warfarin sodium that: a. Partial thromboplastin time values determine the dosage of warfarin sodium b. Protamine sulfate is used to reverse the effects of warfarin sodium c. The international normalized ration (INR) is used to assess effectiveness d. Warfarin sodium will facilitate clotting of the blood Ans: C - the INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium’s anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots. 52. Good dental care is an important measure in reducing risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of: a. A manual toothbrush b. An electric toothbrush c. An irrigation device d. Dental floss Ans: A – daily dental care and frequent checkups by a dentist who is informed about the client’s condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device, or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the bloodstream, increasing the risk of endocarditis. 53. Before a client’s disease discharge after mitral valve replacement surgery, the nurse should evaluate the client’s understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month-old postdischarge appointment with the surgeon? a. Showering b. Lifting anything heavier than 10 pounds c. A program of gradually progressive walking d. Light housework Ans: B – most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge. 54. Three days after mitral valve surgery, a 45-year-old woman comments that she hears a “ clicking” noise coming from her chest and her “ rather large” chest incision. The nurse’s response should reflect the understanding that the client may be experiencing which of the following? a. Anxiety related to altered body image b. Anxiety related to altered health status c. Altered tissue perfusion d. Lack of knowledge regarding the postoperative course Ans: A – verbalized concerns from the client may stem from her anxiety over the changes her body has gone through after open heart surgery. Although the client may experience anxiety related to her altered health status or may have a lack of knowledge regarding her postoperative course, she is pointing out the changes in her body image. The client is not concerned about altered tissue perfusion. The Client With Hypertension 55. An industrial health nurse at a large printing plant finds a male employee’s blood pressure to be elevated on two occasions 1 month apart and refers him to his provide physician. The employee is about 25 pounds overweight and has smoked a pack of cigarettes daily for more than 20 years. The client’s physician prescribes atenolol for the hypertension. The nurse should instruct the client to: a. Avoid sudden discontinuation of the drug b. Monitor the blood pressure annually c. Follow a 2-g sodium diet d. Discontinue the medication if severe headaches develop -adrenergic antagonists indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a doctor’s order. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension.bAns: A –
atenolol is 56. The nurse teaches her client, who has recently been diagnosed with hypertension, about his dietary restrictions: a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client’s? a. Mixed green salad with blue cheese dressing, crackers, and cold cuts b. Ham sandwich on rye bread and an orange c. Baked chicken, an apple, and a slice of white bread d. Hot dogs, baked beans, and celery and carrot sticks Ans: C – processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both and fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement\ with clients who are basically asymptomatic. 57. A client’s job involves working in a warm, dry room, frequently bending and crouching to check the underside of a high-speed press, and wearing eye guards. Given this information, the nurse should assess the client for which of the following? a. Muscle aches b. Thirst c. Lethargy d. Postural hypotension Ans: D – possible dizziness from postural hypotension when rising a crouched or bent position increases the client’s risk of being injured by the equipment. The nurse should assess the client’s blood pressure in all three positions (lying, sitting, and standing) at all routine visits. The client may experience muscle aches, or thirst from working in a warm, dry room, but these are not as potentially dangerous as postural hypotension. The client should not be experiencing lethargy. 58. An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program? a. Giving the client a written exercise program. b. Explaining the exercise program to the client’s spouse. c. Reassuring the client that he or she can do the exercise program. d. Tailoring a program to the client’s needs and abilities. Ans: D – tailoring or individualizing a program to the client’s lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client’s spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program. 59. The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan? a. Review the negative effects of smoking on the body. b. Discuss the effects of passive smoking on environmental pollution. c. Established the client’s smoking pattern. d. Explain how smoking worsens high blood pressure. Ans: C - a plan to reduce or stop smoking begins with establishing the client’s personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risk, but this knowledge has not been shown to help clients change their smoking behavior. 60. Essential Hypertension would be diagnosed in a 40-year-old man whose blood pressure readings were consistently at or above which of the following? a. 120/90 mmHg b. 130/85 mmHg c. 140/90 mmHg d. 160/80 mmHg Ans: C – Heart Center of the Philippines standards define hypertension as a consistent systolic blood pressure level greater than 140 mmHg and a consistent diastolic blood pressure level 2.greater than 90 mmHg.
. When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride a. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. b. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. c. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. d. Is an angiotensin-converting enzyme (ACE) inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II. -adrenergic blocking agent. Actions of propranolol hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing conduction.bAns: A – propranolol is 2. The nurse understands that a priority nursing diagnosis for the client with hypertension would be a. Pain. b. Deficient Fluid Volume. c. Impaired skin integrity. d. Ineffective health maintenance.
Ans: D – managing hypertension is a priority for the client with hypertension. Clients with hypertension frequently do not experience other signs and symptoms such as pain, deficient fluid volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat, because clients may not recognize they are hypertensive or may not perceive the need for aggressive management of the disease. 3. The most important long-term goal for a client with hypertension would be to a. Learn how to avoid stress. b. Explore a job change or early retirement. c. Make a commitment to long-term therapy. d. Control high blood pressure. Ans: C – compliance is the most critical element of hypertension therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without during therapy. Stress management and weight management are important components of hypertension therapy, but the priority goal is related to compliance. 4. The client with hypertension is prone to long-term complications of the disease. Which of the following is a long-term complication of hypertension? a. Renal insufficiency and failure. b. Valvular heart disease. c. Endocarditis d. Peptic ulcer disease. Ans: A – renal disease, including renal insufficiency and failure is a complication of hypertension. effective treatment of hypertension assists in preventing this compliance valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension. 5. Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes undetected until symptoms of other system failures occur. This may occur in the form of a. Cerebrovascular accidents (CVA’s) b. Liver disease. c. Myocardial infarction. d. Pulmonary disease. Ans: A – hypertension is referred to as the silent killer for adults, because until the adult has significant damage to others systems, the hypertension may go undetected. CVAs can be related to long-term hypertension. Liver or pulmonary disease is not generally associated with hypertension. Myocardial infraction is generally related to coronary artery disease. 6. During the past few months, a 56-year old woman h as felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friend’s apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client deal with this problem? a. Visit her friend b. Rest for at least an hour before climbing the stairs c. Take a nitroglycerin tablet before climbing the stairs. d. Lie down once she reaches the friend’s apartment. Ans: C – nitroglycerin may be used prophylactically before stressful physical activities such as stair-climbing to help the client remain pain free. Visiting her friend early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode. 7. The client who experiences angina pectoris has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low – cholesterol diet? a. Hamburger, salad, and milkshake. b. Baked liver, green beans, and coffee. c. Spaghetti with tomato sauce, salad, and coffee d. Fried chicken, green beans, and skim milk Ans: C – pasta, tomato sauce, salad, and coffee would be the best selection for the client following a lowcholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol. 8. Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician? a. A change in the pattern of her pain b. Pain during sexual activity c. Pain during an argument with her husband d. Pain during or after an activity such as lawn mowing Ans: A – the client should report a change in the pattern of chest pain. It may help increasing severity of coronary artery disease. Pain occurring during stress or sexuality activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities. 9. The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: a. Open and dilate blocked coronary arteries b. Assess the extent of arterial blockage
c. Bypass obstructed vessels d. Assess the functional adequacy of the valves and heart muscle Ans: B – cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. Coronary bypass surgery would be used to bypass obstructed vessels. Although cardiac catheterization can be used to assess the functional adequacy of the valves and heart muscle, in this case the client has unstable angina and therefore would need the procedure to assess the e xtent of arterial blockage. 10. The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA would include: a. Minimizing dyspnea b. Maintaining adequate blood pressure control c. Decreasing myocardial contractility d. Preventing fluid volume deficit Ans: D – because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis. Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control should not be a problem after the procedure. Increased myocardial contractility would be a goal, not decreased contractility. 11. Which of the following is not generally considered to be a risk factor for the development of atheroclerosis? a. Family history of early heart attack b. Late onset of puberty c. Total blood cholesterol level greater than 220 mg/dL d. Elevated fasting blood sugar concentration Ans: B – late onset of puberty is not generally considered to be a risk factor of the development of atherosclerosis. Risk factors for atherosclerosis include cigarette smoking, hypertension, high blood cholesterol level, male gender, family history of atherosclerosis, diabetes mellitus, obesity, and physical inactivity. 12. Many more men than women younger than 50 years of age have coronary artery disease as a result of atherosclerosis. The leading cause of death in women is: a. Acquired immunodeficiency syndrome b. Breast cancer c. Coronary artery disease d. Chronic obstructive pulmonary disease Ans: C – coronary artery disease is the leading cause of dearth in women as well as men. Although it is generally agreed that estrogen helps protect women from atherosclerotic changes before menopause, women are still at risk for coronary artery disease. Much attention has been focused on the lack of research studies dealing with cardiac disease in women and minorities, and work is under way to gain a better understanding of cardiac disease in these populations. 13. A client angina asks the nurse, “ What information does an ECG provide?” The nurse would respond that an electrocardiogram (ECG) primarily gives information about the: a. Electrical conduction of the myocardium b. Oxygenation and perfusion of the heart c. Contractile status of the ventricles d. Physical integrity of the heart muscle Ans: A – an ECG directly reflects the transmission of electrical cardiac impulses through the heart. This information makes it possible to evaluate indirectly the functional status of the heart muscle and the contractile response of the ventricles. However, these elements are not measured directly. The ECG does not give information about the oxygenation and perfusion of the heart. 14. As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug’s principal effects are produced by: a. Antispasmodic effects on the pericardium b. Causing an increased myocardial oxygen demand c. Vasodilation of peripheral vasculature d. Improved conductivity in the myocardium Ans: C – nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium. 15. The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including: a. Headache b. High blood pressure c. Shortness of breath d. Stomach cramps Ans: A – because of its widespread vasodilating effects, nitroglycerin often produces such as side effects as headache, hypotension, and dizziness. The client should sit or lie down to avoid fainting. Nitroglycerin does not cause shortness of breath or stomach cramps. 16. Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? a. Take one tablet every 2 to 5 minutes until the pain stops b. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes
c. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after these tablets d. Take one tablet. If pain still persists 5 minutes later, call the physician Ans: C – the correct protocol for nitroglycerin use involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of three tablets. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. 17. A client with angina has been taking nifedipine. The client shou ld be taught to: a. Monitor blood pressure monthly b. Perform daily weights c. Inspect gums daily d. Limit intake of green leafy vegetables Ans: C – the client taking nifedipine should inspect the gums daily to monitor for gingival hyperplasia. This is an uncommon side effect but one that requires monitoring and intervention if it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more than monthly. These clients would not generally need to perform daily weights or limit intake of green leafy vegetables. The Client With A Permanent Pacemaker 18. A 74-year-old woman is admitted to the telemetry unit for placement of a permanent pacemaker would be to: a. Maintain skin integrity b. Maintain cardiac conduction stability c. Decrease cardiac output d. Increase activity level Ans: B – maintaining cardiac conduction stability to prevent dysrythmias is a priority immediately after artificial pacemaker implantation. The client should have continuous electrocardiographic (ECG) monitoring until proper pacemaker functioning is verified. 19. The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. Outcome criteria include that the client: a. Selects a low-cholesterol diet to control coronary artery disease b. States a need for bed rest for 1 week after discharge c. Verbalizes safety precautions needed to prevent pacemaker malfunction d. Explain sign and symptoms of myocardial infraction Ans: C – education is a major component of the discharge plan for a client with an artificial pacemaker. The client with a permanent pacemaker needs to be able to state specific information about safety precautions necessary to maintain proper pacemaker function. The Client Requiring Cardiopulmonary Resuscitation 20. A rescuer is called to a neighbor’s home after a 56 -year-old man collapses. After quickly assessing the victim, the rescuer determines that the victim is unresponsive. To determine unresponsiveness, the rescuer can: a. Call the victim’s name and gently shake the victim b. Perform the chin-tilt to open the victim’s airway c. Feel for any air movement from the victim’s nose or mouth d. Watch the victim’s chest for respirations Ans: A – calling the victim’s name and gently shaking the victim is used to establish unresponsiveness. The headtilt, chin-lift maneuver is used to open the victim’s airway. Feeling for any air movement from the victim’s nose or mouth indicates whether the victim is breathing on his own. The rescuer can watch the victim’s chest for respirations to see if the victim is breathing. 21. Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which of the following complications? a. Gastrointestinal bleeding b. Myocardial infraction c. Emesis d. Rib fracture Ans: D – proper hand placement during chest compressions is essential to reduce the risk of rib fractures, which may lead to pneumothorax and other internal injuries. Gastrointestinal bleeding and myocardial infarction are generally not considered complications of CPR. Although the victim may vomit during CPR, this is not associated with poor hand placement, but rather with distention of the stomach. 22. The American Heart Association guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for: a. Early defibrillation in cases of atrial fibrillation b. Cardioversion in cases of atrial fibrillation c. Pacemaker placement d. Early defibrillation in cases of ventricular fibrillation Ans: D – AEDs are used for early defibrillation in cases of ventricular fibrillation. The American Heart Association places major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a toll to increase sudden cardiac arrest survival rates. 23. A client who has been given CPR is transported by ambulance to the hospital’s emergency department, where the admitting nurse quickly assesses the client’s condition. Of the following observations, the one most often recommended for determining the effectiveness of CPR is noting whether the: a. Pulse rate is normal b. Pupils are reacting to light
c. Mucous membranes are pink d. Systolic blood pressure is at least 80 mmHg Ans: B – Pupillary reaction is the best indication of whether oxygenated blood has been reaching the client’s brain. Pupils that remain widely dilated and do not react to light probably indicate that serious brain damage has occurred. The pulse rate may be normal, mucous membranes may still be pink, and systolic blood pressure may be 80 mmHg or higher, and serious brain damage may still have occurred. 24. The client receives epinephrine during resuscitation in the emergency department. This drug is administered primarily because of its ability to: a. Dilate bronchioles b. Constrict arterioles c. Free glycogen from the liver d. Enhance myocardial contractility Ans: D. Epinephrine is administered during resuscitation efforts primarily for its ability to improve cardiac activity. Epinephrine has great affinity for adrenergic receptors in cardiac tissue and acts to strengthen and speed the heart rate as well as to increase impulses conduction from atria to ventricles. Epinephrine dilates bronchioles and constricts arterioles, but these are not the primary reasons for administering it during resuscitation. Epinephrine is not associated with freeing glycogen from the liver. 25. The rescuer understands that the compression-to-ventilation ratio for one-rescuer adult CPR is: a. 5:1 b. 15:1 c. 5:2 d. 15:2 Ans: D – With one-rescuer CPR, the compression to ventilation ratio is 15:2. 26. During CPR, the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for laceration by forceful compressions over the xiphoid process? a. Lung b. Liver c. Stomach d. Diaphragm Ans: B Because of its location near the xiphoid process, the liver is the organ most easily damaged from pressure exerted over the xiphoid process during CPR. The pressure on the victim’s chest wall should be sufficient to compress the heart but not so great as to damage internal organs. Injury may result, however, even when CPR is performed properly. 27. When performing external chest compressions on an adult during CPR, the rescuer should depress the sternum. a. 0.5 to 1 inch b. 1 to 1.5 inches c. 1.5 to 2 inches d. 2 to 2.5 inches Ans: C – an adult’s sternum must be depressed 1.5 to 2 inches with each compression to ensure adequate heart compression. 28. The American Heart Association guidelines for Basic Cardiac Life Support recommend that the rescuer after first establishing unresponsiveness, should: a. Perform CPR for 2 minutes on the adult victim then place a call for emergency assistance b. Place a call for emergency assistance immediately c. Begin rescue breathing for the victim d. Begin CPR on the adult victim and wait until help comes on the scene Ans: B – the American Heart Association guidelines for Basic Cardiac Life Support now recommends that the rescuer call for emergency assistance immediately after establishing unresponsiveness in the adult victim. A call for emergency assistance takes places precedence over initiating CPR in the adult victim, in an effort to get emergency personnel and an AED to the scene. Early defibrillation and prompt bystander CPR have increased sudden cardiac arrest survival rates. 29. If the victim’s chest wall fails to rise with each inflammation when rescue breathing is administered during CPR, the most likely reason is that the: a. Airway is not opened properly b. Victim is beyond resuscitation c. Inflations are being given at too rapid a rate d. Rescuer is using inadequate force for cardiac compression Ans: A – if the airway is not opened properly, it is impossible to inflate the lungs during CPR. A common signs of airway obstruction is failure of the victim’s chest wall to rise with each inflation. The victim should not be considered beyond resuscitation; rather the airway should be opened properly. Inflations may be being given too rapidly. However, this is not the usual cause of not being able to adequately ventilate the victim. If the rescuer is using inadequate force for cardiac compression, it should not interfere with how ventilations are delivered. 30. During rescue breathing in CPR, the victim with exhale by: a. Normal relaxation of the chest b. Gentle pressure of the rescuer’s hand on the upper chest c. The presence of cardiac compressions d. Turning the head to the side Ans: A – the exhalation phase of ventilation is a passive activity that occurs during CPR as part of the normal
relaxation of the victim’s chest. No action by the rescuer is necessary. 1.If parents or legal guardians aren't available to give consent for treatment of a life-threatening situation in a minor child, which of the following statements is most accurate? a.)Consent may be obtained from a neighbor or close friend of the family. b.)Consent may not be needed in a life-threatening situation. c.)Consent must be in the form of a signed document; therefore, parents or guardians must be contacted. d.)Consent may be given by the family physician. B. RATIONALE: In emergencies, including danger to life or possibility of permanent injury, consent may be implied, according to the law. Parents have full responsibility for the minor child and are required to give informed consent whenever possible. Verbal consent may be obtained. 2. You're admitting a 15-month-old boy who has bilateral otitis media and bacterial meningitis. Which room arrangements would be best for this client? a.)In isolation off a side hallway b.)A private room near the nurses' station c.)A room with another child who also has meningitis d.)A room with two toddlers who have croup B. RATIONALE: With meningitis, the child should be isolated for the first day but be close to where he can be observed frequently. In isolation off a side hallway is too far away for frequent observation. Putting the client in a room with another child who has meningitis or with two toddlers who have croup present an infectious hazard to the other children. 3. Which of the following points should a team leader consider when delegating work to team members in order to conserve time? a.)Assign unfinished work to other team members. b.)Explain to each team member what needs to be done. c.)Relinquish responsibility for the outcome of the work. d.)Assign each team member the responsibility to obtain dietary trays. B. RATIONALE: When all team members know what needs to be done, they can work together on the most efficient plan for accomplishing necessary tasks. Delegation can be flexible, ranging from telling a staff member exactly what needs to be done and how to do it to allowing team members some freedom to decide how best to carry out the tasks. Assigning unfinished work to other team members and assigning each team member the responsibility to obtain dietary trays don't allow for input from team members. It's the team leader's job to maintain responsibility for the outcome of a task. 4. The nurse is caring for a client admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless: a.)the client is mentally ill. b.)the client refuses to give informed consent. c.)the client is in an emergency situation. d.)the client asks the nurse to give substituted consent. C. RATIONALE: The law doesn't require informed consent in an emergency situation when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. Even though a client who is declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent. 5. The nurse is assigned to care for an elderly client who is confused and repeatedly attempts to climb out of bed. The nurse asks the client to lie quietly and leaves her unsupervised to take a quick break. While the nurse is away, the client falls out of bed. She sustains no injuries from the fall. Initially, the nurse should treat this occurrence as: a.)a quality improvement issue. b.)an ethical dilemma. c.)an informed consent problem. d.)a risk-management incident. D. RATIONALE: The nurse should treat this episode as a risk-management incident; her immediate responsibility is to fill out an incident report and notify the risk manager. Quality improvement and ethics aren't the nurse's initial concerns. The facility may choose to look at these types of problems and make changes to deliver a higher standard of care institutionally. Informed consent isn't a relevant issue in this incident. 6. The nurse receives an assignment to provide care to 10 clients. Two of them have had kidney transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of clients. In addition, the nurse has never cared for a client who has undergone recent transplantation surgery. What's the appropriate action for the nurse to take? a.)Speak to the manager and document in writing all concerns related to the assignment. b.)Refuse the assignment. c.)Ignore the assignment and leave the unit. d.)Trade assignments with another nurse. A. RATIONALE: When a nurse feels incapable of performing an assignment safely, the appropriate action is to speak to the manager or nurse in charge. The nurse should also document the concerns in writing and ask that
the assignment be changed. In the event that the manager chooses to leave the assignment as given, the nurse should accept the assignment. The nurse should never abandon the assigned clients by leaving the workplace or asking another nurse to care for them. The nurse may, however, refuse to perform a task outside the scope of practice. 7. The nurse works with a colleague who consistently fails to use standard precautions or wear gloves when caring for clients. The nurse calls the colleague's attention to these oversights. The colleague tells the nurse that standard precautions and gloves aren't necessary unless the client is known to have tested positive for the human immunodeficiency virus. What's the most appropriate action for the nurse to take? a.)Ignore it because it isn't directly the nurse's problem b.)Document the problem in writing for the manager. c.)Talk to other staff members to ascertain their practices. d.)Instruct the clients to remind this colleague to wear gloves. B. RATIONALE: The nurse has spoken to her colleague under the appropriate circumstances and the behavior hasn't changed. Therefore, the appropriate action is to bring the problem to the manager's attention. It's unproductive to talk with other staff members about the situation because they don't have the authority to bring the colleague's practice into compliance. The nurse should never point out to a client that another staff member's practice isn't meeting standards. 8. An adult client is diagnosed with acquired immunodeficiency syndrome. The nurse who is caring for the client is also his friend. The nurse tells the client's parents about the diagnosis; after all, they know their son is the nurse's friend. Several weeks later, the nurse receives a letter from the client's attorney stating that the nurse has committed an intentional tort. Which intentional tort has this nurse committed? a.)Fraud b.)Defamation of character c.)Assault and battery d.)Breach of confidentiality D. RATIONALE: A nurse shouldn't disclose confidential information about a client to a third party who has no legal right to know; doing so is a breach of confidentiality. Defamation of character is injuring someone's reputation through false and malicious statements. Assault and battery occurs when the nurse forces a client to submit to treatment against the client's will. A nurse commits fraud when she misleads a client to conceal a mistake she made during treatment. 9. A nurse accidentally administers 40 mg of propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, the nurse should: a.)call the facility's attorney. b.)inform the client's family. c.)complete an incident report. d.)do nothing because the client's condition is stable. C. RATIONALE: The nurse should file an incident report. Incident reports highlight areas of potential liability. It's then the risk manager's responsibility to notify the facility's attorney if the incident is believed to be serious. The risk manager, in consultation with the physician and facility administrator, will decide who should inform the family of the error. The quality assurance coordinator may choose to use such incidents when trying to improve the quality of care received by clients in a particular facility. Taking no action isn't an acceptable option. 10. The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to: a.)encourage the client to ask questions about personal sexuality. b.)provide time for privacy. c.)provide support for the spouse or significant other. d.)suggest referral to a sex counselor or other appropriate professional. D. RATIONALE: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling. 11. The nurse is assigned to care for eight clients. Two nonprofessionals are assigned to work with the nurse. Which statement is valid in this situation? a.)The nurse may assign the two nonprofessionals to work independently with a client assignment. b.)The nurse is responsible to supervise assistive personnel. c.)Nonprofessionals aren't responsible for their own actions. d.)Nonprofessionals don't require training before they work with clients. B. RATIONALE: Assistive personnel may not be assigned to care for clients without the supervision of a professional nurse. It's essential that assistive personnel understand that they're responsible for their own actions. Assistive personnel must be adequately trained to perform all tasks they're assigned to perform. 12. Each state has guidelines that regulate the different levels of nursing & licensed practical or vocational nurse, registered nurse, or advanced practice nurse. Legal guidelines outlining the scope of practice for nurses are known as: a.)consent to treatment. b.)client's bill of rights. c.)nurse practice acts. d.)licensure requirements.
C. RATIONALE: Each state has a nurse practice act that defines the scope of nursing practice within the state. Consent to treatment refers to informed consent for a treatment or procedure. The client's bill of rights defines the rights of clients. Licensure requirements are constructed by the state board of nursing to set standards for receiving a nursing license. 13. A client is dissatisfied with his hospitalization. He decides to leave against medical advice and refuses to sign the paperwork. The nurse's next course of action is to: a.)detain him until he signs the paperwork. b.)detain him until his physician arrives. c.)call security for assistance. d.)let him leave. D. RATIONALE: The nurse is obligated to let him leave. Detaining him in any form is a violation of the patient's bill of rights. 14. A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and h urts herself. The nurse is at fault because she hasn't: a.)properly educated this client about safety measures. b.)restrained the client. c.)documented that she left the client. d.)arranged for continual care of the client. D. RATIONALE: By leaving the client, the nurse is at fault for abandonment. The better course of action is to turn on the call bell or elicit help on the way to the client's room. Educating the client about safety measures doesn't alleviate the nurse from responsibility for ensuring the client's safety. The nurse can't restrain the client without a physician's order and restraints won't ensure the client's safety. Documenting that she left the client doesn't excuse the nurse from her responsibility for ensuring the client's safety. 15. When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be: a.)allowing the family to see a newly admitted client. b.)ambulating the client in the hallway. c.)administering pain medication. d.)placing wrist restraints on the client. C. RATIONALE: In Maslow's hierarchy of needs, pain relief is on the first layer. Activity is on the second layer. Safety is on the third layer. Love and belonging are on the fourth layer. 16. When developing a therapeutic relationship with a client, the nurse should begin preparing the client for termination of the relationship: a.)at discharge. b.)during the first meeting. c.)at the midpoint of the relationship. d.)when the client demonstrates the ability to function independently. B. RATIONALE: When initiating a therapeutic relationship with a client, preparation for termination of the relationship should begin during the first meeting. For example, the nurse should introduce herself to the client and tell him exactly when she'll be involved in his care. This sets the boundaries of the relationship. In the middle and at discharge of care, the relationship may be too involved to end abruptly without warning. The client's ability to function independently isn't the deciding factor in preparing the client for the termination of the therapeutic relationship. 17. To be effective, a clinical nurse-manager in a managed care environment must: a.)expect all staff to accept change. b.)go along with a proposed change. c.)be a catalyst for change. d.)document staff nurses' reactions to change. C. RATIONALE: The clinical nurse-manager is responsible for making things happen, not just letting things happen. She must be more than a role model who goes along with change & she must also encourage change and support staff during change. Documentation of the nurses' reactions to change can be threatening and serves no purpose in helping change to occur. 18. In community-based nursing, primary responsibility for decisions related to health care belongs to the: a.)nurse. b.)client. c.)health care team. d.)physician. B. RATIONALE: The client is primarily responsible for health care decisions in community-based nursing. The nurse assists with monitoring of health treatment and teaching and intervenes only as needed after assessing the client's ability to follow a regimen. The health care team collaborates on decisions related to treatment. The physician dictates medical orders related to treatment and medication. 19. A client became seriously ill after a nurse gave him the wrong medication. After his recovery, he files a lawsuit. Who is most likely to be held liable?
a.)No one because it was an accident b.)The hospital c.)The nurse d.)The nurse and the hospital D. RATIONALE: Nurses are always responsible for their actions. The hospital is liable for negligent conduct of its employees within the scope of employment. Consequently, both the nurse and the hospital are liable. Although the mistake wasn't intentional, standard procedure wasn't followed. 20. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to: a.)change his own dressing. b.)walk in the hallway. c.)walk from his room to the end of the hall and back before discharge. d.)eat a special diet. C. RATIONALE: Walking from his room to the end of the hall and back before discharge is a specific, measurable, attainable, timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case. 21. A client with end-stage liver cancer tells the nurse he doesn't want extraordinary measures used to prolong his life. He asks what he must do to make these wishes known and legally binding. How should the nurse respond to the client? a.)Tell him that it's a legal question beyond the scope of nursing practice. b.)Give him a copy of the client's bill of rights. c.)Provide information on active euthanasia. d.)Discuss documenting his wishes in an advance directive. D. RATIONALE: Advance directives give a competent client control over his situation and a legal forum in which to express his wishes about his care. Discussion of advance directives isn't outside the scope of nursing practice. The client's bill of rights involves multiple client rights and doesn't provide detailed information about advance directives. Active euthanasia is illegal. 22. While admitting a client with pneumonia, the nurse notes multiple bruises in various stages of healing. The client has Alzheimer's disease and a history of multiple fractures. Legally, the most important action for the nurse to take is to: a.)document findings thoroughly. b.)question the client about the bruising. c.)inform appropriate local authorities. d.)tell the client's physician. C. RATIONALE: This client may be experiencing elder abuse based on her history and symptoms. Authorities to be notified may include local social service or law enforcement agencies. The nurse should also document findings and include illustrations to support the assessment. The client with Alzheimer's disease may not be able to accurately inform the nurse about what happened. Reporting findings to the physician may not be sufficient for fulfilling the nurse's legal responsibility. 23. The nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes of remissions and exacerbations. Which resource can best help the client adapt to the disease? a.)The client's family b.)Pastoral care c.)Support group .)Hospice care C. RATIONALE: Support groups consist of clients with the same diagnoses who share experiences of the disease with each other. Sharing experiences helps the client understand disease-related problems and gives him a forum in which he can vent his feelings, which are usually similar to those of the group. The client's family and clergy, although supportive, can't share similar disease experiences. Hospice care is usually implemented late in the disease, at the end of life. 24. A client with brain cancer is deteriorating and the prognosis is poor. The client meets brain-death criteria. Which nursing intervention is most appropriate at this time? a.)Approach the client's family about organ donation. b.)Make the decision to withdraw life support. c.)Sedate the client. d.)Talk to the staff about their feelings. A. RATIONALE: The most appropriate nursing intervention is to discuss organ donation with the family. The decision to withdraw life isn't within a nurse's scope of practice. Because the client is brain-dead, he doesn't need sedation. Although talking to the staff is a viable strategy for staff decompression, it isn't the first action to take. 25. A client is scheduled to have a descending colostomy. He's very anxious and has many questions concerning the surgical procedure, care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team? a.)Social worker b.)Registered dietitian c.)Occupational therapist
d.)Enterostomal nurse therapist D. RATIONALE: An enterostomal nurse therapist is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support. Social workers provide counseling and emotional support, but they can't provide preoperative and postoperative teaching. A registered dietitian can review any dietary changes and help the client with meal planning. The occupational therapist can assist a client with regaining independence with activities of daily living. 26. A 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesn't want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's advance directive, which intervention should the nursing care plan include? a.)Check on the client once per shift. b.)Provide mouth and skin care only if the family requests it. c.)Turn the client only if he's uncomfortable. d.)Provide emotional support and pain relief. D. RATIONALE: When advance directives state that a client doesn't want life-prolonging interventions, nursing care focuses on providing emotional and spiritual support and comfort measures. The client still needs to be checked regularly. The client and family shouldn't feel as if they've been abandoned. Providing mouth and skin care makes the client more comfortable. Turning the client provides comfort and prevents potentially painful complications such as pressure ulcers. 27. The registered nurse has an unlicensed assistant working with her for the shift. When delegating tasks, the registered nurse understands that the unlicensed assistant: a.)interprets clinical data. b.)collects clinical data. c.)is trained in the nursing process. d.)can function independently. B. RATIONALE: Unlicensed personnel make observations, collect clinical data, and report findings to the nurse. The registered nurse has learned critical thinking skills and is able to interpret the clinical findings. Unlicensed assistants are trained to perform skills & they don't learn the nursing process. Unlicensed assistants don't function independently & they're assigned tasks by a registered nurse who retains overall responsibility for the client. Other nursing responsibilities when delegating tasks to unlicensed assistants include knowing the institutions policies regarding delegation, knowing the assistant's training, knowing the client's needs, receiving frequent updates from the assistant, asking specific questions, and making frequent rounds of clients. 28. A nurse on a medical-surgical floor is making assignments for an 8-hour sh ift. Which of the following considerations has the highest priority? a.)Complexity of care required b.)Age of the clients c.)Skills of the assigned personnel d.)The number of clients C. RATIONALE: The nurse is legally responsible for assigning personnel according to skill level. All of the other factors are important but don't take priority. 29. The nurse is caring for a homeless client with active tuberculosis. The client is almost ready for discharge; however, the nurse is concerned about the client's ability to follow the medical regimen. Which intervention will best ensure that the client complies with treatment? a.)Referring the client to a social worker for discharge planning b.)Providing individualized client education c.)Having the client attend a formal education session d.)Attempting to contact a member of the client's family to provide assistance A. RATIONALE: Referring the client to a health care professional with knowledge of community resources is the best intervention to ensure compliance in a homeless client. Educating the client about his condition may help, but basic needs for shelter, food, and clothing must be met first. Providing formal education and attempting to contact family members are inappropriate when seeking to help a homeless client. 30. The nurse is following a critical pathway to help a client who underwent hip replacement surgery meet specific objectives. What's a critical pathway? a.)A nursing care plan that helps the nurse to decide which intervention to perform first b.)A multidisciplinary care plan that helps the nurse to use a variety of critical interventions c.)A standardized care plan that lists basic interventions for the nurse to use with every client d.)A clinical management tool that organizes the major interventions for a multidisciplinary health care team D. RATIONALE: Critical pathways are management tools developed for particular types of cases or conditions. They set forth expectations for interventions, outcomes, and client progression. Elements of the nursing care plan are commonly folded into the critical pathway. The descriptions of standardized and multidisciplinary plans of care don't adequately describe the critical pathway. Because the critical pathway is standardized and multidisciplinary, the nurse may need to develop a separate care plan to document nursing diagnoses for an individual client.
1.Thiamine has been prescribed for an alcoholic patient. The rationale for administration of this medication is the prevention of: a. Alcoholic dementia b. Huntington’s disease c. Wernicke-korsakoff syndrome d. Alcohol withdrawal syndrome Ans: C - Chronic thiamine deficiency of alcoholism leads to the degenerative encephalopathy known as wernickekorsakoff syndrome 2. When caring for a patient with organic brain disorder, the nurse evaluates outcomes by: a. The emotional and financial support of a family b. The elimination of antipsychotic medications c. Maintenance of optimal level functioning d. How safety the patient performs ADLs Ans: C- This patient must be evaluated daily for activities that will help him achieve the highest level of functioning possible. 3. The patient is experiencing a fixed, false vbelief that cannot be corrected by logical reasoning. This is a/an: a. Delusion b. Hallucination c. Illusion d. Symbolism Ans: A- A delusion is a false belief, and it is almost impossible for the patient to change that belief once it is in belief system. 4. A patient complains that he cannot get rid of the idea that harm is looming all around him. The thought comes, unbidden, and upsets him. This repeated, unbidden thought is a/an: a. Obsession b. Compulsion c. Delusion d. Illusion Ans: A- an obsession is a repeated thought that the patient has little or nio control over. The anxiety that the obsessive thought causes usually leads to compulsive behavior. 5. An acutely patient is screaming, “I’m dead; I’m dying; my body is greeting stiff.” The nurse attempts to refocus on reality by stating to the patient: a. “You are very upset. Let me help you” b. “That’s hard to believe c. “Why do you keep saying that?” d. “You’re not dead. Your heart is still beating.” Ans: A- This response reorients the patient to reality and offers assistance. 6. In planning care for the patient with a personally disorder, the nurse realizes that this patient will most likely. a. Not need long-term therapy b. Will not require medication c. Require anti-anxiety medication d. Resist any change in behavior Ans: D- Persons who suffer from a personality disorder seldom see the need to change, causing much resistance to therapy.
7. To understand the meaning of the cleaning rituals the nurse must realize: a. The patient cannot help herself b. The patient cannot change c. Rituals relieve intense anxiety d. Medications cannot help Ans: C- The level of intensity is so high the person must relieve it through some kind of physical activity. 8. The nursing assessment indicates the patient is creating new words. This is documented as: a. Cryptic language b. Magical thinking c. Loose associations d. Neologisms Ans: D- Neologisms are expressed when a patient is experiencing serious disturbances of thought processes
9. You have been working with a nine-year-old client, and his parents, to help him stop sucking his thumb. Each time he sucks his thumb, you note it on the chart, and he does not get to have his next dessert. When he no longer sucks most thumbs, you evaluate his thumb-sucking behavior as most likely. a. Reinforced b. Faded c. Extinguished d. Generalized
Ans: C- Behavior is extinguished when the child realizes that the does not want to consequences of the of the behavior to continue. 10. Shaping of behavior occurs when: a. Reinforcement is directed toward a desired is achieved b. Behavior is separated in situations similar to the originally reinforced situation c. The client changes behavior d. Learning of appropriate behavior is achieved Ans: A- Reinforcement ids directed toward a desired response 11. A patient has been given a diagnosis of Neuroleptic Malignant Syndrome (NMS). What would the movement plan include? a. Monitor temperature and blood pressure b. Administer neulroeptic medications c. Encourage mild activity d. Increase antipsychotic medication Ans: A- Monitor temperature and blood pressure unexplained tachycardia, unstable blood pressure, tachypnea, muscle rigidity, cyanotic skin mottling, and rapidly rising body temperature at the onset; however, the signs are quite subtle and may resemble a cold or flu.
12. In providing supportive therapy to the depressed patient, the nurse is aware that depression is often caused by the repression of: a. Anxiety b. Anger c. Fear d. Grief Ans: B- One of the most common causes anger is repressed anger and the inability to ventilate anger. 13. One morning, the patient says to the nurse.” I do love my mother, but sometimes I wish she would just go ahead and die.” This statement reflects feelings of: a. Conversion b. Ambivalence c. Anxiety d. Conflict Ans: B- The love-hate relationship is a classic sign of ambivalence 14. A priority nursing intervention initially with this patient is to: a. Help her substitute feeling for her mother b. Encourage her to find other interests c. Develop a trusting relationship with her d. Tell her to forget the past Ans: C- A therapeutic relationship that involves a basic trust in one another is essential before other therapy can occur. 15. A patient with Organic Brain Syndrome (OBS) is confused at night. The plan of care should include: a. Keep the room well lighted b. Keep sensory stimulation to a minimum c. Offer a sedative at about 10 p.m d. Always use physical restraints Ans: B- This patient needs minimal stimulation and a quite environment as a Milieu therapy.
16. When a patient freely expresses his feelings, thoughts, anxieties and gets a sense of emotional relief. This experience is termed: a. Revelation b. Déjà vu c. Catharsis d. Projection Ans: C- The patient may experience a catharsis in many ways, but most often through psychotherapy. 17. A suspicious patient says, “Its not for us to talk in the hospital. They are everything.” The nurse responds: a. “Don’t worry about it. It is safe here.” b. “Don’t be silly. We could see the recorders if they were here.” c. “Who told you that you are being recorded?” d. “You appear to be stressed. Let’s take a walk.” Ans: D- The statement shows support, but does not feed into the patient’s paranoia 18. A patient is staying in his room very quite and withdrawn. The nurse approaches the patient and say: a. “I’ve noticed that you have been very quiet.” b. “Get out and join the others.” c. You are suicidal today, aren’t you?” d. “The doctor won’t like you staying secluded.”
Ans: A- The statement reflect the nurse’s assessment of the patient’s behavior and shows concern to which the patient can respond.
19. A patient speaks in a whisper. The nurse replies: a. “I cannot hear you. Please speak more loudly.” b. “Are you saying something?” c. “Why aren’t you talking right?” d. “Are you afraid someone is listening?” Ans: A- This statement is the most supportive to which the patient might respond. 20. A patient complains,” My sister always hated me. She was jealous.” The nurse respond: a. “Your sister was jealous?” b. “Tell me about on e of the times she was jealous.” c. “Why was she so hate full and jealous?” d. “Mother are often jealous and teach their daughters.” Ans: B- This reply takes a broad, generalized statement and asks for specific incident that can be addressed in therapy
21. While teaching the patient the nurse explains the purpose of antipsychotic drugs. These medications have been proven to be effective in: a. Curing symptoms b. Controlling symptoms c. Preventing psychosis d. Curing mental illness Ans: B- The primary purpose of antipsychotic medication is to control symptoms so that the patient can begin functioning and participate in therapy: 22. The nursing interventions most effective in working with substances patient are: a. Firm and Directive b. Instillation of values c. Helpful and advisory d. Subjective and non-judgmental Ans: A- The patient suffering with a addictive behaviors requires firm, directive, limit-setting in a structured environment. 23. The nurse promptive reports which symptom when the patient is taking psychotic medications? a. Mild rash b. Dry mouth c. Sore throat d. Photosensitivity Ans: C- Sore throat and other flu-like symptoms, are often the first signs of neuroleptic malignant syndrome and should be reported immediately
24. A very angry patient is threatening to leave the hospital AMA. What action should be taken? a. Let him check out of the hospital b. Inform him of the consequences of leaving AMA c. Tell him that no one is allowed to leave the hospital d. Put the patient in restraints until the physician comes Ans: B- The patient must be informed of the consequences of his behavior. Knowing there will be repercussions may make him changes his mind. 25. A 79-year-old patient spends a lot of time just talking about the past. What action is appropriate regarding their behavior? a. Get him involved with others his age b. Tell him he should talk about current events c. Reorient him to present and ignore past d. Listen attentively and encourage talking Ans: D- Talking about the past can be quite therapeutic as the person grows older. Some units have “reminiscence therapy” based on this theory. 26. A patient is masturbating in his room. There is no one present. The nurse should: a. Ask the patient to stop at once b. Sternly criticize the patient’s behavior c. Threaten to tell the doctor if he doesn’t stop d. Quietly leave, allow the behavior Ans: D-Masturbating under most circumstances is considered normal behavior. 27. A patient states, “I am a bird, you know, rat, cat, no one knows. He, That it.” This is an example of: a. Word salad b. Associate looseness c. Flight of ideas
d. Cognitive distortion Ans: A- This is classic sign of disturbance of thought processes, and this patient should be re-oriented 28. The best response to a patient who is verbalizing words that cannot be understood is: a. “You are not making sense.” b. “Go on says what you really mean.” c. “Say that so I can understand.” d. “Please repeat yourself.” Ans: A-This statement is a caring way to re-orient the person to reality.
29. Maslow see the individual being capable of reaching a peak capacity of fulfilling his human potential and of being satisfied with this no matter what it is. Maslow called this peak experience: a. Homeostesis b. Alarm reaction c. Existentialism d. Self-actualization Ans: D-The top level of Maslow’s hierarchy of need is self-actualization 30. In attempting to control a patient who is suffering panic, the nursing priority is: a. Provide safety b. Hold the patient c. Describe crisis in detail d. Demonstrate ADLs frequently Ans: A-The patient who is in state of panic is out of control, and safety is the priority consideration. 31. The patient states, “ I want to talk about elusive bombardment.” The nurse respond: a. “You don’t know what you are talking about.” b. “Just what is elusive bombardment.” c. “Tell me more about this.” d. “Where did you study that?” Ans: B- The nurse’s response should be one that will begin to reorient the patient to reality. This statement should be the opening to make the patient aware that there is no bombardment. 32. The nurse-therapies utilizing cognitive therapy in working with a 35-year-old woman diagnosed with depression. The focus of his approach to therapy is to: a. Learn to intellectualize feelings b. Learn to focus on thought, not feeling c. Replace concrete thinking with abstract d. Replace irrational, negative thinking Ans: D- Cognitive therapy focuses on a resolving cognitive thinking or the making of assumptions without knowing the facts. Cognitive therapy helps to resolve these distortions through positive thinking and restructuring 33. A patient is constantly complaining with a variety of vague aches and pains. A physical exam shows no reason for her symptoms. The nurse: a. Explains that she is not all b. Encourage her to talk c. Gives her sympathy d. Tells her she is psychotic Ans: B- The patient who has psychosomatic complains will benefit from verbalizing her anxieties. 34. During a family therapy session, the family is complaining about excessive bickering at mealtimes. The nurse instructs them to engage in bickering for the minutes at the beginning of each meal. This therapeutic techniques is: a. Self- disclosure b. Paradoxical intervention c. Friendly confrontation d. Family collaboration Ans: B- This intervention is sometimes used when the therapist wants the family to become aware of the absurdity of their actions 35. The nurse is teaching new parents about parenting skills. She explains that a child’s mental health is best promoted by: a. Material goods b. Parents who stay together c. Unconditional love d. Strict discipline Ans: C- From birth, the child needs the unconditional love of significant to feel secure and to learn to trust. 36. After several meetings, then nurse realizes that she has not been able to establish a therapeutic relationship with the patient. What action should be a priority in this situation? a. Refer the patient to another nurse or another unit b. Do a self-assessment on interactions with the patient
c. Limit the amount of time with this particular patient d. Ask the unit manager to change nursing assignment Ans: B- The nurse should assess why she is not able to implement the therapeutic Use of self-establishing a therapeutic relationship with this patient. The nurse should carefully monitor for transference or countertransference issues. 37. For patient in group therapy, the goal is: a. Exchanging information and ideas b. Developing insight by relating to others c. Learning that everyone has problems d. Identifying with other group members e. All of the above Ans: E- The instillation of hope, the imparting of information, altruism, the development of social skills, and corrective emotional experience are therapeutic factors of group therapy that contribute to positive outcomes. 38. A 76-year-old man is sobbing and is quite agitated following the death of his wife from cancer just 6 hours ago. He is not following anyone to talk with or comfort him. He repeats, “I can’t go on without her. I don’t know what I am going to do.” The nurse includes in the plan of care: a. Nutritional needs b. Sleep and rest c. Calling family members d. Suicide precautions Ans: D- The threat of the impulsive act of committing suicide when the man is distraught with grief must be considered in this plan of care. 39. A 19-year-old female has been diagnosed with bulimia and is hospitalized. The nurse enters the room when the patient’s mothers is visiting and asks the patient a question. The mother interrupts as her daughter begins to answer, and the mother answers for her. The nurse should respond by saying: a. To the mother: “ Thank you. I think you are correct.” b. To the patient: “I would like for you to answer.” c. To the patient: “ Do you always let your mother speak for you?” d. To the patient: “ Do you agree with what your mother is saying?” Ans: B-This reply speaks directly to the patient, and elicits a direct response from the patient while indirectly implying to the mother not to answer. 40. The priority in working with a patient with a thought disorder is: a. Get him to understand what you’ve saying b. Get him to do his ADLs c. Reorient him to reality d. Administer antipsychotic medications Ans: C- The person with a thought disorder is not in touch with reality and must be reorient before any other communication takes place. 41. The nurse is taking a history on a female patient with migraine headaches. It is noted that the husband appears more attentive when the patient is complaining of headache pain. This attention may be assessed as a: a. Coping mechanism b. Caring behavior c. Secondary gain d. Positive reinforcement Ans: C- A patient who experience chronic pain may experience a benefit related to having the pain. This benefit, whether it is negative or positive, is called a secondary gain. 42. The family is being taught the safety issues in taking care of the A lzheimer’s patient at home. I initiating the discharge planning, the nurse cautions: a. Medications should be avoided b. That nursing care is very expensive c. Self-care can be accomplished eventually d. Burn-out among family members is common Ans: D- Family members, in the g\beginning, often do not realize the demands in keeping the Alzheimer’s patient in a safe environment. 43. Frustrated parents of a 5-year-old boy are being taught new parenting skills. The man problem is that he throws temper tantrums when he does not get his way. When the parents reward him for handling his frustration in ways other than throwing a tantrum, this concept is called: a. Negative reinforcement b. Positive reinforcement c. Parental modeling d. Cognitive reinforcement Ans: B- Reinforcement is a significant concept of behavioral theory, which states that when a behavior is rewarded, or reinforced, in some way (whether negative or positive) it is likely to be repeated. 44. The nurse-therapist is utilizing cognitive therapy in working with 35-year-old woman diagnosed with depression. The focus of this approach to therapy is to: a. Learn to intellectualize feelings b. Learn to focus on thoughts, not feeling c. Replace concrete thinking with abstract d. Replace irrational, negative thinking
Ans: D- Cognitive therapy focuses on a resolving a cognitive distortion, which is irrational, negative thinking or the making of assumptions without knowing the facts. Cognitive therapy helps to resolve these distortions through positive thinking and restructuring 45. The function of encouraging communication and facilitating group interaction is accomplished by the: a. Contributor b. Hamonizer c. Gate-keeper d. Standard keeper Ans: C- Several different labels are put on the roles that group members assume in group therapy. The gatekeeper assumes the role of regulating who will interact, or participate, ion the group therapy process. 46. The nurse is assessing a patient’s nonverbal behavior. Which is a priority in interpreting this behavior? a. Consider the usual meaning of the behavior b. Consider the patient’s cultural background c. Validate any perceptions with patient d. Consult best reference on nonverbal behavior Ans: C- It is always best to clarify, and not interpret, any behavior the patient is exhibiting, whether it be verbal or nonverbal behavior. 47. The nurse finds a female patient crying in her room. The patient asks the nurse to leave. As the nurse lightly touches her shoulder, the nurse states, “ I would like to stay with you for a while.” The rationale for this action is: a. To show sympathy and understanding b. To show the patient how to help herself c. Convey empathy and a willingness to listen d. Find out what the patient is crying about Ans: C-The best way for the nurse to comfort this patient is to provide a supportive atmosphere. With a light touch and an empathetic voice, this support is conveyed. 48. A young adolescent patient is to be discharged in two days. He has been prescribed Haldol for hallucinations, and will be given a prescription when he goes home. Patient teaching regarding Haldol should begin: a. The day of discharge b. With the discharge summary c. Before the medication is administered d. Whenever the patient can come to the hospital Ans: C- Patient teaching regarding medication, especially psychotropic medications, should begin even before administration. Depending upon the state laws, the patient and /or significant others may be asked to sign an informed consent regarding the medication’s actions and side effects. 49. The patient diagnosed with schizophrenia exhibits an inappropriate affect and shows no interest in communicating with others. This is a part of the schizophrenia process called: a. Paranoia b. Delusions c. Loosening d. Ambivalence Ans: D- One of the most obvious characteristic of schizophrenia is social withdrawal and indifference toward others 50. The nurse is explaining why the family of the schizophrenia patient should participate in therapy. The focus of therapy is: a. Communication and interaction b. Explanation of medications c. Finding the identified patient d. Establishing boundaries Ans: A- The therapy will focus on communicating support to the patient and changing negative interactions. 51. An alcoholic patient asks. “Is there any medication to help me get over this alcoholism?” Which drug may be prescribed? a. Xanax b. Librium c. Antabuse d. Catapres Ans: C- Antabuse is a medications often used in conjunction with behavior modification to stop drinking. If the alcoholic drinks while taking this medication, he will become very ill and will probably require emergency care. 52. In taking with the manipulative patient, the nurse realizes that she must set firm limits. This is particularly necessary because she realizes what this patient is attempting is to: a. Help b. Control c. Gain acceptance d. Be appreciated Ans: B- The manipulative person always to control, and the nurse must be alert assertive in controlling this patient. 53. The nurse is providing patient to the patient who has just diagnosed with major depression and prescribed amitriptyline (Elavil) 50 mg hs. The patient is instructed that medication will take effect.
a. Immediately b. In about 36 hours c. In 14-21 days d. In about a month Ans: C- The depressed patient will begin to feel therapeutic effect of Elavil in 2-3 weeks. However, the patient should be instructed that the sedative effects will take effect immediately
54. In giving a patient information regarding psychotropic medications, the nurse stresses that the primary purpose of these medications is to: a. Cure most psychosis b. Modify learned behavior c. Provide missing chemicals d. Decrease psychotic symptoms Ans: D- The greatest benefit of psychotropic medications is controlling the symptoms enough for the patient to participate in therapy 55. The patient asks the nurse, “What is this therapy for anyway. I just don’t understand it.” The best reply is: a. “It keeps you from being put on medications.” b. It helps you to change other in the family.” c. “The purpose of therapy is to help you change.” d. NO one but professionals can really understand it.” Ans: C- When a person goes into therapy she is , in effect, saying, “I’m not happy with the way things are going.” The primary purpose is to facilitate the change that the person decides to make. 56. Blood levels are drawn on the patient who has been taking Lithium for about six months. The present level is 2.1 mEq/L. The nurse evaluate this level as: a. Therapeutic b. Below therapeutic c. Potentially dangerous d. Fatally toxic Ans: D- The therapeutic level for Lithium is 0.8 to 1.8 mEq/L. Lithium has a narrow therapeutic range and blood levels can become toxic very quickly.
57. A manipulative alcoholic patients asks the nurse to go out with him when he gets out of the hospital. She discusses her role and the importance of a therapeutic relationship with him. Which techniques is she implementing? a. Defining professionalism b. Telling him no politely c. Quietly reprimanding him d. Defining boundaries Ans: D-In a therapeutic relationship, it is important to set limits by establishing boundaries. When the patient attempts to overstep boundaries, the nurse must redefine the limits.
58. While discussing his recent divorce, the nurse states to the patient,” I notice you become anxious when we start talking out your ex-wife.” What communication techniques is being implement? a. Confronting behavior b. Initiating awareness c. Initiating change d. Making an observation Ans: D- The nurse is stating was she assesses. The purpose is to get to patient to confirm the behavior and discuss it. 59. The new patient states,” I just don’t understand this therapy business. What does it do anyway?” The nurse explains that the focus of the therapeutic process is: a. Identifying significant others as support system b. Therapist telling patient what he needs to do c. Recognizing needs and discovering ways to change d. Discovering goals in life Ans: C- Therapy often focuses on what the patient states his needs or problems are, and ideally, he will gain insight and make necessary changes to get these needs filled.
60. In working with a difficult patient, the nurse recognizes that transference is most likely to occur in which stages of therapy? a. Initial b. Working c. Termination d. Preorientation Ans: B- The working stage, when the therapist and the patient are focusing on problems, is when the patient is most likely to experience transference. The therapist should be aware of his in order to facilitate working through this barrier
61. The nursing staff notes that a patient is constantly seeking attention and approval from the staff and other patients. The care plan must address the problem of: a. Displacement b. Regression c. Manipulation d. Compensation Ans: D- The dependent patient usually experience low self-esteem and is constantly seeking approval and attention from to others. 62. A 16-year-old girl states that she doesn’t get along with her mother,” I hate her for what she has done to me.” Then, a few minutes later she tells the therapist, “I can’t help but love my mother for all she has done form e.” The patient is exhibiting: a. Confusion b. Helplessness c. Manipulation d. Ambivalence Ans: D-When a person expresses a love-hate relationship, or exhibits two different behavior regarding another significant person, this is called ambivalence 63. An adolescent,16, who has been diagnosed with schizophrenia, is boasting to peers that he doesn’t need an education or “anything else.” He keeps insisting that he can make a million dollars before he is twenty by creating his own business. He is exhibiting: a. Delusion thinking b. Unrealistic thinking c. Magical thinking d. Delusions of grandeurs Ans: C- Magical thinking is a type of primitive, prelogical thinking like that often seen in normal children with active imaginations. It is common to schizophrenia patients. 64. The nurse is assigned to assist in the administration of electroconvulsive therapy (ECT). She prepares to administer: a. Valium b. Ativan c. Brevital d. Morphine Ans: C- Brevital is muscle relaxant that decreases the jerking movements caused by ECT. 65. The priority nursing intervention while ECT is being administered to the patient? a. Controlling seizure b. Controlling movements c. Watching vital signs d. Maintaining airway Ans: D- since, the patient will undergo a seizure during ECT, the patency of the airway must be constantly monitored. 66. In caring for the alcoholic patient, the nurse recognizes the early signs and symptoms of DTs are: a. Apathy and helplessness b. Fever and chills c. Headaches and restlessness d. Sudden decrease in vital signs Ans: C- The cause of headaches and restless during the onset of delirium tremens (DTs) is not known but is probably related to the response to abrupt withdrawal of alcohol. 67. A patient is admitted with physical restlessness and generalized apprehension. He is expressing pessimism and is having difficulty concentrating in therapy. He states. “I just don’t know what is the matter with me.” The nurse assesses the patient is experiencing: a. Depression b. Obsessions c. Paranoid thoughts d. Free-floating anxiety Ans: D-Free-floating anxiety is the vague sensation that something is wrong. The patient feels helpless in coping with the feeling. 68. The depressed patient who has been taking Nardil states she is going to stop taking the drug. She asks the nurse, ”When can I start eating normally again?” The information that the nurse to a tyramine-free diet for: a. 2-3 days b. About a week c. About 2 weeks d. About a month Ans: C-Nardil is a MAOI, and it takes about 14 days for it to clear the bloodstream. During this period the patient could experience a hypertensive reaction if food with tramline is ingested. 69. The patient has been taking in therapy six weeks working on experiencing and resolving issues related to anger. During on session the patient suddenly states,” I am really getting angry, ”The nurse evaluates this as: a. Repression b. Regression
c. Progress d. Hopeless Ans: c- when the patient begins to express anger and deal with openly, progress begins. 70. The fight-flight response causes increasing blood pressure and heart rate, quickening respiration, dilated pupils, and sweating. What body system initiates this physical stimulation to a psychological stressors? a. Neurological b. Cardiovascular c. Sympathetic nervous system d. Parasympathetic nervous system Ans: C- When a stressors is encountered and a threatening situation occurs the sympathy nervous system responds with a primitive response that prepares the body for fight or flight. 71. A Retired postal worker is being admitted to the psychiatric unit He states to the nurse that he is the president of foreign country and postal executives from all over the world seek his advice on mailing letters. He is exhibiting : a. Delirium b. Illusions c. Grandiosity d. Confabulation ANS: C-When a person, expresses feelings of great importance and delusions of wealth, he is experiencing grandiosity 72. While performing an initial assessment on a patient admitted with depression, what physical aspect is most important to assess? a. Height and weight b. Urinary functioning c. Last menstrual period d. Sleeping patterns Ans: D-A patient suffering depression often complains of early morning awakening difficulty going back to sleep. Medication is sometimes prescribed, and some antidepressants such as Elavil have sedative qualities. 73. The nurse assesses increasing restless, agitation, swinging of legs, and pacing in the patient who has been talking Thorazine 400 mg daily. The nursing evaluation is: a. EPS b. NMS c. Dystonia d. Akathisia Ans: D-Akathisia, a common side effect of phenothiazines is a feeling of uncontrollable restlessness. It is treated by decreasing dose, changing medications, and administering Benadryl. 74. The nurse calls the physician and requires an order for restraints. Which factor will be most decisive when the nurse is face with decision to implement the use of restraints? a. Cooperation b. Safety c. Court orders d. Family request Ans: B-When a patient’s safety is at issue; the use of restrains is warranted. Then nurse should carefully document the safety issue. 75. The nurse is caring for a client with hypochondriasis. Which behavior would the nurse most likely encounter? a.)Ready acceptance of the physician's explanation that all medical and laboratory tests are normal b.)Expression of fear of dying after being diagnosed with advanced breast cancer c.)Expression of fear of colorectal cancer following 3 days of constipation d.)Lack of concern about having a serious disease C. RATIONALE: The client with hypochondriasis is preoccupied with having a serious disease. She may convince herself that a relatively minor symptom, such as constipation, is a sign of a serious disorder. The client's fear of serious illness persists, even after a physician reassures her that all medical and laboratory tests are normal. The fear of dying after receiving a diagnosis of advanced breast cancer wouldn't be considered hypochondriasis. A client with hypochondriasis shows an exaggerated level of anxiety, rather than a lack of concern about having a serious disease or illness. 76. The nurse is caring for a client who has been diagnosed with hypochondriasis. The client attributes his cough to tuberculosis. A chest X-ray and skin test are negative for tuberculosis. The client begins to complain about the sudden onset of chest pain. How should the nurse react initially? a.)Let the client know the nurse understands his fears of serious illness. b.)Encourage the client to discuss his fear of having a serious illness. c.)Report the complaint of chest pain to the physician. d.)Determine if the illness is fulfilling a psychological need for the client. C. RATIONALE: Because of the risk of missing an actual medical problem, any new symptoms reported by a client with hypochondriasis should be reported to the physician. The other interventions are appropriate after the nurse has determined that the client doesn't have a serious medical disorder. 77. The nurse is talking with a client who recently attempted suicide. The client asks h er not to tell anyone one about their conversation. How should the nurse respond?
a.)I'll need to share information with the rest of your health care team if it's important to your care. b.)I promise I won't tell anyone about the information you share with me today. c.)I promise I won't tell anyone about the information you share with me today unless you give me permission to do so. d.)Please don't tell me anything that you wouldn't want others on your health care team to know. A. RATIONALE: The nurse must tell the client that she'll share information if it affects his safety or his care. The nurse shouldn't promise to withhold information because she may not be able to uphold her promise if the information must be shared with others. The nurse shouldn't promise to ask permission before disclosing information to others. The nurse also shouldn't encourage the client to withhold information from her. Doing so violates the nurse's responsibility to develop a therapeutic relationship with the client. The nurse & not the client & should judge what specific information must be shared with others on the health care team. 78. The nurse is administering atropine sulfate to a client about to undergo electroconvulsive therapy. Which assessment indicates that the medication is effective? a.)The client's heart rate is 48 beats/minute. b.)The client states that his mouth is dry. c.)The client appears calm and relaxed. d.)The client falls asleep. B. RATIONALE: Atropine sulfate is administered approximately 30 minutes before electroconvulsive therapy to reduce oral secretions; therefore, the client's mouth would feel dry. Atropine also blocks the vagal stimulation of the heart, causing a rise in heart rate (much higher than 48 beats/minute). Atropine sulfate isn't given to make the client feel calm and relaxed nor does it induce sleep. 79. The nurse is documenting a care plan for a client who has undergone electroconvulsive therapy. Which intervention should the nurse include? a.)Monitoring the client's vital signs every hour for 4 hours b.)Placing the client in Trendelenburg's position c.)Encouraging early ambulation d.)Reorienting the client to time and place D. RATIONALE: Confusion and temporary memory loss are the most common adverse effects of electroconvulsive therapy. The nurse should continually reorient the client to time and place as he wakes up from the procedure. Following electroconvulsive therapy, the nurse should monitor the client's vital signs every 15 minutes for the 1st hour. The nurse should position the client on his side after the procedure to reduce the risk of aspiration. The client should remain on bed rest until he's fully awake and oriented. 80. The nurse is caring for a client in the manic phase of bipolar disorder who is ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is most appropriate? a.)Expressing feelings of anxiety b.)Displaying anger, shouting, and banging the table. c.)Withdrawing from the nurse in silence d.)Rationalizing the termination, saying that everything comes to an end A. RATIONALE: Anxiety is a normal reaction to the termination of the nurse-client relationship. The nurse should help the client explore his feelings about the end of the therapeutic relationship. While anger about the termination may be a healthy response, banging the table, shouting, and other forms of acting out aren't appropriate behavior. Withdrawal isn't a healthy response to the termination of a relationship. By rationalizing the termination, the client avoids expressing his feelings and emotions. 81. A client with a borderline personality disorder has been playing one staff member against another. In formulating a care plan for this client, the nursing staff should include which intervention? a.)Assigning the same staff members to work with the client b.)Avoiding setting limits c.)Rotating staff members who work with the client d.)Avoiding interaction with the client until splitting behaviors stop C. RATIONALE: Rotating staff members who care for a client with borderline personality disorder reduces the incidence of splitting behaviors. Helping the client to learn to relate to several staff members may reduce fears of abandonment. The staff should set limits on unacceptable behaviors; the client doesn't have the self-control to set his own limits. Avoiding the client won't reduce splitting behaviors. The client needs to interact with staff members to develop relationships and reduce fears of abandonment. 82. The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority? a.)Risk for self- or other-directed violence b.)Imbalanced nutrition c.)Ineffective coping d.)Impaired verbal communication A. RATIONALE: Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others. The other options are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him is established. 83. The nurse is teaching a psychiatric client about her prescribed drugs, chlorpromazine and benztropine. Why is benztropine administered?
a.)To reduce psychotic symptoms b.)To reduce extrapyramidal symptoms c.)To control nausea and vomiting d.)To relieve anxiety B. RATIONALE: Benztropine is an anticholinergic medication, administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic medications. Benztropine doesn't reduce psychotic symptoms, relieve anxiety, or control nausea and vomiting. 84. The nurse is leading group therapy with psychiatric clients. During the working phase, what should the nurse do? a.)Explain the purposes and goals of the group. b.)Offer advice to help resolve conflicts. c.)Encourage group cohesiveness. d.)Encourage a discussion of feelings of loss regarding termination of the group. C. RATIONALE: During the working phase, or the middle phase of a group, the nurse continues to encourage cohesiveness among its members. During the orientation phase, or the initial phase, the nurse leading the group should explain the purpose and goals of the group. During the termination phase, or the final phase, the leader encourages a discussion of feelings associated with termination. When leading a group, the nurse should act as a facilitator; offering advice isn't appropriate. The group members should work together to resolve conflicts. 85. A client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse most likely to administer to reduce the symptoms of alcohol withdrawal? a.)Naloxone (Narcan) b.)Haloperidol (Haldol) c.)Magnesium sulfate d.)Chlordiazepoxide (Librium) D. RATIONALE: Chlordiazepoxide and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are administered to treat seizures only if they occur during withdrawal. 86. The client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse? a.)Why didn't you get someone else to drive you? b.)Tell me how you feel about the accident. c.)You should know better than to drink and drive. d.)I recommend that you attend an Alcoholics Anonymous meeting. B. RATIONALE: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that the client isn't capable of making decisions, thus fostering dependency. 87. A client suffers from depression after the accidental death of her daughter. After a suicide attempt, the client is admitted to the psychiatric unit. During the admission interview, the client tells the nurse that she no longer wants to die. The nurse should: a.)suggest that the client no longer requires close observation. b.)place the client in a private room, away from the nurses' station, so that she has privacy to work through the stages of the grieving process. c.)inspect the client's personal belongings for potentially dangerous objects. d.)avoid any further discussion of suicide, unless the client brings up the topic. C. RATIONALE: The client must be protected from harming herself. This includes checking all personal items that the client brought to the hospital, such as a suitcase or pocketbook. The client must be closely observed until she has been evaluated and receives treatment. A client who is suicidal should be placed in a room near the nurses' station in full view of a nurse or other observer. The nurse shouldn't ignore the client's suicide attempt. The client may feel relief talking about the suicide attempt and knowing that she'll be protected from harm. 88. The nurse is caring for a client diagnosed with panic disorder. The client begins to hyperventilate. How should the nurse respond initially? a.)Stay with the client during the panic attack. b.)Shout for help and obtain assistance. c.)Teach the client relaxation exercises. d.)Help the client explore the reason for the anxiety. A. RATIONALE: Because the presence of a calm nurse provides a feeling of security, the nurse should remain with a client during an anxiety attack and assure the client of his safety. Shouting for help and bringing others running to the scene can increase the client's anxiety. The nurse should keep the client's environment calm by reducing noise and limiting the number of people present. Teaching the client relaxation exercises and other methods to reduce stress and exploring the reasons underlying anxiety are important interventions but shouldn't be performed during an anxiety attack. During an attack a client isn't capable of learning new behaviors or achieving insight. 89. The nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention
would best help the client achieve healthy long-term sleeping habits? a.)Administering sleeping pills b.)Encouraging the use of relaxation exercises c.)Suggesting he talk with other clients until he feels ready to sleep d.)Telling him to play ping-pong in the day room B. RATIONALE: Relaxation exercises provide the client with a healthy way to gain control over anxiety. These exercises also produce a physiological response opposite to that produced by stress. Giving a sleeping pill would provide short-term relief for sleeplessness but wouldn't teach healthy sleep habits. Suggesting the client stay up and talk won't help him develop healthy sleep habits or control stress and anxiety. Playing ping-pong or engaging in other exercises just prior to sleep produces a physiological response similar to stress. 90. A teenager was driving a car that slipped off a road in Tagaytay, killing two of his friends. He repeatedly tells the nurse that he should be dead instead of his friends. The client's behavior is an example of: a.)survivor's guilt. b.)denial. c.)anticipatory grief. d.)repression. A. RATIONALE: Individuals who survive a traumatic experience in which others have died commonly report powerful feelings of guilt that they survived and others didn't. This guilt is referred to as survivor's guilt. In denial, a person refuses to accept that a situation or feeling exists. Anticipatory grief occurs when an individual experiences grief before a loss occurs. In repression, an individual involuntarily blocks an unpleasant experience, memory, or feeling from consciousness. 91. The nurse is caring for a client with schizophrenia. Which of the following outcomes is least desirable? a.)The client spends more time by himself. b.)The client doesn't engage in delusional thinking. c.)The client doesn't harm himself or others. d.)The client demonstrates the ability to meet his own self-care needs. A. RATIONALE: The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous objects, and administering medications. Because the client with schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome. 92. The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate? a.)Approach the client and touch him to get his attention. b.)Encourage the client to go to his room where he'll experience fewer distractions. c.)Acknowledge that the client is hearing voices, but make it clear that the nurse doesn't hear these voices. d.)Ask the client to describe what the voices are saying. C. RATIONALE: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination. 93. A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms? a.)Benztropine (Cogentin) b.)Dantrolene (Dantrium) c.)Clonazepam (Klonopin) d.)Diazepam (Valium) A. RATIONALE: Benztropine mesylate is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central ne rvous system (CNS). Dantrolene, a hydantoin drug that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine drug that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine drug, is administered to reduce anxiety. 94. The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? a.)Carbonated beverages b.)Aftershave lotion c.)Toothpaste d.)Cheese
B. RATIONALE: Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese don't contain alcohol and don't need to be avoided by the client. 95. Which statement about somatoform pain disorder is accurate? a.)The pain is intentionally fabricated by the client in order to receive attention. b.)The pain is real to the client, even though there may n ot be an organic etiology for the pain. c.)The pain is less than would be expected from what the client identifies as the underlying disorder. d.)The pain is what would be expected from what the client identifies as the underlying disorder. B. RATIONALE: In a somatoform pain disorder, the client has pain even though a thorough diagnostic work up reveals no organic cause. The nurse must recognize that the pain is real to the client. By refusing to believe that the client is in pain, the nurse impedes the development of a therapeutic relationship based on trust. While somatoform pain offers the client secondary gains, such as attention or avoidance of an unpleasant activity, the pain isn't intentionally fabricated by the client. Even if a pathologic cause of the pain can be identified, the pain is often in excess of what would normally be expected. 96. The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during assessment? a.)History of gainful employment b.)Frequent expression of guilt regarding antisocial behavior c.)Demonstrated ability to maintain close, stable relationships d.)A low tolerance for frustration D. RATIONALE: Clients with an antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a lack of impulse control. They commonly have a history of unemployment, miss work repeatedly, and quit work without plans for other employment. They don't feel guilt about their behavior and commonly perceive themselves as victims. They also display a lack of responsibility for the outcome of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships. 97. The nurse is caring for a client with antisocial personality disorder. Which of the following statements is most appropriate for the nurse to make when explaining unit rules and expectations to the client? a.)"I and other members of the health care team would like you to attend group therapy each day." b.)"You'll find your condition will improve much faster if you attend group therapy each day." c.)"You'll be expected to attend group therapy each day." d.)"Please try to attend group therapy each day." C. RATIONALE: Rules and explanations must be brief, clear, and leave little room for misinterpretation. A client with antisocial personality disorder tends to disregard rules and authority and be socially irresponsible. The words "You'll be expected to attend" are concise and concrete and convey precisely what behavior is expected. The other options leave open the interpretation that attendance is suggested but not mandatory. 98. A 58-year-old client on a mental health unit has lost control, despite having been properly medicated, and is threatening to harm himself and others. He has been placed in four-point restraints. Which nursing measure should be taken next? a.)Release one restraint every 15 minutes. b.)Have a staff member stay with the client at all times. c.)Leave the client alone to reduce his sensory stimulation and allow him to regain control. d.)Restrict fluids until the restraint period is over. B. RATIONALE: A client such as this one needs sensory stimulation and should never be left alone (although the nurse should maintain the client's privacy). Restraints should be removed for 5 minutes at least every 2 hours. A client in restraints should have someone with him at all times. Fluids are offered, and the client is given food at mealtimes. 99. Which nursing assessment has priority while a client's extremities are restrained? a.)Measuring urine output b.)Checking circulation in extremities c.)Assessing pupillary responses d.)Noting respiratory pattern B. RATIONALE: The nurse must check extremities for signs of circulatory impairment. Measuring urine output isn't crucial; the client may void into a urinal as necessary. Assessing pupillary responses isn't relevant to the situation. Although the nurse should check vital signs every 15 minutes for 1 hour, assessment for circulation takes priority over respiratory pattern. 100. A psychiatric client who was voluntarily admitted now wishes to be discharged from the hospital, against medical advice. What's the most important assessment the nurse should make of the client? a.)Ability to care for himself b.)Degree of danger to self and others c.)Level of psychosis
d.)Intended compliance with aftercare B. RATIONALE: A voluntary client who poses a danger to himself or others may be denied permission to leave the hospital. The other options are important assessments, but the client's danger to himself or others takes priority. 2. 51. The client asks the nurse what causes a peptic ulcer to develop. The nurse responds that research indicates that many peptic ulcer are the result of which of the following? a. Work-related stress b. Helicobacter pylori infection c. Diets high in fat d. A genetic defect in the gastric mucosa Ans: B – recent research has indicated that most peptic ulcers may be caused by Helicobacter pylori, which is a gram-negative bacterium. If this organism is detected through diagnostic tests, treatment of the ulcer will indicate the use of antibiotics and bismuth compounds such as Pepto-Bismol. It has not been proven that workrelated stress or a genetic defect causes ulcers. Diets high in fat do not cause peptic ulcer disease. 52. A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information which nursing diagnosis would be most appropriate? a. Imbalanced nutrition: less than body requirements related to anorexia b. Disturbed sleep pattern related to epigastric pain c. Ineffective coping related to exacerbation of duodenal ulcer d. Activity intolerance related to abdominal pain Ans: B – based on the data provided, the most appropriate nursing diagnosis would be disturbed sleep pattern. A client with a duodenal ulcer commonly awakens during the night with pain. The client’s feelings of anxiety do not necessarily indicate that she is coping ineffectively. 53. The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following? a. Bland foods b. High-protein foods c. Any foods that are tolerated d. Large amounts of milk Ans: C – diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts.
54. The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse’s response to observing these actions should be based on knowledge that: a. Involvement with his job will keep the client from becoming bored b. A relaxed environment will promote ulcer healing c. Not keeping up with his job will increase the client’s stress level d. Setting on the client’s behavior is an important nursing responsibility Ans: B – a relaxed environment is an essential component of ulcer healing. Nurses can help clients understand the importance of relaxation and explore with them ways to balance work and family demands to promote healing. Not keeping up with his job will probably increase the client’s stress level, but the nurse’s response is best if it is based on the fact that a relaxed environment is an essential component of ulcer healing. Nurses cannot set limits on a client’s behavior; clients must make the decision to make lifestyle changes. 55. A client with peptic ulcer has been instructed to avoid intense physical activity and stress. Which activity should the client incorporate into the home care plan? a. Conduct physical activity in the morning so that he can rest in the afternoon b. Have the family agree to perform the necessary yard work at home c. Give up jogging and substitute a less demanding hobby d. Incorporate periods of physical and mental rest in his daily schedule Ans: D – it would be most effective for the client to develop a health maintenance plan that incorporates regular periods of physical and mental rest in the daily schedule. Strategies should be identified to deal with the types of physical and mental stressors that the client needs to cope with in the home and work environment. Scheduling physical activity to occur only in the morning would not be restful or practical. There is no need for the client to avoid yard work or jogging if these activities are not stressful. 56. A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The nurse knows that the client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times? a. Before meals b. With meals c. At bedtime d. When pain occurs Ans: C – ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime.
57. A client has been taking aluminum hydroxide (Amphojel) 30 mL is six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client’s constipation? a. The client has not been including enough fiber in his diet b. The client needs to increase his daily exercise c. The client is experiencing a side effect of the aluminum hydroxide d. The client has developed a gastrointestinal obstruction Ans: C – it is most likely that the client is experiencing a side effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction.
58. A client is taking an antacid for treatment of peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? a. “ I should take my antacid before I take my other medications.” b. “ I need to decrease my intake of fluids so that I don’t dilute the effects of my antacid.” c. “ My antacid will be most effective if I take it whenever I experience stomach pains.” d. “ It is best for me to take my antacid 1 to 3 hours after meals.” Ans: D – antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug’s action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing side effects increases. Therefore, the client should not take antacids as often as desired to control pain. 59. Which of the following would be an expected outcome for a client with peptic ulcer disease? a. The client will demonstrate appropriate use of analgesics to control pain b. The client will explain the rationale for eliminating alcohol from the diet c. The client will verbalize the importance of monitoring hemoglobin and hematocrit every 3 months d. The client will eliminate contact sports from his or her lifestyle Ans: B – alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client’s hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing. 60. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of potential complication? a. The client complains of a sore throat b. The client displays signs of sedation c. The client experiences a sudden increase in temperature d. The client demonstrates a lack of appetite Ans: C – the most likely complication of an endoscopic procedure is perforation. A sudden temperature spike within 1 to 2 hours after the procedure is indicative of a perforation and should be reported immediately to the physician. A sore throat is to be anticipated after an endoscopy. Clients are given sedatives during the procedure, so it is expected that they will display signs of sedation after the procedure is completed. A lack of appetite could be the result of many factors, including the disease process.
61. The nurse is completing a health assessment of a 42-year-old woman with suspected Grave’s disease. The nurse should asses this client for: a. Anorexia b. Tachycardia c. Weight gain d. Cold skin Ans: B-grave’s disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increase metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.
62. A female client with thyrotoxicosis would probably report which changes related to the menstrual cycle during initial assessment? a. Dysmenorrhea b. Metrorrhagia c. Oligomenorrhea d. Menorrhagia Ans: C- A change in menstrual interval, diminished menstrual flow (oligomenorrhea), or even the absence of menstruation (amenorrhea) may result from the hormonal imbalances of thyrotoxicosis. Oligomenorrhea in women and decreased libido and impotence in men are common features of thyrotoxicosis. Dysmenorrhea is
painful menstruation. Metrorrhagia, blood loss between menstrual periods, is a symptom of hypothyroidism.
63. Prophylthiouracil (PTU) is prescribed for a client with Grave’s disease to decrease circulating thyroid hormone. The nurse should teach the client to immediately report which of the following signs and symptoms? a. Sore throat b. Painful, excessive menstruation c. Constipation d. Increased urine output Ans: A- The most serious side effect of PTU are leukopenia and agranulocytosis, which usually occur within the first three months of treatment. The client should be thought to promptly report to the health care provider any signs and symptoms of infection, such as sore throat and fever. Any client complaining of sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be held until the result are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy. 64. A client with thyrotoxicosis says to the nurse, “ I am so irritable. I am having problems at work because I lose my temper very easily.” Which of the following responses by the nurse would give the client the most accurate explanation of her behavior? a. “ Your behavior is caused by temporary confusion brought on by your illness.” b. “ Your behavior is caused by the excess thyroid hormone in your system.” c. “ Your behavior is caused by your worrying about the seriousness of your illness.” d. “ Your behavior is caused by the stress of trying to manage a career and cope with illness.” Ans: B- A typical signs of thyrotoxicosis is irritability caused by the high level of circulating thyroid hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about her illness, and stress may influence her mood; however, irritability is common symptom of thyrotoxicosis and the client should be informed of that fact rather than blamed. 65. Serum concentrations of thyroid hormones and thyroid-stimulating hormone (TSH) are tests ordered for the client with thyrotoxicosis. Which of the following laboratory values are indicative of thyrotoxicosis? a. Elevated thyroid hormone concentrations and normal TSH b. Elevated TSH and normal concentrations and elevated TSH c. Decreased thyroid hormone concentrations and elevated TSH d. Elevated thyroid hormone concentrations and decreased TSH Ans; D- Elevated serum concentrations of thyroid hormones and suppressed serum TSH are the features of thyrotoxicosis. Decreased or absent serum TSH is very accurate indicator of thyrotoxicosis. Increase level of circulating thyroid hormones cause the feedback mechanism to the brain to suppress TSH secretion. 66. The nurse should teach the client to prevent corneal irritation from mild exophthalmos by: a. Massaging the eyes at regular intervals b. Instilling an ophthalmic anesthetic as ordered c. Wearing dark-colored glasses d. Covering both eyes with moistened gauze pads Ans C- Treatment of mild opthalmopathy that may accompany thyrotoxicosis includes measures such as wearing sunglasses to protect the eye from corneal irritation. Treatment of opthalmopathy should be performed in consultation with an opthalmologist. Massaging the eye will not help to protect the cornea. An ophthalmic anesthetic is used to examine and possibly treat a painful eye, not protect the cornea. Covering the eyes with moist gauze pads is not satisfactory nursing measure to protect the eyes of the client with exopthalmus because treatment is not focused on moisture to the eye but rather on protecting the cornea and optic nerve. In exopthalmus, the retrobulbar connective tissues and extraocular muscle volume are expanded because of fluid retention. The pressure is also increased.
67. A client with Grave’s disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works? a. “ The radioactive iodine stabilizes the thyroid hormone levels before a thyroidectomy.” b. “ The radioactive iodine reduces uptake of thyroxine and thereby improves your condition.” c. “ The radioactive iodine lowers the levels of thyroid hormones by slowing your body’s production of them.” d. “ The radioactive iodine destroys thyroid tissue so that thyroid hormones are no longer produced.” Ans: D- Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones are no longer produced. Use of RAI is often recommended for many clients with Grave’s disease, especially the elderly. The treatment results in “ medical thyroidectomy”. RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of thyroxine. The outcome of giving the RAI is the destruction of thyroid follicular cells. It is possible to slow the production of the thyroid hormones with RAI.
68. Which of the following nursing diagnoses would most likely be appropriate for a client with Grave’s disease performing self-care after treatment with RAI in the form of sodium iodide 131I? a. Risk for injury related to altered level of consciousness b. Ineffective breathing pattern related to effects of radioactive iodine c. Total self-care deficit related to the need for immobilization after RAI therapy d. Risk for ineffective therapeutic regimen related to lack of knowledge about disease management Ans: D- management of the disease process is priority for the client who has undergone RAI therapy with sodium
iodide 131I. Signs of hyperthyroidism usually persist for 1 to 2 months and may be still present for up to 1 year until thyroid hormone production stops. Permanent hypothyroidism is the major complication of radioactive treatment. At that time, the client will be able to recognize symptoms of hypothyroidism. Changes in level of consciousness or breathing pattern are not expected. The client does not need to be immobilized after RAI treatment. 69. After treatment with RAI in the form of sodium iodide 131I, the n urse teaches the client to: a. Monitor signs and symptoms of hyperthyroidism b. Rest for 1 week to prevent complications of the medication c. Take thyroxine replacement of the remainder of the client’s life d. Assess for hypertension and tachycardia resulting from altered activity Ans: C- The client needs to be educated about the need for lifelong thyroid hormone replacement. Permanent hypothyroidism is the major complication of RAI 131I treatment. Lifelong medical follow-up and thyroid replacement are warranted. The client needs to monitor for signs and symptoms of hypothyroidism, not hyperthyroidism. Resting for 1 week is not necessary. Hypertension and tachycardia are signs of hyperthyroidism, not hypothyroidism. 70. A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The primary reason for using this drug is that it helps; a. Slow progression of exophthalmos b. Reduce the vascularity of the thyroid gland c. Decrease the body’s ability to store thyroxine d. Increase the body’s ability to excrete thyroxine Ans: B- SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that present a hazard during surgery. Preparation of the client or surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exopthalmus, and it does not decrease the body’s ability to store thyroxine or increase the body’s ability to excrete thyroxin.
71. Which of the following measures is most recommended when preparing SSKI for administration? a. Pour the solution over ice chips b. Mix the solution with water, milk or fruit d. Dilute the solution with water, milk fruit juice and have the client drink it with a straw Disguise the solution in a pureed fruit or vegetable Ans: C- SSKI should be diluted well in milk, water, juice, or carbonated beverage before administration to disguise the strong, bitter taste. Also, this drug is irritating to mucosa if taken undiluted. The client should sip the diluted preparation through a drinking straw to prevent staining of the teeth. Pouring the solution over ice chips will not sufficiently dilute the SSKI or cover the taste. Antacids are not used to dilute or cover the taste of SSKI. Mixing in a purée would put the SSKI in contact with the teeth.
72. The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this primarily to monitor for signs of which of the following? a. Internal hemorrhage b. Decreasing level of consciousness c. Laryngeal nerve damage d. Upper airway obstruction Ans: C- Laryngeal nerve damage is not a potential complication of thyroid surgery because of the proximity of the thyroid gland to the recurrent laryngeal nerve. Asking the client to speak helps to Asses for signs of laryngeal nerve damage. Persistent or worsening hoarseness and weak voice are signs of laryngeal nerve damage and should be reported to the physician immediately. Internal hemorrhages are detected by changes in vital signs. The client’s level; of consciousness can be partially assed by asking her to speak, but it is n ot the primary reason for doing so in this situation. Upper airway obstruction is detected by color and respiratory rate pattern. 73. A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to: a. Begin total parenteral nutrition b. Start a cutdown infusion c. Administer tube feedings d. Perform a tracheostomy Ans: D- Equipment for an emergency tracheostomy should be kept in the room, in case tracheal edema and airway occlusion occur. Laryngeal nerve damage can result in vocal cord spasm and respiratory obstruction. A tracheostomy set , oxygen and suction equipment, and suture removal set ( for respiratory distress from hemorrhage) make up the emergency equipment that should be readily available. Total parenteral nutrition is not anticipated for the client undergoing thyroidectomy. Intravenous infusion via a cutdown is not expected possible treatment for thyroidectomy. Tube feedings are not anticipated emergency care. 74. Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy? a. Pains in the joints of the hands and feet b. Tingling in the fingers
c. Bleeding on the back of the dressing d. Tension on the suture line Ans: B- Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed during surgery. This would cause a disturbance in serum calcium levels. An early sign of tetany is n umbness and tingling of the fingers or toes and in the circumoral region. Tetany may occur from 1 to 7 days postoperatively. Late signs of tetany include seizures, contraction of the glottis, and respiratory obstruction. Pains in the joints of the hands and feet are not early symptoms of tetany. Bleeding on the back of the dressing is related to possible incisional complications. Tension on the suture line may indicate swelling, infection, or internal bleeding, but it is not related to tetany. 75. Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? a. Sodium phosphate b. Calcium gluconate c. Echothiophate iodide d. Sodium bicarbonate Ans: B- The client with tetany is suffering from hypocalcemia, which is treated by administering an intravenous preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then necessary until parathyroid function returns. Sodium phosphate is a laxative. Echothiopate iodide is an eye preparation used as miotic for antiglaucoma effect. Sodium bicarbonate is a potent systemic antacid. 76. A 60-year-old woman is diagnosed with hypothyroidism. Signs and symptoms of hypothyroidism include: a. Tachycardia b. Weight gain c. Diarrhea d. Anorexia Ans: B- Typical symptoms of hypothyroidism include weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, hair loss, constipation, and numbness and tingling of fingers. Tachycardia is sign of hyperthyroidism, not hypothyroidism. Diarrhea and anorexia are not symptoms of hypothyroidism. 77. Appropriate nursing diagnoses for a client with hypothyroidism would probably include which of the following? a. Risk for injury (corneal abrasion) related to incomplete closure of eyelid b. Imbalanced nutrition: less than body requirements related to hypermetabolism c. Deficient fluid volume related to diarrhea d. Activity intolerance related to fatigue associated with the disorder Ans: D- A major problem for the person with hypothyroidism is fatigue. Other sign and symptoms include lethargy, personality changes, generalized edema, impaired memory, slowed speech, cold intolerance, dry skin, muscle weakness, constipation, weight gain, and hair loss. Incomplete closure of the eyelids, hypermetabolism, and diarrhea are associated with hyperthyroidism. 78. When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are: a. The effects of thyroid hormone replacement therapy and will diminish over time b. Related to the thyroid hormone replacement therapy and will not diminish over time c. A normal part of having a chronic illness d. Most likely related to low thyroid hormone levels and will improve with treatment Ans: D- Hypothyroidism may contribute to sadness and depression. It is good practice for clients with newly diagnosed depression to be monitored for hypothyroidism by checking the thyroid hormone and TSH levels. This client needs to know that these feelings may be related to her low thyroid hormone levels and may improve with treatment. Replacement therapy does not cause depression. Depression may accompany chronic illness, but it is not “ normal.”
79. A 55-year-old male client has recently been diagnosed with type 2 diabetes mellitus (DM) and is prescribed the sulfonylurea compound tolbutamide (Orinase). He is concerned about the diagnosis and says he knows nothing about diabetes. The nurse determines that the client needs teaching and support. The nurse explains that tolbutamide is believed to lower the blood glucose level by which of the following actions? a. Potentiating the action of insulin b. Lowering the renal threshold of glucose c. Stimulating insulin release from functioning beta cells in the pancreas d. Combining with glucose to render it inert. Ans: C – oral hypoglycemic agents of the sulfonylurea group, such as tolbutamide (Orinase),lower the blood glucose level by stimulating functioning beta cells in the pancreas to release insulin. These agents also increase insulin’s ability to bind to the body’s cells. They may also act to increase the number of in sulin receptors in the body. Tolbutamide does not potentiate the action of insulin. Tolbutamide does not lower the renal threshold of glucose, which would not be a factor in the treatment of diabetes in any case. Tolbutamide does not combine with glucose to render it inert. 80. When teaching the diabetic client about foot care, the nurse should instruct the client to do which of the following: a. Avoid going barefoot b. Buy shoes a half size larger c. Cut toenails at angles
d. Use heating pads for sore throat Ans: A – the client with diabetes is prone to serious foot injuries secondary to peripheral neuropathy and decreased circulation. The client should be taught to avoid going barefoot to prevent injury. Shoes that do not fit properly should not be worn, because they will cause blister that can become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight across. A heating pad should not be used because at risk for burns to insensitivity to temperature. 81. A client with DM asks the nurse to recommend something to remove corns from his toes. The nurse should advise him to: a. Apply a high-quality corn plaster to the area b. Consult his physician or podiatrist about removing the corns c. Apply iodine to the corns before peeling them off d. Soak his feet in borax solution to peel off the corns Ans: B – a client with diabetes should be advised to consult a physician or podiatrist for corn removal because of the danger or traumatizing the foot tissue and potential development of ulcers. The diabetic client should never self-treat foot problems but should consult a physician or podiatrist. 82. A client with DM presents to the clinic for a regular 3-month follow-up appointment. The nurse notes several small bandages covering cuts on the client’s hands. The client says, “ I’m so clumsy. I’m always cutting my finger cooking or burning myself on the iron.” Which of the following responses by the nurse would be most appropriate? a. “ Wash all wounds in isopropyl alcohol.” b. “ Keep all cuts clean and covered.” c. “ Why don’t you have your children to do the cooking and ironing?” d. “ You really should be fine as long as you take your daily medication.” Ans: B – proper and careful first-aid treatment is important when a client with diabetes has a skin cut or laceration. The skin should be kept supple and as free or organisms as possible. Washing and bandaging the cut will accomplish this. Washing wounds with alcohol is too caustic and drying to the skin. Having the children help is an unrealistic suggestion and does not educate the client about proper care of wounds. Tight control of blood glucose levels through adherence to the medication regimen is vitally important; however, it does not mean that careful attention to cuts can be ignored.
83. The client with DM says, “ If I could just avoid what you call carbohydrates in my diet, I guess I would be okay.” The nurse should base the response to this comment on the knowledge that diabetes affects metabolism of which of the following? a. Carbohydrates only b. Fats and carbohydrates only c. Protein and carbohydrates only d. Proteins, fats, and carbohydrates Ans: D – DM is a multifactorial, systemic disease associated with problems in the metabolism of all food types. The client’s diet should contain appropriate amounts of all three nutrients, plus adequate minerals and vitamin.
84. A client with type 1 DM is admitted to the emergency department. Which of the following respiratory patterns requires immediate action? a. Deep, rapid respirations with long expirations b. Shallow respirations alternating with long expirations c. Regular depth of respirations with frequent pauses d. Short expirations and inspirations Ans: A – deep, rapid respirations with long expirations is indicative of Kussmaul’s respiration, which occurs in metabolic acidosis. The respirations increase in rate and depth, and the breath has a “ fruity” or acetone-like odor. This breathing pattern is the body’s attempt to blow off carbon dioxide and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to ketoacidosis and would not compensate for the acidosis.
85. The nurse should caution the client with DM who is taking a sulfonylurea medication that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following? a. Hypokalemia b. Hyperkalemia c. Hypocalcemia d. Disulfiram (Antabuse)-like symptoms Ans: D – a client with diabetes who takes any first-or second-generation sulfonylurea should be advised to avoid alcohol intake. Sulfonylurea in combination with alcohol can cause serious reactions of disulfiram (Antabuse)-like reactions including flushing, angina, palpitations, and vertigo. Serious reactions such as seizures and possibly death may also occur. Hypokalemia, Hyperkalemia, and hypocalcemia do not result from taking sulfonylureas in combination with alcohol. 86. A client with allergic rhinitis is instructed on the correct technique for using an intranasal inhaler. Which of the following statements would demonstrate to the nurse that the client understands the instructions? a) “ I should limit the use of the inhaler to early morning and bedtime use.” b) “ It is important to not shake the canister, because that can damage the spray device.” c) “ I should hold one nostril closed while I insert the spray into the other nostril.” d) “ The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall.”
Ans: C- When using an intranasal inhaler, it is important to close off one nostril while inhaling the spray into the nostril to ensure the best inhalation of the spray. Use of inhaler is not limited to mornings and bedtime. The canister should be taken immediately before use. The inhaler tip should be inserted into the nostril and pointed toward the outside nostril wall to maximize the inhalation of medication. 87. Which of the following would be an expected outcome for a client recovering from an u pper respiratory tract infection? a) The client maintains a fluid intake of 800 mL every 24 hours b) The client experiences chills only once a day c) The client coughs productively without chest discomfort d) The client experiences less nasal obstruction and discharge Ans: D- A client recovering from upper respiratory tract infection should report decreasing or no nasal discharge or obstruction. Daily fluid intake should be increased to more than 1 L every 24 hours to liquefy secretions. The temperature should be below 100ºF (37.8ºC) with no chills or diaphoresis. A productive cough with chest pain indicates pulmonary infection, not an upper respiratory tract infection. 88. The nurse teaches the client how to instill nasal drops. Which of the following techniques is correct? a) The client uses sterile technique when handling the dropper b) The client blows the nose gently before instilling drops c) The client uses a new dropper for each installation d) The client sits in a semi-fowler’s position with the head tilted forward after administration of the drops Ans: B- The client should blow the nose before instilling nose drops. Instilling nose drops is a clean technique. The dropper should be cleaned after each administration, but it does not to be changed. The client should assume a position that will allow the medication to reach the desired area; this is usually supine position. 89. A client with acute sinusitis is examined in an ambulatory clinic. The nurse can anticipate the use of which of the following medications in the client’s treatment plan? a) Antibiotics b) Antihistamines c) Bronchodilators d) Oral corticosteroids Ans: A- The plan of care for a client who has acute sinusitis includes antibiotics to treat the bacterial infection. In addition the nasal cortecosteroids and decongestants are frequently ordered to decrease mucosal inflammation and edema. Nasal cortecosteroids are preferred to oral cortecosteroids because they do not produce systematic side effects when used as prescribed. Anti histamines can promote an increase in secretion viscosity and continued symptoms; they should be avoided. Bronchodilators are ineffective in sinusitis. 90. The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis? a) Avoid the use of caffeinated beverages b) Perform postural drainage every day c) Take hot showers twice daily d) Report a temperature of 102oF (38.9oC) or higher Ans: C- The client with chronic sinusitis should be instructed to take hot showers in the morning and evening to promote drainage of secretions. There is no need to limit caffeine intake. Performing postural drainage will inhibit removal of secretions, not promote it. Clients should elevate the head of the bed to promote drainage. Client should report all temperature higher than 100.4ºF (38ºC), because a temperature that is high can indicate infection. 91. Which of the following individuals would the nurse consider to have the highest priority for receiving an influenza vaccination? a) A 60-year-old man with a hiatal hernia b) A 36-year-old woman with three children c) A 50-year-old woman caring for a spouse with cancer d) A 60-year-old woman with osteoarthritis Ans: C- Individuals who are household members or home care providers for high-risk individuals are high priority targeted groups for immunization against influenza to prevent transmission to those who have a decreased capacity to deal with the disease. The wife who is caring for the husband with a cancer has the highest priority of the clients described, because her husband is likely to be immunocompromised and particularly susceptible to flu. A healthy 60-year old man or 36-year-old woman is not in a high priority category for influenza vaccination than a home care provider. 92. A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client? a) “ Use your nasal decongestant spray regularly to help clear your nasal passages.” b) “ Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.” c) “ It is important to increase you activity. A daily brisk walk will help promote drainage.” d) “ Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks.” Ans: D- it is important for clients with allergic rhinitis to determine the precipitating factors so that they can be avoided. Keeping a diary can help identify these triggers. Nasal decongestant sprays should not be used regularly because they can cause a rebound effect. Antibiotics are not appropriate for allergic rhinitis because an infection is not present. Increasing activity will not control the client’s symptoms; in fact walking outdoors may increase them if the client is allergic to pollen. 93. An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings?
a) It is likely that the client is developing a secondary bacterial pneumonia. b) The assessment findings are consistent with influenza and are to be expected c) The client is getting dehydrated and needs to increase her fluid intake to decrease secretions d) The client has not been taking her decongestants and bronchodilators as prescribed Ans: A- pneumonia is the most common complication of influenza, especially in the elderly. The development of purulent cough and crackles may be an indicative of bacterial infection and are consistent with diagnosis of influenza. These findings are not indicative of dehydration. Decongestants and bronchodilators are not typically prescribed for the flu. 94. Guaifenesin 300 mg four times a day has been ordered as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose? a) 5.0 mL b) 7.5 mL c) 9.5 mL d) 10.0 mL Ans: B- 300 mg/x= 200 mg/ 5 ml; x= 7.5 mL 95. Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible side effect of this drug? a) Constipation b) Bradycardia c) Diplopia d) Restlessness Ans:D Side effects of pseudoephedrine are experienced primarily in the cardiovascular system and through sympathetic effects on the central nervous system (CNS) The most common CNS side effects include restlessness, dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular side effects include tachycardia, hypertension, palpitations and arrhythmias. Constipation and diplopia are not side effects of pseudoephedrine. Tachycardia and not bradycardia is a side effect of pseudoephedrine.
96. A 27-year-old woman has had elective nasal surgery for a deviated septum. Which of the following would be an important initial clue that bleeding was occurring even if the nasal drip pad remained dry and intact? a) Complaints of nausea b) Repeated swallowing c) Increased respiratory rate d) Increased pain Ans: B- Because of the dense nasal packing, bleeding may not be apparent through the nasal drip pad. Instead the blood may run down the throat, causing the client to swallow frequently. The back of the throat, where blood will be apparent, can be assessed with a flashlight. An accumulation of blood in the stomach can cause nausea and vomiting, but nausea would not be the initial indicator of bleeding. 97. A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. Which of the following discharge instructions would be appropriate for the client? a) Avoid activities that elicit the valsalva maneuver b) Take aspirin to control nasal discomfort c) Avoid brushing the teeth until the nasal packing is removed d) Apply heat to the nasal area to control swelling Ans: A- The client should be instructed to avoid any activities that cause Valsalva’s maneuver (eg. Constipation, vigorous coughing, exercise) in order to reduce bleeding and stress on suture line. The client should n ot take aspirin because of its antiplatelet properties, which may cause bleeding. Oral hygiene is important to rid the mouth of old dried blood and to enhance the client’s appetite. Cool compresses, not heat, should be applied to decrease swelling and control discoloration of the area. 98. Which of the following statements would indicate to the nurse that a client has understood the discharge instructions provided after her nasal surgery? a) “ I should not shower until my packing is removed.” b) “ I will take stool softeners and modify my diet to prevent constipation.” c) “ Coughing every 2 hours is important to prevent respiratory complications.” d) “ It is important to blow my nose each day to remove the dried secretions.” Ans: B- Constipation can cause straining during defecation, which can induce bleeding. Showering is not contraindicated. The client should take measure to prevent coughing, which can cause bleeding. The client should avoid blowing her nose for 48 hours after the packing is removed. Thereafter, she should blow her nose gently, using the open-mouth technique to minimize bleeding in the surgical area. 99. The nurse is planning to give preoperative instructions to a client who will be undergoing rhinoplasty. Which of the following instructions should be included? a) After surgery, nasal packing will be place for 7 to 10 days b) Normal saline dose drops will need to be administered preoperatively c) The results of the surgery will be immediately obvious postoperatively d) Aspirin-containing medications should not be taken for 2 weeks before surgery Ans: D- Aspirin-containing medications should be discontinued for 2 weeks before surgery to decrease the risk of bleeding. Nasal packing is usually removed the day after surgery. Normal saline drops are not routinely administered pre-operatively. The result of surgery will not be obvious immediately after surgery because of edema and ecchymosis. 100. Which of the following assessments would be a priority immediately after nasal surgery? a) Assessing the client’s pain
b) Inspecting for periorbital ecchymosis c) Assessing respiratory status d) Measuring intake and output Ans: C- Immediately after nasal surgery, ineffective breathing patterns may develop as a result of nasal packing and nasal edema. Nasal packing may dislodge, leading to obstruction. Assessing airway obstruction is a priority Assessing for pain is important, but it is not as a high priority as assessment of the airways. It is too early to detect ecchymosis. Measuring intake and output is not typically a priority nursing assessment after nasal surgery.
. At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? a. At bedtime b. On arising c. Immediately after a meal d. On an empty stomach Ans: C – drugs that cause gastric irritation, such as ibuprofen (Motrin), are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will lead to gastric irritation. Taking the drug at bedtime with food may cause the client to gain weight, possibly aggravating the osteoarthritis. When the client arises, he is stiff from immobility and should used warmth and stretching until he gets food in his stomach. 2. When preparing a teaching plan for the client with osteoarthitis who is taking celexocib (Celebrex), the nurse expects to explain that the major advantage of celecoxib over diclofenac (Voltaren) is that celecoxib is less likely to produce which of the following? a. Hepatotoxicity b. Renal toxicity c. Gastrointestinal (GI) bleeding d. Nausea and vomiting Ans: C – the major advantage of celecoxib (Celebrex), the new generation of cyclooxygenase-2 (COX-2) inhibitors, over diclofenac (Voltaren), a COX-1 inhibitor, is that celecoxib is less likely to produce GI problems such as ulcers and bleeding. There is no evidence of less hepatotoxicity, renal toxicity, or nausea and vomiting with COX-2 inhibitors. 3. The client diagnosed with osteoarthritis states, “ My friend takes steroid pills for her rheumatoid arthritis. Why don’t take steroids for my osteoarthritis?” The nurse’s response to the client is based on an understanding of which of the following? a. Intra-articular corticosteroid injections are used to treat osteoarthritis b. Oral corticosteroids can be used in osteoarthritis c. A systemic effect is needed in osteoarthritis d. Rheumatoid arthritis and osteoarthritis are two s imilar diseases Ans: –A- Rheumatoid arthritis and osteoarhtritis are two different diseases. Cortecosteroids are used for patient with osteoarthritis to obtain a local effect. Therefore, they are given only via intra-articular injection. Oral cortecosteroids are avoided because they can cause an acceleration of osteoarthritis. 4. In preparation for total knee surgery, a 200-pound client with osteoarthritis is being discharged from the hospital to lose weight to reduce the risks of anesthesia. In conjunction with a weight loss program, which of the following exercises would the nurse recommend as best if t he client has no contraindications? a. Weight lifting b. Walking c. Aquatic exercise d. Tai chi exercise Ans: C – When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allow the client o burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote a healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client’s osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be best exercise for this client to help with weight loss. 5. The physician recommends a total hip replacement for a client with osteoporosis who reports increasingly severe pain in the left hip. The nurse would initiate the preoperative teaching plan for the client, beginning with which of the following? a. Teaching how to prevent hip flexion b. Demonstrating coughing and deep breathing techniques c. Showing the client what an actual hip prosthesis looks like d. Assessing the client’s fears about the procedure Ans: – D- before implementing teaching plan, the nurse should determine the client’s fears about the procedure. Only then the client begin to hear what the nurse has to share about the individualized teaching plan designed to meet the clients needs. In the preoperative period, the clients needs to learn how to correctly prevent hip flexion and to demonstrate coughing and deep breathing. However, this teaching can be effective only after the clients fear has been assessed. and addressed. Although the client may appreciate seeing what a hip prosthesis looks like, so as to understand the new body part, this is not a necessity. 6. After the client undergoes a total knee replacement for severe osteoarthritis, which of the following assessment findings would lead the nurse to suspect possible nerve damage? a. Numbness
b. Bleeding c. Dislocation d. Pinkness Ans: – A- The urse would suspect a nerve damage if numbness is present. However, the damage is short term and related to edema or long term and related to permanent nerve damage would not be clear at this point. The nurse need to continue to assess the client’s neurovascular status, including pain, pallor, pulselessnes, parenthesis, and paralysis (the five P’s). Bleeding would suggest vascular damage or hemorrhage. Dis location would suggest malalignment. Pink color would suggest adequatwe circulation to area. Numbness would suggest neurologic damage. 7. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and inability to move the extremity. The nurse interprets these findings as indicating which of the following? a. A developing infection b. Bleeding in the operative site c. Joint dislocation d. Glue seepage into soft tissue Ans: C – The joint has dislocated when the client with total joint prosthesis develops sudden severe pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness erythema, and possibly drainage and separation of the wound. Bleeding could be external (eg. Blood visible from the wound or on the dressing) or internal and manifested by signs of shock (eg. Pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue dries into hard fixed form before the wound is closed 8. Which of the following would the nurse assess in a client with an intracapsular hip fracture? a. Internal rotation b. Muscle flaccidity c. Shortening of affected leg d. Absence of pain in the fracture area Ans: – C- With an intracapsular hip fracture, the affected leg is shorter than the unaffected leg because of the muscle spasms and external rotation. The client also experiences severe pain in the region of the fracture. 9. When developing the plan of care for an older adult client with a hip fracture, which of the following chronic health problems would the nurse be lest likely to assess in the client? a. Hypertension b. Cardiac decompensation c. Pulmonary disease d. Multiple sclerosis Ans: D – Multiple sclerosis would be the least likely chronic health problem for an older adult with a hip fracture, Typically, multiple sclerosis is consider a severe crippling disorder of young adults. Hypertension is a common chronic health problems in older adults. Cardiac decompensation is common on older adults; it arises from cardiac musculature changes and age-related changes in the heart. This comorbid condition can complicate the treatment and care when the older adult experiences a hip fracture. Pulmonary disease commonly arises from age-related changes in the respiratory system. These comorbid conditions can complete the treatment and care when the other adult experiences a hip fracture. 10. When teaching a client with an extracapsular hip fracture scheduled for surgical internal fixation with the insertion of a pin, the nurse bases the teaching on the understanding that this surgical repair is the treatment of choice for which of the following reasons? a. Hemorrhage at the fracture site is prevented b. Neurovascular impairment risk is decreased c. The risk for infection at the site is lessened d. The client is able to be mobilized sooner Ans: D – insertion of a pin for the internal fixation of a extracapsular fractured hip provides good fixation of the fracture. The fracture is site is stabilized and fractured bone ends are well approximated. As result, the client is able to be mobilized sooner, thus reducing the risks of complications related to immobility. Internal fixation with a pin insertion does not prevent hemorrhage or decrease the risk for neurovascular impairment, potential complications associated with any joint or bone surgery. It does not lessen the client’s risk infection at the site. 11. A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, “ Why does she h ave this tube inserted in her hip?” Which of the following responses by the nurse demonstrates understanding of the primary purpose for this drainage tube? a. “ The tube helps us to detect a wound infection early on.” b. “ This way we won’t have to irrigate the wound.” c. “ Fluid won’t be allowed to accumulate at the site.” d. “ We have a way to administer antibiotics into the wound.” Ans: C – the primary purpose of the drainage tube is to prevent fluid accumulation in the wound. Fluid when it accumulates creates dead space. Elimination of the dead space by keeping the wound free of fluid greatly enhances wound healing and helps prevent abscess formation. Although the characteristics of the drainage from the tube, such as a change in color or appearance, may suggest a possible infection, this is not the tube’s primary purpose. The drainage tube does not eliminate the need for wound irrigation or provide a way to instill antibiotics into the wound. 12. When assessing a client who has just received a femoral head prosthesis, which of the following would alert the nurse to the possibility of neurologic a. Decreased distal pulse b. Inability to move
c. Diminished capillary refill d. Coolness to the touch Ans: B – being unable to move the affected leg suggest neurologic impairment. A decrease in the distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest vascular compromise. 13. A client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which of the following activities would the nurse instruct the client to avoid? a. Crossing the legs while sitting down b. Sitting on a raised commode seat c. Using an abductor splint while lying on the side d. Rising straight from a chair to a standing position Ans: A – any activity or position that causes flexion, adduction, or internal rotation of greater than 90 degrees should be avoided until the soft tissue surrounding the prosthesis has stabilized, at approximately 6 weeks. Crossing the feet while sitting down can lead to dislocation of the femoral head from the hips socket. Sitting on a raised commode seat prevents hip flexion and adduction. Using an abductor splint while side-lying keeps the hip joint in abduction, thus preventing adduction and possible dislocation. Rising straight from a chair to a standing position is acceptable for this client because this action avoids hip flexion, adduction, and internal rotation of greater than 90 degrees. 14. The nurse encourages the client who has h ad a femoral head prosthesis placement to use which of the following types of chairs to sit in during the first 6 to 8 weeks after surgery? a. A desk-type swivel chair b. A padded upholstered chair c. A high-backed chair with armrests d. A recliner with an attached footrest Ans: C – a high-backed straight chair with armrests is recommended to help keep the client in the best possible alignment after surgery for a femoral head prosthesis placement. Use of this type of chair helps to prevent dislocation of the prosthesis from the socket. A desk-type swivel chair, padded upholstered chair, or recliner should be avoided because it does not provide for good body alignment and can cause the overly flexed femoral head to dislocate. 15. While assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning, which of the following would pose the greatest hazard to the client as a risk for falling at home? a. A 4-year-old cooker spaniel b. Scatter rugs c. Snack tables d. Rocking chairs Ans: B – although pets and furniture such as snack tables and rocking chairs may pose a problem, scatter rugs are the single greatest hazard in the home, especially for elderly people who are ensure and unsteady with walking. Falls have been found to account for almost half of the accidental deaths that occur in the home. The risk for falls is further compounded by the client’s need for crutches. 16. Which of the following activities would the nurse instruct the client with low back pain to avoid? a. Keeping light objects below the level of the elbows when lifting b. Leaning forward while bending the knees c. Exceeding prescribed exercise program d. Sleeping on the side with legs flexed Ans: C – the client with low back should not exceed prescribed exercises even though they may think, “ If this will make me well, double will make me well quicker.” When exceeding prescribed exercise programs, the client’s muscle may be unconditioned and easily tired, leading to injury and increased pain. To use proper body mechanics when lifting light objects, the client should bring the item close to the center of gravity, which occurs when the object is kept below the level of the elbows. Leaning forward while bending the knees allows for the muscles of the thigh to be used instead of those of the lower back. Sleeping on the side with the legs flexed is appropriate because the spine is kept in a neutral position without twisting or pulling on muscles. 17. A client was brought to the hospital because he could not get out of bed because of low back pain radiating down to his right heel and lateral foot. When developing the client’s plan of care, which of the following categories of medication would the nurse anticipate the physician’s ordering? a. Angiotensin-converting enzyme (ACE) inhibitors b. - adrenergic blocking agentsb c. Nonsteroidal anti-inflammatory drugs (NSAIDs) d. Barbiturates -blockers are indicated for clients with cardiovascular disorders, such as hypertension and angina, and also for migraine prophylaxis. Barbiturates are central nervous system depressants, they are indicated for clients with seizure or insomnia and for those being prepared for surgery.bAns: C – for the client who has back pain radiating down to his right heel and lateral foot, suggesting radiculopathy of a herniated disc at L5-S1, typically the physician would order NSAIDs, oral analgesics, and muscle relaxants. ACE inhibitors are indicated for clients with hypertension and those with heart failure unresponsive to conventional therapy. 18. A client with a ruptured intervertebral disc at L4-5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating which of the following? a. Motor changes b. Postural deformity c. Alteration of reflexes d. Sensory changes Ans: B – standing with a flattened spine slightly titled forward and slightly flexed to the affected side indicates a
postural deformity. Motor changes would include findings such as hypotonia or muscle weakness. Absent or diminished reflexes related to the level of herniation would indicate alteration in reflexes. Sensory changes would include findings such as paresthesia and numbness related to the specific tract of the herniation. 19. Which of the following positions would be most comfortable for a client with a ruptured disc at L5-S1 right? a. Prone b. Supine with the legs flexed c. High fowler’s d. Right Sims’ Ans: B – a supine position with the client’s legs flexed is the most comfortable position because it allows for the disc to recess off of the nerve, thus alleviating the pressure and pain. The prone position cause hyperextension of the spine and increased pressure of the disc on the nerve root on the right. A ruptured disc at L5-S1 right is a term commonly used in the analysis of a history and physical examination, magnetic resonance image, or myelogram to identify a ruptured disc compressing the right nerve root exiting the L5-S1 spinous process, as opposed to the central area or the left nerve foot of that spinous process. If the ruptured area of the disc were in the central area of the spinous process, the prone position and hyperextension might relieve the disc pressure on the nerve. A high-Fowler’s or sitting position increases the pressure of the disc on the nerve root because of gravity, as does a right Sim’s position. 20. The client with a herniated intervertebral disc schedule for a myelogram asks the nurse about the procedure. The nurse explains that radiographs will be taken of the client’s spine after an injection of which of the following? a. Sterile water b. Normal saline solution c. Liquid nitrogen d. Radiopaque dye Ans: D – myelography, used to determine the exact location of a herniated disk, involves the use of radiopaque dye (usually an iodized oil, but in some instances water-soluble compound). In some instances, used for an aircontract study. 21. Which of the following would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a ruptured disc? a. Informing the client that the procedure is painless b. Taking a thorough history of past surgeries c. Checking for previous complaints of claustrophobia d. Starting an intravenous line at keep-open rate Ans: D – an intravenous line is not required for an MRI client has an intravenous line, it is usually converted an intermittent infusion device, such as a heparin to avoid infiltration during transport of the client and completion of the procedure. When a contrast agents used, the client is moved out of the cylinder, the contrast material is injected, and the client is moved back-in. an MRI scan is painless. Typically the staff position, the client with pillows, blankets, ear plugs, and muscle to ensure client comfort, before the procedure started. A history of past surgeries is important, especially if the surgery involved implantation of any metallic devices (eg, implants, clips, pacemakers). Additionally, the nurse needs to assess for any hearing aids, electronic devices, shrapnel, bra hooks, necklace jewelry, credit cards, zippers, or any type of metal that the magnet of the MRI unit would attract. Although open MRI units are now available, they are not in widespread use. Therefore, the nurse needs to check determine whether the client is claustrophobic because this unit is a closed cylinder in which the client hears popular noise. A number of clients develop claustrophobic that causes the procedure to be cancelled. If the client’s claustrophobic, the procedure may need to be rescheduled after an open MRI unit is located or made available. 22. A client complaining of numbness from the back of h is left buttock to the dorsum of his foot and big toe is scheduled to undergo a laminectomy. The operative consent form states,” a left lumbar laminectomy of L3-4.” Based on the nurse’s understanding of the client’s complaints and intended surgical procedure which of the following would the nurse do next? a. Have the client sign the consent form b. Call the surgeon c. Change the consent form d. Review the client’s history Ans: B – based on the client’s complaints, the nurse should call the surgeon to verify the location of the surgery. The client’s complains indicate radiculopathy of ___ but the consent form states L3-4, radiculopathy L3-4 involves pain radiating from the back to the tocks to the posterior thigh to the inner calf. The nurse mus t act as a consent until the correct procedure is identified and confirmed on the consent. The nurse has legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history if contradictory, the physician should be contacted to clarify the situation. Ultimately, it is the surgeon’s responsibility to identify the site of surgery specified on the surgical consent form. 23. After a bilateral lumbar laminectomy at L5-S1, which of the following is a priority nursing diagnosis for the client in the immediate postoperative phase? a. Impaired physical mobility related to back pain b. Imbalanced nutrition: less than body requirements related to postoperative status c. Bowel incontinence related to decreased physical activity d. Disturbed body image related to fear of disfiguring surgical scar Ans: A – impaired physical mobility related to back pain, muscle spasms, and tissue manipulation is a priority after a laminectomy, because based on individual factors such as the length of time of the disease and previous scarring or injury to the muscles or nerves before the surgery, spasms and pain can be quite severe. Imbalances nutrition: less than body requirements related to inability to eat in the supine position is not a priority problem because the client is encouraged to take fluids as soon as the gag reflex returns, no nausea is present, and bowel sounds begin to return. Bowel incontinence related to decreased physical activity is not a priority problem
because the client is encouraged to sit up and to ambulate to the bathroom with assistance as soon as the anesthesia wears off. Disturbed body image related to fear of disfiguring surgical scar should also not be a priority problem because the laminectomy incision is commonly small, possibly as small as 1 inch for a lumbar laminectomy L5-S1 bilateral. 24. Immediately after the lumbar laminectomy, the nurse administers ondansetron hydrochloride (Zofran) to the client as ordered. The nurse determines that the drug is effective when which of the following is controlled? a. Muscles spasms b. Nausea c. Shivering d. Dry mouth Ans: B – ondansetron hydrochloride (zofran) is a selective serotonin receptor antagonist tat acts centrally to control the client’s nausea in the postoperative phase. It does not control muscle spasms, shivering, or dry mouth. 25. After a laminectomy, the client states, “ The doctor said that I can do anything I want to.” Which of the following activities, if stated by the client, indicates need for further teaching? a. Drying the dishes b. Sitting outside on firm cushions c. Making the bed walking from side to side d. Sweeping the front porch Ans: D – sweeping causes a twisting motion, which should be avoided because twisting can cause undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture. Although the client should not bend at the waist, such as when washing dishes at the sink, the client can dry dishes because no bending is necessary. The client can sit in a firm chair that keeps the back anatomically aligned. The client sh ould not twist and pull, so when making the bed, the client should pull the covers up on one side and then walk around to the other side before trying to pull the covers up there. 26. When developing the drainage teaching plan for a client who has undergone a lumbar laminectomy L4-5 left and will be returning to work in 6 weeks, which of the following actions would the nurse encourage the client to avoid? a. Placing one foot on a stepstool during prolonged standing b. Sleeping on the back with support under the knees c. Maintaining average body weight for height d. Sitting whenever possible Ans: D – after a lumbar laminectomy L4-5 left, a client who is returning to work should avoid sitting whenever possible, if the client must sit, he or she should s it only in chairs that allows the knees to be higher than the hips and support the arms to maintain correct body alignment and reduce undue stress on the spine. Maintaining good body postures is most important after a lumbar laminectomy L4-5 left. By 6 weeks after the surgery, the client should have regained stamina. To maintain correct body posture, the client should also place one foot on a stepstool during prolonged standing. Sleeping on the back with a support under the knees is effective in maintaining correct body posture. Maintaining an average weight for height is important in maintaining a healthy back because carrying extra weight caused undue stress on back muscles. 27. A male client, who had normal preoperative baseline data except for dysfunction associated with this operative diagnosis, underwent a spinal fusion yesterday. Which of the following nursing assessments would alert the nurse to the development of a possible complication? a. Lateral rotation of the head and neck b. Clear yellowish fluid on the dressing c. Use of the standing position to void d. Nonproductive cough Ans: B – clear yellowish fluid on the dressing may be cerebral spinal fluid, this fluid must be tested for glucose to determine whether it is cerebral spinal fluid. If so, the client is at great risk for an infection of the central nervous system, which has a high mortality rate. The patient should be able to laterally rotate the head and neck, which is above the surgical site in the spinal column. During the nursing postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should find results consistent with the preoperative baseline status. Using the standing position to void is normal for a male client. Coughing is the body’s defense mechanism to help clear the lungs in response to a sustained deep inspiration for ventilation of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should be avoided. Also, a productive cough of thick yellow sputum would indicate the complication of a respiratory infection. 28. After a spinal fusion, a client is required to wear a back brace. Which of the following would the nurse expect to do before applying the brace? a. Have the client in bed lying on the side b. Verify with the physician the position to use c. Ask the client to stand with arms held out to the side d. Encourage the client to sit in a straight chair Ans: B – the nurse should verify with the surgeon the preferred position to use before applying the brace. Traditionally, the client who had a spinal fusion was asked to lie on the side and log roll onto the brace. Now doctors also have clients stand and sit for the brace application. Therefore, the nurse needs to verify the surgeon’s preference. 29. After teaching a client required to wear a back brace after a spinal fusion, which of the following client statements indicate effective teaching about skin protection measures with the brace? a. “ I will apply lotion before putting on the brace.” b. “ I will be sure to pad area around my iliac crest.” c. “ I can use baby powder under the brace to absorb perspiration.”
d. “ I should wear a thin cotton undershirt under the brace.” Ans: D – the client should wear a thin cotton undershirt under the brace to prevent the brace from abrading directly against the skin. The cotton material also aids in absorbing any moisture, such as perspiration, which could lead to skin irritation and breakdown. Applying lotion is nor recommended before applying the brace because further skin breakdown can result (related to the collection of moisture where microorganisms can grow) and irritants from the lotion can cause further irritation. Applying extra padding (eg, to the iliac crests) is not recommended because the padding can become wrinkled, producing more pressure sites and skin breakdown. Use of baby or talcum powder is not recommended because the irritation from the talcum also can cause irritation and skin breakdown. 30. When developing the teaching plan for a client scheduled for a spinal fusion, which of the following would the nurse expect to include? a. The client typically experiences more pain at the donor site than at the fusion site than at the fusion site b. The surgeon will apply a simple gauze dressing to the donor site c. Neurovascular checks are unnecessary if the fibula is the donor site d. The client’s level of activity restriction is determined by the amount of pain Ans: A – typically, the do not site causes more pain than the fused site does because inflammation, swelling, and venous oozing around the nerve endings in the donor site, where the subcuticular tissue was removed, occurs during the first 24 to 48 hours postoperatively. After surgery, the surgeon applies a pressure dressing to the donor site to compress the veins that were transected for the removal subcutaneous tissue but that did not stop oozing blood after surgical cauterization during the surgical procedure. Pressure on a transected vein, which is low pressure, stops the oozing and loss of blood from the venous site. When the donor site is the fibula, neurovascular checks must be performed every hour to ensure adequate neurologic function of and circulation to the area. The surgeon, not the degree or amount of pain, specifies activity restrictions. 31. The nurse determines that the client who has had a lumbar laminectomy with a spinal fusion understands his protective instructions when he places his feet in which of the following positions when sitting in a chair? a. On the floor with the feet flat b. On a low footstool c. In any comfortable position with legs uncrossed d. On a high footstool so the feet are level with the ch air seat Ans: A – a client who has had back surgery should place his feet flat on the floor to avoid strain on the incision. Placing the feet on a low or high footstool or in any other position of comfort with the legs uncrossed increases the pressure on the suture line and increases the inflammation around the involved nerve root, thereby increasing the risk for possible rerupture of the disc site. 32. When developing the plan of care for a client undergoing a lumbar laminectomy, which of the following activities would be contraindicated during the initial postoperative period? a. Assisting with her daily hygiene activities b. Lying flat in bed c. Walking in the hall d. Sitting all afternoon in her room Ans: D – after a lumbar laminectomy, a client should not sit for prolonged periods in a chair because of the increased pressure against the nerve root and incision site. Assisting with daily hygiene is an appropriate activity during the initial postoperative period because, as with any surgical procedure, the patient needs to return to her optimal level of functioning as soon as possible. There is no limitation on the patient’s participation ion daily hygiene activities except for her individual response of pain, nausea, vomiting, or weakness. Lying flat in bed is appropriate because it does not cause stress on the spinal column where the laminectomy was preformed and the disc tissue was removed. Positions that should be avoided are those that would cause twisting and flexion of the spine. Walking in the hall is an acceptable activity. It promotes good postoperative ventilation, circulation, and return of peristalsis, which are needed for all surgical patients. In addition, walking provides the postoperative lumbar laminectomy patient an opportunity to build u p endurance and muscle strength and to promote circulation to the operative and incision sites for healing without twisting or stressing the, 33. Which of the following exercises would the nurse advise the client to avoid after a lumbar laminetcomy? a. Knee-to-chest lifts b. Hip tilts c. Sit-ups d. Pelvic tilts Ans: C – sit-ups are not recommended for the client who has had a lumbar laminectomy, because these exercises place too great a stress on the back. Knee-to-chest lifts, hip tilts, and pelvic tilt exercises are recommended to strengthen back and abdominal muscles. 34. When obtaining the history of a client with peripheral vascular disease who requires an amputation, which of the following would the nurse identify as the least likely factor contributing to the client’s peripheral vascular disease? a. Uncontrolled diabetes mellitus for 15 years b. A 20-pack-year history of cigarette smoking c. Current age of 39 years d. A serum cholesterol concentration of 275 mg/dL Ans: C – typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease, uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease. Nicotine is a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/dL are considered a risk factor for peripheral vascular disease.
35. When assessing the client with severe arterial occlusive disease and gangrene of the left great toe, which of the following findings would the nurse observe in the client’s left leg and foot? a. Edema around the ankle b. Loss of hair on the lower leg c. Thin, soft toenails d. Warmth in the foot Ans: B – the client with severe arterial occlusive disease and gangrene of the left great toe would have lost the ___ on the leg due to decreased circulation to the ___. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin ___ toenails (ie, thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically the foot would be to cold if a severe arterial occlusion were present. 36. A client with absent peripheral pulses and pain at rest is scheduled for an arterial Droppler study of the affected extremity. Which of the following would the nurse include when preparing the client for this test? a. Have the client sign a consent form of the procedure b. Administer a pretest sedative as appropriate c. Keep the client tobacco-free for 30 minutes before the test d. Wrap the client’s affected foot with a blanket Ans: C – the client should be tobacco-free for 30 minutes before the test to avoid false readings related to the vasoconstrictive effects of smoking on the arterial. Because this test is noninvasive, the client does not need to sign a consent form. The client should receive narcotic analgesic, not a sedative, to control, the ___ the blood pressure cuffs are inflated during the Droppler studies to determine the ankle-to brachial pressure index. The client’s ankle should not be considered with a blanket, because the weight of the blanket on the ishemic foot will cause pain. A bed cradle should be used to keep even the weight of a sheet at the affected foot. 37. The client with peripheral arterial disease says, “ I’ve really tried to manage my condition well.” Which of the following, if reported by the client during the history, would the nurse determine as appropriate for this client? a. Resting with the legs elevated above the level of the heart b. Walking slowly but steadily for 30 minutes twice a day c. Minimizing activity as much and as often as possible d. Wearing antiembolism stockings at all times when out of bed Ans: B – slow, steady walking is a recommended activity in the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the above the heart is an appropriate strategy for reducing venous congestion, wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause t he disease to worsen.
38. Which of the following would the nurse include in the teaching plan for a client with arterial insufficiency to the feet is being managed conservatively? a. Daily lubrication of the feet b. Soaking the feet in warm water c. Applying antiembolism stocking s d. Wearing firm, supportive leather shoes Ans: A – daily lubrication, inspection, cleaning, and pattern dry of the feet should be performed to prevent cracking of the skin and possible infection. Soaking the foot in a warm water should be avoided, because soaking on lead to maceration and subsequent skin breakdown. Additionally, the client with arterial insufficiency typically experiences sensory changes, so that client may be unable to detect water that is too warm, thus placing the client at risk clients with venous insufficiency, are inappropriate for clients for with arterial insufficiency could lead to worsening of the condition. Footwear should be roomy, soft, and protective and allow to circulate. Therefore, firm, supportive leather shoes would be appropriate. 39. While the nurse is providing preoperative teaching, the client says, “ I hate the idea of being an invalid after they cut off my leg.” Which of the following would be the nurse’s most thermometric response? a. “ At least you will still have one good leg to use.” b. “ Tell me more about how you’re feeling.” c. “ Let’s finish the preoperative teaching.” d. “ You’re lucky to have a wife to care for you.” Ans: B – encouraging the client who will be undergoing amputation to verbalize his feelings is the most therapeutic response. Asking the client to tell more about how he is feeling helps to elicit information, providing insight into his view of the situation and also providing the nurse with ideas to help him cope. The nurse should avoid value-laden responses, such as, “ At least you will still have one good leg to use,” that may make the client feel guilty or hostile, thereby blocking further communication. Furthermore, stating that the client still has one good leg ignores his expressed concerns. The client has verbalized feelings of helplessness by using the term “ invalid.” The nurse needs to focus on this concern and n ot to try to complete the teaching first before discussing what is on the client’s mind. The client’s needs, not the nurse’s needs, must be met first. It is inappropriate for the nurse to assume to know the relationship between the client and his wife or the roles they now must assume as dependent client and caregiver. Additionally, the response about the client’s wife caring for him may reinforce the client’s feelings of helplessness as an invalid.
40. The client asks the nurse, “ Why can’t the doctor tell me exactly how much of my leg he’s going to take off? Don’t you think I should know that?” The nurse responds based on the understanding that the final decision about the level of amputation required depends primarily on which of the following?
a. The need to remove as much of the leg as possible b. The adequacy of the blood supply to the tissues c. The ease with which a prosthesis can be fitted d. The client’s ability to walk with a prosthesis Ans: B – the level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply the prosthesis will not function properly because tissue necrosis will occur. Although the client’s ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant. 41. A client who has a history of mitral valve prolapse tells the nurse during a clinical visit that she is scheduled to get her teeth cleaned. Which of the following replies by the nurse is most appropriate? a. “ The physician will need to revaluate the status of your heart condition before your dental appointment.” b. “ Be sure to remind your dentist that you have a heart condition.” c. “ It is important for you to care for your teeth because your heart condition makes you more susceptible to developing oral infections.” d. “ We will prescribe a prophylactic antibiotic for you to take before getting your teeth cleaned.” Ans: D – clients who are at risk for developing infective endocarditis due to cardiac conditions such as mitral valve prolapse must take prophylactic antibiotics before any dental procedure that may cause bleeding. The client is not more susceptible to developing oral infections. Rather, the client is more susceptible to developing endocarditis that results from oral bacteria that enter the circulation during the dental procedure. The physician does not necessarily need to re-evaluate the heart condition of a client who is stable, but antibiotics must be prescribed. It is not enough to simply remind the dentist about the heart condition.
42. The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the client’s daily care? a. Assess the oral cavity each time mouth care is given and record observations b. Use a soft toothbrush to brush the client’s teeth after each meal c. Swab the client’s tongue, gums, and lips with a soft foam applicator every 2 hours d. Rinse the client’s mouth with mouthwash several times a day Ans: B – a soft toothbrush should be used to brush the client’s teeth after every meal and more often as needed. Mechanical cleansing is necessary to maintain oral health, stimulate gingival, and remove plaque. Assessing the oral cavity and recording observations is the responsibility of the nurse, not the nursing assistant. Swabbing with a safe foam applicator does not provide enough friction to cleanse the mouth. Mouthwash can be a drying irritant and is not recommended for frequent use. 43. During the assessment of a client’s mouth, the nurse notes the absence of saliva. The client is complaining of pain in the area of t he ear. The client has been NPO for several days because of the insertion of a nasogastric tube. Based on these findings, the nurse suspects that the client may be developing which of the following mouth conditions? a. Stomatitis b. Oral candidiasis c. Parotitis d. Gingivitis Ans: C – the lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client should lead the nurse to suspect the development of parotitis, to inflammation of the parotid gland. Parotitis usually develops in cases of dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventive measures include the use of sugarless hard candy or gum to stimulate saliva production, adequate hydration, and frequent mouth care. Stomatitis (inflammation of the mouth) produces excessive salivation and a sore mouth. Oral cadidiasis (thrush) causes bluish-white mouth lesions. Gingivitis can be recognized by the inflamed gingival and bleeding that occur during toothbrushing. 44. The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation? a. Use of alcohol b. Frequent use of mouthwash c. Lack of vitamin B12 d. Lack of regular teeth cleaning by a dentist Ans: A – chronic and excessive use of alcohol can lead to oral cancer. Smoking and use of smokeless tobacco are other significant risk factors. Additional risk factors include chronic irritation such as a broken tooth or ill-fitting dentures, poor dental hygiene, overexposure to sun (lip cancer), and syphilis. Use of mouthwash, lack of vitamin B12 and lack of regular teeth cleaning appointments have not been implicated as primary risk factors for oral cancer. 45. A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. He tells the occupational health nurse at his place of employment that he has not smoked a cigarette for 3 weeks, but is afraid he is going to “slip up” and smoke because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the client’s comments? a. “ Don’t worry about it. Everybody has difficulty quitting smoking, and you should expect to as well.”
b. “ If you increase your self-control, I am sure you will be able to avoid smoking.” c. “ Try taking a couple of days of vacation to relieve the stress of your job.” d. “ It is good that you can talk about your concerns. Try calling a friend when you want to smoke.” Ans: D – it is important for individuals who are are engaged in smoking cessation efforts efforts to feel comfortable with sharing their fears of failure with others and seeking support. Although fewer than 5% of smokers successfully quit on their first attempt, it is not helpful to tell a client that he found anticipate failure. Telling the client to exercise more self-control dose not provide him with support. Taking a vacation to avoid job pressures does not address the issue of fearing he will smoke a cigarette when in a stressful situation.
46. A client who was in a motor vehicle accident has a fractured mandible. Surgery has been performed to immobilize the injury by wiring the jaw. What is the nurse’s priority in regard to care in the immediate postoperative phase? a. Prevent nausea and vomiting b. Maintain a patent airway c. Provide frequent airway d. Establish a way for the client to communicate Ans: B – the priority of care in the immediate immediate postoperative phase is to maintain maintain a patent airway. The nurse should observe the client carefully for signs of respiratory distress. If the client becomes nauseated, antiemetics should be administered to decrease the chance of vomiting with obstruction of the airway and aspiration of vomitus. Providing frequent oral hygiene and an alternative means of communication are important aspects of nursing care, but maintaining a patent airway is most important. 47. A client has returned from surgery during which her jaws were wired as treatment for a fractured mandible. The client is in stable condition. The nurse is instructing the assistant on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give the assistant? a. Keep the client in a side-lying position with the head slightly elevated b. Do not reposition the client without the assistance of a registered nurse c. The client can assume any position that is comfortable d. Keep the client’s head elevated on two pillows at all times Ans: A- immediately after surgery the client should be placed on the side with the head head slightly elevated. This position helps facilitate removal of secretions and decreases the likelihood of aspiration should vomiting occur. A registered nurse does not need to be present to reposition the presence of the nurse. Although it is important to elevate the head, there is no need to keep the client’s head elevated on two pillows unless that position is comfortable for the client.
48. A client who has had her jaws wired begins to vomit. What should be the nurse’s first action? a. Insert a nasogastric tube and connect it to suction b. Use wire cutters to cut the wire c. Suction the client’s airway as needed d. Administer an antiemetic intravenously Ans: C – the nurse’s first action is to clear clear the client’s airway as necessary. Inserting Inserting a nasogastric tube or administering an antiemetic may prevent future vomiting episodes, but these procedures are not helpful when the client is actually vomiting. Cutting the wires is done only as a last resort or in case of respiratory or cardiac arrest. 49. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following? a. An intestinal obstruction has developed b. Additional ulcers have developed c. The esophagus has become inflamed d. The ulcer is perforated Ans: D – the body reacts to perforation perforation of an ulcer by immobilizing the area as much as possible. possible. This results in boardlike abdominal rigidity, usually extreme pain. This may occur over several hours or days. It is a medical emergency requiring immediate intervention. An intestinal obstruction would not cause midepigastric pain. Esophageal inflammation or the development of additional ulcers would not cause a rigid, boardlike abdomen. 50. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? a. Ineffective coping related to fear of diagnosis of chronic illness b. Deficient knowledge related to unfamiliarity with significant signs and symptoms c. Constipation related to decreased gastric motility d. Imbalanced nutrition: less than body requirements related to gastric bleeding Ans: B – black, tarry stools are an important important warning of bleeding in peptic ulcer disease. disease. Digested blood in the stool because it to be black. The odor of the stool s tool is very offensive. Clients with peptic ulcer disease should be instructed to report the incidence of black stools promptly to their primary health care provider. 1. Assessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which nursing intervention is most appropriate for this client? a.)Provide her with the information and teach her the skills she'll need to understand and cope during birth. b.)Provide her with written information about the birthing process. c.)Have a more experienced pregnant woman assist her. d.)Do nothing in hopes that she'll begin coping as the pregnancy progresses.
A. RATIONALE: Because the client is in her second trimester, trimester, the nurse has ample time to establish establish a trusting relationship with her and to teach her in a style that fits her needs. Written information would be effective only in conjunction with teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Doing nothing won't address the client's needs. 52. The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to: a.)assess the client's readiness to stop. b.)suggest that the client reduce the daily number of cigarettes smoked by one-half. c.)provide the client with the telephone number of a formal smoking cessation program. d.)help the client develop a plan to stop. A. RATIONALE: Before planning any intervention intervention with a client who smokes, it's essential to determine determine whether the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop smoking for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation. 53. The nurse is recording an Apgar score for a neonate. The nurse should assess: a.)heart rate, respiratory effort, temperature, reflex irritability, and color. b.)heart rate, respiratory effort, reflex irritability, and color. c.)heart rate, respiratory effort, temperature, and color. d.)heart rate, respiratory effort, temperature, sucking reflex, and color. B. RATIONALE: When recording an Apgar score for a neonate, the nurse should assess heart rate, respiratory effort, reflex irritability, and color. The neonate's temperature and sucking reflex will be assessed shortly after birth, but they aren't components of the Apgar score. 54. The nurse is teaching the mother of a neonate about the importance of immunizations. The nurse should teach her that active immunity: a.)develops rapidly and is temporary. b.)occurs by antibody transmission. c.)results from exposure of an antigen through immunization or disease contact. d.)may be transferred by mother to neonate. C. RATIONALE: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission. It occurs rapidly but is temporary. Passive immunity may be transferred by the mother to the neonate. 55. When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her? a.)"I'll report increased frequency of urination." b.)"If I have blurred or double vision, I should call the clinic immediately." c.)"If I feel tired after resting, I should report it immediately." d.)"Nausea should be reported immediately." B. RATIONALE: Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy. 56. The nurse has a client at 30 3 0 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her neonate? a.)Encourage breast-feeding so that she can get her rest and get healthier. b.)Encourage breast-feeding because it's healthier for the neonate. c.)Encourage breast-feeding to facilitate bonding. d.)Discourage breast-feeding because HIV can be transmitted through breast milk. D. RATIONALE: Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case. 57. A neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: a.)peripheral acrocyanosis. b.)bradycardia. c.)lethargy. d.)jaundice. C. RATIONALE: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia, not bradycardia, is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia. 58. The nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate? a.)Weak sucking response b.)Enlarged breast tissue c.)Soft skin d.)Vernix caseosa B. RATIONALE: It's common to see enlarged breast tissue in both male and female neonates in their first few days of life due to maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen.
59. A 20-year-old female's pregnancy is confirmed at a clinic. She says her husband will be excited but she's concerned because she isn't excited. She fears this may mean she'll be a bad mother. The nurse should respond by: a.)referring her to counseling. b.)telling her such feelings are normal in the beginning of pregnancy. c.)exploring her feelings. d.)recommending she talk her feelings over with her husband. B. RATIONALE: Misgivings and fears are common in the beginning of pregnancy. It doesn't necessarily mean that she requires counseling at this time. Exploring her feelings may help her understand her concerns more deeply but won't provide reassurance that her feelings are normal. She may benefit by discussing her feelings with her husband, but the husband also needs to be reassured that these feelings are normal at this time. 60. A woman who is 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should: a.)recognize these as normal early pregnancy signs and symptoms. b.)question her further about these signs and symptoms. c.)tell her that she'll need blood work and urinalysis. d.)tell her that she may be excessively worried. A. RATIONALE: Fatigue and frequent urination urination are early signs and symptoms of pregnancy pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she s he may be excessively worried isn't therapeutic. 61. A client with hypotonic labor dysfunction has been started on oxytocin (Pitocin). Despite adequate contractions, the fetus doesn't descend lower than 0 station. The physician recommends cesarean delivery. The client and her husband are confused because she had given birth previously to an average-size neonate. They ask several questions about cesarean birth. What would be the most accurate nursing diagnosis for this client? a.)Anger related to loss of planned birth experience b.)Anxiety related to lack of knowledge about the need for cesarean birth c.)Acute pain related to long, unproductive labor d.)Fear related to the unknown B. RATIONALE: The couple's questions indicate their lack of knowledge. Anxiety is expected because a cesarean delivery was unplanned. The other options aren't indicated by the stated assessment data. 62. The nurse is providing care for a pregnant woman. The woman asks the nurse how she can best deal with her fatigue. The nurse should instruct her to: a.)take sleeping pills for a restful night's sleep. b.)try to get more rest by going to bed earlier. c.)take her prenatal vitamins. d.)tell her not to worry because the fatigue will go away soon. B. RATIONALE: She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. Vitamins won't take away fatigue. False reassurance is inappropriate and doesn't help her deal with fatigue now. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus. 63. The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying: a.)"Now isn't a good time to begin dieting because you are eating for two." b.)"Let's explore your feelings further." c.)"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." d.)"The prenatal vitamins should ensure the baby gets all the necessary nutrients." C. RATIONALE: Depriving the developing fetus of nutrients can cause serious problems, and the nurse should discuss this with the client. The client isn't eating for two; this is a misconception. Exploring feelings helps the client understand her concerns, but she needs to be aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or neonate needs; they work in congruence with a balanced diet. 64. The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to: a.)start using insulin. b.)start taking an oral antidiabetic drug. c.)monitor her urine for glucose. d.)be taught about diet. D. RATIONALE: The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall dietary intake to control her blood glucose level. Oral antidiabetic drugs aren't used in pregnant females. Urine sugars aren't an accurate indication of blood glucose levels. 65. The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nu rse should know that: a.)the delivery may need to be induced early. b.)the delivery must be by cesarean. c.)the mother will carry to term safely. d.)it's too early to tell.
A. RATIONALE: Early induction or early cesarean delivery are possibilities if the mother has diabetes and euglycemia that hasn't been maintained during pregnancy. Cesarean delivery isn't always necessary. 66. A newly pregnant woman tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to stressing the importance of taking the vitamins, the nurse should advise the client to: a.)switch brands. b.)take the vitamin on a full stomach. c.)take the vitamin with orange juice for better absorption. d.)take the vitamin first thing in the morning. B. RATIONALE: Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea. 67. A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation? a.)Keeping him away from drafts b.)Putting a blanket between him and cold surfaces c.)Putting a cap on his head d.)Drying him thoroughly after a bath D. RATIONALE: Neonates lose heat through evaporation as liquid is converted to a vapor. Drying a neonate after birth and following a bath prevents heat loss caused by evaporation. Keeping a neonate away from drafts prevents heat loss caused by convection. Keeping a neonate off a cold surface, such as a scale, prevents the heat loss caused by conduction. Placing a cap on the neonate's head preserves heat and prevents heat loss caused by radiation. 68. The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward: a.)ensuring adequate nutrition. b.)preventing infection. c.)promoting neural tube sac drainage. d.)conserving body heat. B. RATIONALE: The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all neonates, including those with a myelomeningocele. Like all neonates, the neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac. 69. nurse is conducting a neonate assessment of a boy, born 3 hours earlier. Which assessment would make the nurse suspect a congenital hip dislocation? a.)Limited abduction of the affected leg b.)Unequal gluteal folds c.)Lengthening of the limb on the affected side d.)Crepitus of the affected hip on movement B. RATIONALE: Unequal gluteal folds are signs of congenital hip dislocation. Other signs include unequal thighs, limited adduction of the affected side, and shortening of the limb on the affected side. Crepitus of the affected hip isn't felt, but an audible click may be heard when the hip on the affected side is adducted. 70. The nurse has been teaching a new mother how to feed her infant son who was born with a cleft lip and palate. Which action by the mother would indicate that the teaching has been successful? a.)Placing the neonate flat during feedings b.)Providing fluids with a small spoon c.)Placing the nipple in the cleft palate d.)Burping the neonate frequently D. RATIONALE: Because a neonate with a cleft lip and palate can't grasp a nipple securely, he may swallow a large amount of air during feedings and, therefore, require frequent burping. A neonate with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons aren't used. A neonate with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration. 71. A client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal, and the client isn't in labor. Which nursing intervention should the nurse perform? a.)Allow the client to ambulate with assistance. b.)Perform a vaginal examination to check for cervical dilation. c.)Monitor the amount of vaginal blood loss. d.)Notify the physician for a fetal heart rate of 130 beats/minute. C. RATIONALE: Estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A pelvic examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute;
therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute. 72. A nurse in a prenatal clinic is assessing a 28-year-old who is 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia? a.)Glycosuria, hypertension, seizures b.)Hematuria, blurry vision, reduced urine output c.)Burning on urination, hypotension, abdominal pain d.)Hypertension, edema, proteinuria D. RATIONALE: The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. Seizures are a sign of eclampsia. The other findings aren't typically found in women with preeclampsia. 73. A client who is 24 weeks pregnant and diagnosed with preeclampsia is sent home with orders for bed rest and a referral for home health visits by a community health nurse. Which comment made by the client should indicate to the nurse that the client understands the reasons for home health visits? a.)"The community health nurse will help fix my meals." b.)"The community health nurse will give me my antihypertensive medication." c.)"The community health nurse will check me and my baby and talk with my physician." d.)"The community health nurse will give me prenatal care so that I won't have to see my physician." C. RATIONALE: Community health nurses provide skilled nursing care, such as assessing and monitoring blood pressure, providing treatments and education, and communicating with the physician. For the prenatal client with preeclampsia, this may include monitoring the therapeutic effects of antihypertensive medications, assessing fetal heart tones, and providing nutrition counseling. The professional nurse doesn't fix meals in the home this service may be provided by a home health aide or housekeeper. The community health nurse teaches the client to take her own medications, including the proper time, dose, frequency, and adverse effects. The community health nurse doesn't replace the care provided by the client's physician. 74. A client who is 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. Which nursing diagnosis takes the highest priority? a.)Risk for deficient fluid volume b.)Anxiety c.)Acute pain d.)Impaired gas exchange A. RATIONALE: A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. All the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, but risk for deficient fluid volume through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may be due to such factors as the risk of dying and the fear of future infertility. Acute pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss. 75. A client delivered a healthy full-term baby girl 2 hours ago by cesarean delivery. When assessing this client, which finding requires immediate nursing action? a.)Tachycardia and hypotension b.)Gush of vaginal blood when she stands up c.)Blood stain (5.1 cm) in diameter on the abdominal dressing d.)Complaints of abdominal pain A. RATIONALE: A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartal woman who has been sitting and may suddenly gush out when she stands up. A blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in the size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. It's normal for a woman who has had a cesarean section to feel pain at the incision site once her anesthesia has worn off. 76. A nurse in the nursery is preparing to perform phenylketonuria (PKU) testing. Which neonate is ready for the nurse to test? a.)A 3-day-old neonate who has been fed I.V. since birth b.)A 2-day-old neonate who has been breast-fed c.)A 1-day-old neonate receiving formula d.)A breast-fed neonate being discharged within 24 hours of birth B. RATIONALE: To test for PKU, a neonate must have had a sufficient intake of phenylalanine through the ingestion of either formula or breast milk for at least 2 days. A neonate who has been receiving I.V. fluids and hasn't yet received breast milk or formula isn't ready to be tested for PKU. A neonate who is discharged within 24 hours of delivery will need to see the physician for PKU testing after receiving formula or breast milk for 48 hours. 77. The nurse is teaching a client who is 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling her blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says: a.)"I won't use insulin if I'm sick." b.)"I need to use insulin each day." c.)"If I give myself an insulin injection, I don't need to watch what I eat." d.)"I'll monitor my blood glucose levels twice a week."
B.RATIONALE: When dietary treatment for gestational diabetes is unsuccessful, insulin therapy is started and the client will need daily doses. The client shouldn't stop using the insulin unless first obtaining an order from the physician for insulin adjustments when ill. Diet therapy continues to play an important role in blood glucose control in the client who requires insulin. Diet therapy is important to achieve appropriate weight gain and to avoid periods of hypoglycemia and hyperglycemia when taking insulin. Fasting, postprandial, and bedtime blood glucose levels need to be checked daily. 78. A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and delivers a boy. Which priority intervention should be included in the care plan for the neonate during his first 24 hours? a.)Administer insulin subcutaneously. b.)Administer a bolus of glucose I.V. c.)Provide frequent early feedings with formula. d.)Avoid oral feedings. C. RATIONALE: The neonate of a mother with diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia. 79. A 28-year-old woman gave birth 1 hour ago to a full-term baby boy. Which finding should the nurse expect when palpating the client's fundus? a.)Soft, at the level of the umbilicus b.)Firm (1.9 cm) below the umbilicus c.)Firm, at the level of the umbilicus d.)Boggy, midway between the umbilicus and symphysis pubis C. RATIONALE: Within 1 hour after delivery, the fundus should be firm and at the level of the umbilicus. A soft or boggy fundus isn't contracting well due to such factors as a full bladder or retained pieces of placenta and places the postpartum woman at risk for hemorrhage. 80. Which finding is considered normal in a neonate during the first few days after birth? a.)Weight loss of 25% b.)Birth weight of 2,000 to 2,500 g c.)Weight loss then return to birth weight d.)Weight gain of 25% C. RATIONALE: Babies lose approximately 10% of their birth weight during the first 3 or 4 days, due to the loss of excess extracellular fluids and meconium as well as limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 2,700 to 4,000 g. 81. The mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What's the best response by the nurse? a.)"Why don't you wait and see how things go? You may be tired of breast-feeding by then." b.)"Let your daycare provider give the baby formula in a bottle and breast-feed when you're home." c.)"Your baby won't need breast-feeding by then, so just switch completely to formula when you return to work." d.)"You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle." D. RATIONALE: Breast-feeding should continue for the first 6 months after birth when possible. Breast milk can be pumped at work to give to the neonate at daycare. This will also keep the mother's milk production up. 82. Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy? a.)Abdominal pain, vaginal bleeding, and a positive pregnancy test b.)Hyperemesis and weight loss c.)Amenorrhea and a negative pregnancy test d.)Copious discharge of clear mucus and prolonged epigastric pain A. RATIONALE: Abdominal pain, vaginal bleeding, and a positive pregnancy test are cardinal signs of an ectopic pregnancy. Nausea and vomiting may occur prior to rupture, but significantly increase after rupture. Amenorrhea and a negative pregnancy test may indicate another type of metabolic disorder such as hypothyroidism. Discharge of clear mucus isn't indicative of an ectopic pregnancy, and referred shoulder pain, not epigastric pain, should be expected. 83. The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rh (D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility? a.)Administration of Rh (D) Immune Globulin I.M. to the neonate within 7 2 hours b.)Administration of Rh (D) Immune Globulin I.M. to the mother within 72 hours c.)Injection of Rh (D) Immune Globulin to the mother during her 6 week follow-up visit d.)Administration of Rh (D) Immune Globulin I.M. to the mother within 3 months B. RATIONALE: When a mother is Rh (D)-negative and a neonate is Rh-positive, the mother forms antibodies against the D antigen. Most of the antibodies develop within the first 72 hours after she has given birth due to the exchange
of maternal and fetal blood during delivery. If the mother becomes pregnant again, she'll have a high antibody D level that may destroy fetal blood cells during the second pregnancy. However, if the mother receives an injection of Rh (D) Immune Globulin within 72 hours, no antibodies will be formed. Rh (D) Immune Globulin may also be given to the mother during pregnancy, if the neonate is Rh-positive. The neonate isn't given Rh (D) Immune Globulin. 84. On the 9th postpartum day, a client breast-feeding her neonate experiences pain, redness, and swelling of her left breast. She's diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? a.)Wear a loose-fitting bra to avoid constricting the milk ducts. b.)Stop breast-feeding permanently. c.)Take antibiotics until the pain is relieved. d.)Use a warm moist compress over the painful area. D. RATIONALE: Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding may resume once the infection is treated. The client will need to pump the breast in the meantime to keep the breast empty of milk and to ensure an adequate milk supply. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside. 85. The nurse teaches a postpartum client about breast-feeding. Which statement best indicates that the client knows how to avoid breast engorgement? a.)"I'll apply warm, moist compresses to my breasts." b.)"I'll breast-feed every 1& to 3 hours." c.)"I'll use an electric breast pump." d.)"I'll wear a bra 24 hours per day." B. RATIONALE: Frequent breast-feeding keeps the breasts relatively empty and increases circulation, thereby helping to remove fluid that may lead to engorgement. Applying warm compresses to the breasts stimulates the let-down reflex, filling the breasts and increasing engorgement. An electric breast pump usually isn't used if the neonate can breast-feed frequently. Although a bra supports the breasts, it can't prevent engorgement. 86. The nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a.)One fingerbreadth above the umbilicus b.)One fingerbreadth below the umbilicus c.)At the level of the umbilicus d.)Below the symphysis pubis B. RATIONALE: After a client gives birth, the height of her fundus should decrease about one fingerbreadth (about 1 cm) each day. Immediately after birth, the fundus may be above the umbilicus. At 6 to 1 2 hours after birth, it should be at the level of the umbilicus. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. After 10 days, it should be below the symphysis pubis. 87. The nurse is helping to prepare a client for discharge following childbirth. During a teaching session, the nurse instructs the client to do Kegel exercises. What's the purpose of these exercises? a.)To prevent urine retention b.)To relieve lower back pain c.)To tone the abdominal muscles d.)To strengthen the perineal muscles D. RATIONALE: Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They also improve vaginal tone and help prevent stress incontinence and hemorrhoids. Kegel exercises can't prevent urine retention, relieve lower back pain, or tone abdominal muscles. 88. The nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones? a.)7 weeks b.)11 weeks c.)17 weeks d.)21 weeks B. RATIONALE: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks of gestation. 89. The nurse is planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy? a.)Iron deficiency anemia b.)Varicosities c.)Nausea and vomiting d.)Gestational diabetes A. RATIONALE: Iron deficiency anemia is a common complication of adolescent pregnancies. Adolescent girls may already be anemic. The need for iron during pregnancy, for fetal growth and an increased blood supply, compounds the anemia even further. Varicosities are a complication of pregnancy more likely seen in women over age 35. An adolescent pregnancy doesn't increase the risk of nausea and vomiting or gestational diabetes. 90. The nurse is caring for a 16-year-old pregnant client. The client is taking an iron supplement. What should this client drink to increase the absorption of iron?
a.)A glass of milk b.)A cup of hot tea c.)A liquid antacid d.)A glass of orange juice D. RATIONALE: Increasing vitamin C enhances the absorption of iron supplements. Taking an iron supplement with milk, tea, or an antacid reduces the absorption of iron.
91. The nurse is caring for a client who is on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy? a.)Hypoglycemia b.)Crackles c.)Bradycardia d.)Hyperkalemia B. RATIONALE: Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia. 92. The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client would indicate an understanding of the nurse's teaching? a.)"I'll need to lie perfectly still." b.)"You won't need to come in and check on me while I'm wearing this monitor." c.)"I can lie in any comfortable position, but I should stay off my back." d.)"I know that the external monitor increases my risk of a uterine infection." C. RATIONALE: A woman with an external monitor should lie in the position that's most comfortable to her, although the supine position should be discouraged. A woman should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who is wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection. 93. The nurse is developing a care plan for a client in her 34th week of gestation who is experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor? a.)Encouraging ambulation b.)Serving a nutritious diet c.)Promoting adequate hydration d.)Performing nipple stimulation D. RATIONALE: Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions. 94. A client treated for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan? a.)Report a heart rate greater than 120 beats/minute to the physician. b.)Take terbutaline every 4 hours, during waking hours only. c.)Call the physician if the fetus moves 10 times in 1 hour. d.)Increase activity daily if not fatigued. A. RATIONALE: Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home. 95. The nurse is caring for a client in labor. Which assessment finding indicates fetal distress? a.)Lack of meconium staining b.)Early decelerations in fetal heart rate during contractions c.)An increase in fetal heart rate with fetal scalp stimulation d.)Fetal blood pH less than 7.20 D. RATIONALE: A fetal blood pH less than 7.20 is an indication of fetal hypoxia. During labor, a fetal pH range of 7.20 to 7.30 is considered normal. Fetal blood is sampled from the fetal scalp through a dilated cervix. The other options are normal findings. 96. The nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction? a.)Deep breathing b.)Shallow chest breathing c.)Deep, cleansing breaths d.)Chest panting B. RATIONALE: Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent
hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated. 97. The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? a.)Administer ephedrine to raise her blood pressure. b.)Administer oxygen using a mask. c.)Place the woman flat on her back with her legs raised. d.)Ensure adequate hydration before the anesthetic is administered.
D. RATIONALE: Because the woman is in a state of relative hypovolemia, administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. O xygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in a supine position can contribute to hypotension because of uterine pressure on the great vessels. 98. A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate? a.)Gently pulling at the neonate 's head as it's delivered b.)Holding the neonate 's head back until the physician arrives c.)Applying gentle pressure to the neonate 's head as it's delivered d.)Placing the mother in a Trendelenburg position until the physician arrives C. RATIONALE: Gentle pressure applied to the neonate's head as it's delivered prevents rapid expulsion, which can cause brain damage to the neonate and perineal tearing in the mother. Never pull at the neonate 's head or h old the head back. Placing the mother in the Trendelenburg position won't halt labor and may cause respiratory difficulties. 99. The nurse is caring for a client who is in labor. The physician still isn't present. After the neonate's head is delivered, which nursing intervention would be most appropriate? a.)Checking for the umbilical cord around the neonate 's neck b.)Placing antibiotic ointment in the neonate 's eyes c.)Turning the neonate's head to the side, to drain secretions d.)Assessing the neonate for respirations A. RATIONALE: After the neonate 's head is delivered, the nurse should check for the cord around the neonate 's neck. If the cord is around the neck, it should be gently lifted over the neonate 's head. Antibiotic ointment, to prevent gonorrheal conjunctivitis, is administered to the neonate after birth, not during delivery of the head. The neonate's head isn't turned during delivery. After delivery, the neonate is held with his head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after delivery. 100. The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? a.)Apply an ice pack to her perineum. b.)Take a Sitz bath. c.)Perform perineal care after voiding or a bowel movement. d.)Drink plenty of fluids. A. RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after delivery may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a Sitz bath may reduce discomfort by promoting circulation and healing. While perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection not reduce discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn't relieve perineal discomfort.
