prometric review

Question 1 CORRECT An adolescent adolescent brings a physician's physician's note to school school stating that he is not not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct? The student experiences experiences pain pain in the inferior aspect aspect of the knee. The student is trying trying to avoid participation participation in physical physical education. The condition was was caused by the student's competitive competitive swimming schedule.

B C will most likely likely require require surgical surgical intervention. intervention.  The student will

Question 1 Explanation: Osgood-Schlatterr disease occurs in adolescents in rapid growth Osgood-Schlatte phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is usually self-limited self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 1 CORRECT "n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$ The student experiences experiences pain pain in the inferior aspect aspect of the knee. The student is trying trying to avoid participation participation in physical physical education. The condition was was caused by the student's competitive competitive swimming schedule.

B C will most likely likely require require surgical surgical intervention. intervention.  The student will

Question 1 Explanation: Osgood-Schlatterr disease occurs in adolescents in rapid growth Osgood-Schlatte phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior

aspect of the knee. Osgood-Schlatter Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is usually self-limited self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregna pregnant nt and is checking the client for probable signs of pregnancy pregnan cy.. Select all probable signs of pregnancy. !hadwick%s sign

B

&etal heart rate detected by nonelectric device raxton (icks contractions )terine enlargement allottement

!

Outline of the fetus via radiography or ultrasound

Question 2 Explanation: The probable probable signs of pregnancy pregnancy include* include* -)terine +nlargem +nlargement ent -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and vulva. Occurs at week ,. -all -allottement ottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable palpable by the examine examiners rs -Outline of the fetus via radiography or ultrasound Question 1 CORRECT "n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$ The student experiences experiences pain pain in the inferior aspect aspect of the

knee. The student is trying trying to avoid participation participation in physical physical education. The condition was was caused by the student's competitive competitive swimming schedule.

B C will most likely likely require require surgical surgical intervention. intervention.  The student will Question 1 Explanation: Osgood-Schlatterr disease occurs in adolescents in rapid growth Osgood-Schlatte phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is usually self-limited self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregna pregnant nt and is checking the client for probable signs of pregnancy pregnan cy.. Select all probable signs of pregnancy. !hadwick%s sign

B


!


Question 2 Explanation: The probable probable signs of pregnancy pregnancy include* include* -)terine +nlargem +nlargement ent -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and vulva. Occurs at week ,. -all -allottement ottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by

nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound Question 3 CORRECT The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A

(ypostatic blood pressure. Scoliosis

C Spinal 7exibility.  8eg length disparity. Question 3 Explanation: " check for scoliosis a lateral deviation of the spine is an important part of the routine adolescent exam. 9t is assessed by having the teen bend at the waist with arms dangling while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam. Question 1 CORRECT "n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$ The student experiences pain in the inferior aspect of the knee. The student is trying to avoid participation in physical education. The condition was caused by the student's competitive swimming schedule.

B C  The student will most likely require surgical intervention.

Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle

pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is usually self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. !hadwick%s sign

B


!


Question 2 Explanation: The probable signs of pregnancy include* -)terine +nlargement -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and vulva. Occurs at week ,. -allottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound Question 3 CORRECT The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A


C Spinal 7exibility.  8eg length disparity. Question 3 Explanation: " check for scoliosis a lateral deviation of the spine is an important part of the routine adolescent exam. 9t is assessed by having the teen bend at the waist with arms dangling while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam. Question 4 CORRECT " 6 year old patient in the :th week of pregnancy has been hospitali;ed on complete bed rest for , days. She experiences sudden shortness of breath accompanied by chest pain. #hich of the following conditions is the most likely cause of her symptoms$

A

!ongestive heart failure due to 7uid overload. 0ulmonary embolism due to deep vein thrombosis 2<=T3

C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst.

When caring for a client with a central "enous line# which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 1 CORRECT "n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$ The student experiences pain in the inferior aspect of the knee. The student is trying to avoid participation in physical education.

B

The condition was caused by the student's competitive swimming schedule.

C  The student will most likely require surgical intervention. Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is usually self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. !hadwick%s sign

B


!


Question 2 Explanation: The probable signs of pregnancy include* -)terine +nlargement -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and vulva. Occurs at week ,. -allottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound

Question 3 CORRECT The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A



A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an

anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply.

"ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia

Question 1 CORRECT "n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$ The student experiences pain in the inferior aspect of the knee. The student is trying to avoid participation in physical education. The condition was caused by the student's competitive swimming schedule.


Question 1 Explanation:

Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is usually self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. !hadwick%s sign

B


!


Question 2 Explanation: The probable signs of pregnancy include* -)terine +nlargement -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and vulva. Occurs at week ,. -allottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound Question 3 CORRECT

The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A



A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause

of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction

"dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply. Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort.



Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is usually self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. !hadwick%s sign

B


!



The probable signs of pregnancy include* -)terine +nlargement -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and vulva. Occurs at week ,. -allottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound Question 3 CORRECT The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A



A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be long-

B

term venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen. Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG

!laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply. Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8 WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks 0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side. Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

(ome F 0ractice +xams F @!8+G +xam F @!8+G- 1@ 0ractice +xam H

$C%&- ($ )ractice &*am +

•

3

Shares

•

4

Sa!e •

T"eet

•



Sa!e • •

0ractice >ode







#in $ail

+xam >ode Text >ode #!a%ti%e $o&e I Juestions and choices are randomly arranged the answer is revealed instantly after each question and there is no time limit for the exam. Question 1 CORRECT "n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$

B C

The student experiences pain in the inferior aspect of the knee. The student is trying to avoid participation in physical education. The condition was caused by the student's competitive swimming schedule.

 The student will most likely require surgical intervention. Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is usually self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. !hadwick%s sign

B


!


Question 2 Explanation: The probable signs of pregnancy include* -)terine +nlargement -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and vulva. Occurs at week ,. -allottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound Question 3

CORRECT The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A



A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an

anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe

pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply. Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity

when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8 WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks 0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side. Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Question ' WRONG " nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has ?ust been diagnosed with ?uvenile idiopathic arthritis. #hich of the following statements about the disease is most accurate$

A

0hysical activity should be minimi;ed.

@onsteroidal anti-in7ammatory drugs are the /rst choice in treatment. The child has a poor chance of recovery without ?oint deformity. >ost children progress to adult rheumatoid arthritis. Question ' Explanation: @onsteroidal anti-in7ammatory drugs are important /rst line treatment for ?uvenile idiopathic arthritis 2formerly known as ?uvenile

C

rheumatoid arthritis3. @S"9
A nurse is caring for a patient with peripheral "ascular disease ,). /he patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any 0ind. Which of the following is the most li0ely e*planation for these symptoms?

A &luid overload leading to compression of nerve tissue. B 9n7ammation of the skin on the hands and feet. C Sensation distortion due to psychiatric disturbance. 9nadequate tissue perfusion leading to nerve damage. Question 1( Explanation: 0atients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. &luid overload is not characteristic of 0=<. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in 0=< are secondary to decreased tissue perfusion rather than primary in7ammation.




B


!


Question 2 Explanation: The probable signs of pregnancy include* -)terine +nlargement -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and vulva. Occurs at week ,. -allottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound Question 3 CORRECT

The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A



A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause

of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction

"dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply. Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8

WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks 0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side. Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Question ' WRONG " nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has ?ust been diagnosed with ?uvenile idiopathic arthritis. #hich of the following statements about the disease is most accurate$

A


@onsteroidal anti-in7ammatory drugs are the /rst choice in treatment. The child has a poor chance of recovery without ?oint deformity. >ost children progress to adult rheumatoid arthritis. Question ' Explanation: @onsteroidal anti-in7ammatory drugs are important /rst line treatment for ?uvenile idiopathic arthritis 2formerly known as ?uvenile rheumatoid arthritis3. @S"9
C

Question 1( CORRECT " nurse is caring for a patient with peripheral vascular disease 20=<3. The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. #hich of the following is the most likely explanation for these symptoms$

A &luid overload leading to compression of nerve tissue. B 9n7ammation of the skin on the hands and feet. C Sensation distortion due to psychiatric disturbance. 9nadequate tissue perfusion leading to nerve damage. Question 1( Explanation: 0atients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. &luid overload is not characteristic of 0=<. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in 0=< are secondary to decreased tissue perfusion rather than primary in7ammation. Question 11 CORRECT The nurse is assessing a child diagnosed with a brain tumor. #hich of the following signs and symptoms would the nurse expect the child to demonstrate$Select all that apply. (ead tilt =omiting

C 0olydipsia  9ncreased pulse 8ethargy

!

9ncreased appetite

Question 11 Explanation: (ead tilt vomiting and lethargy are classic signs assessed in a child with a brain tumor. !linical manifestations are the result of location and si;e of the tumor.

Question 1

CORRECT "n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$ The student experiences pain in the inferior aspect of the knee. The student is trying to avoid participation in physical education. The condition was caused by the student's competitive swimming schedule.



B


!


Question 2 Explanation: The probable signs of pregnancy include* -)terine +nlargement -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish

coloration of the mucous membranes of the cervix vagina and vulva. Occurs at week ,. -allottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound Question 3 CORRECT The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A



A


C "nxiety attack due to worries about her baby's health

 >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to

B

verify placement if the status is questionable and may require a declotting regimen. Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness.

9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply. Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8 WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks 0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side. Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Question ' WRONG " nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has ?ust been diagnosed with ?uvenile idiopathic arthritis. #hich of the following statements about the disease is most accurate$

A

0hysical activity should be minimi;ed. @onsteroidal anti-in7ammatory drugs are the /rst choice in treatment.

The child has a poor chance of recovery without ?oint deformity. >ost children progress to adult rheumatoid arthritis. Question ' Explanation: @onsteroidal anti-in7ammatory drugs are important /rst line treatment for ?uvenile idiopathic arthritis 2formerly known as ?uvenile rheumatoid arthritis3. @S"9
C



C 0olydipsia

 9ncreased pulse 8ethargy

!

9ncreased appetite

Question 11 Explanation: (ead tilt vomiting and lethargy are classic signs assessed in a child with a brain tumor. !linical manifestations are the result of location and si;e of the tumor. Question 12 CORRECT "n infant with hydrocele is seen in the clinic for a follow-up visit at 4 month of age. The scrotum is smaller than it was at birth but 7uid is still visible on illumination. #hich of the following actions is the physician likely to recommend$

A B

1eferral to a surgeon for repair.

Keeping the infant in a 7at supine position until the 7uid is gone. @o treatment is necessaryL the 7uid is reabsorbing normally. >assaging the groin area twice a day until the 7uid is gone. Question 12 Explanation: " hydrocele is a collection of 7uid in the scrotum that results from a patent tunica vaginalis. 9llumination of the scrotum with a pocket light demonstrates the clear 7uid. 9n most cases the 7uid reabsorbs within the /rst few months of life and no treatment is necessary. >assaging the area or placing the infant in a supine position would have no eEect. Surgery is not indicated.



Question 1 CORRECT "n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$ The student experiences pain in the inferior aspect of the knee.

The student is trying to avoid participation in physical education. The condition was caused by the student's competitive swimming schedule.

B C  The student will most likely require surgical intervention. Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is usually self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. !hadwick%s sign

B


!


Question 2 Explanation: The probable signs of pregnancy include* -)terine +nlargement -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and vulva. Occurs at week ,. -allottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal

movement palpable by the examiners -Outline of the fetus via radiography or ultrasound Question 3 CORRECT The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A



A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and

atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe

pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply. Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity

when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8 WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks 0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side. Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Question ' WRONG " nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has ?ust been diagnosed with ?uvenile idiopathic arthritis. #hich of the following statements about the disease is most accurate$

A


C

anti-in7ammatory eEects to be reali;ed. (alf of children with the disorder recover without ?oint deformity and about a third will continue with symptoms into adulthood. 0hysical activity is an integral part of therapy Question 1( CORRECT " nurse is caring for a patient with peripheral vascular disease 20=<3. The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. #hich of the following is the most likely explanation for these symptoms$



!

9ncreased appetite


(ead tilt vomiting and lethargy are classic signs assessed in a child with a brain tumor. !linical manifestations are the result of location and si;e of the tumor. Question 12 CORRECT "n infant with hydrocele is seen in the clinic for a follow-up visit at 4 month of age. The scrotum is smaller than it was at birth but 7uid is still visible on illumination. #hich of the following actions is the physician likely to recommend$

A B





Question 13 WRONG " patient who has been diagnosed with vasospastic disorder 21aynaud's disease3 complains of cold and stiEness in the /ngers. #hich of the following descriptions is most likely to /t the patient$ "n elderly woman. " young woman.

C "n adolescent male.  "n elderly man. Question 13 Explanation: 1aynaud's disease is most common in young women and is frequently associated with rheumatologic disorders such as lupus and rheumatoid arthritis.

A clinic nurse inter"iews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse %&AS/ li0ely to find in an abusing parent? Self-blame for the in?ury to the child.

B 8ow self-esteem C )nemployment Single status Question 14 Explanation: The pro/le of a parent at risk of abusive behavior includes a tendency to blame the child or others for the in?ury sustained. These parents also have a high incidence of low self-esteem unemployment unstable /nancial situation and single status.

child is admitted to the hospital se"eral days after stepping on a sharp ob1ect that punctured her athletic shoe and entered the flesh of her foot. /he physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started? " complete blood count with diEerential is drawn.

B The parents arrive. C The admission orders are written. " blood culture is drawn. Question 15 Explanation: "ntibiotics must be started after the blood culture is drawn as they may interfere with the identi/cation of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. 0arental presence is important for the ad?ustment of the child but not for the administration of medication.

Question 1 CORRECT

"n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$ The student experiences pain in the inferior aspect of the knee. The student is trying to avoid participation in physical education. The condition was caused by the student's competitive swimming schedule.



B


!


Question 2 Explanation: The probable signs of pregnancy include* -)terine +nlargement -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and

vulva. Occurs at week ,. -allottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound Question 3 CORRECT The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A



A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis

Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8 WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks 0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side. Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Question ' WRONG " nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has ?ust been diagnosed with ?uvenile idiopathic arthritis. #hich of the following statements about the disease is most accurate$

A C

0hysical activity should be minimi;ed. @onsteroidal anti-in7ammatory drugs are the /rst choice in treatment. The child has a poor chance of recovery without ?oint deformity. >ost children progress to adult rheumatoid arthritis.

Question ' Explanation: @onsteroidal anti-in7ammatory drugs are important /rst line treatment for ?uvenile idiopathic arthritis 2formerly known as ?uvenile rheumatoid arthritis3. @S"9


!

9ncreased appetite


A B






C "n adolescent male.  "n elderly man. Question 13 Explanation:

1aynaud's disease is most common in young women and is frequently associated with rheumatologic disorders such as lupus and rheumatoid arthritis. Question 14 WRONG " clinic nurse interviews a parent who is suspected of abusing her child. #hich of the following characteristics is the nurse 8+"ST likely to /nd in an abusing parent$ Self-blame for the in?ury to the child.

B 8ow self-esteem C )nemployment Single status Question 14 Explanation: The pro/le of a parent at risk of abusive behavior includes a tendency to blame the child or others for the in?ury sustained. These parents also have a high incidence of low self-esteem unemployment unstable /nancial situation and single status. Question 15 WRONG " child is admitted to the hospital several days after stepping on a sharp ob?ect that punctured her athletic shoe and entered the 7esh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. #hich of the following actions is done immediately before the antibiotic is started$ " complete blood count with diEerential is drawn.

B The parents arrive. C The admission orders are written. " blood culture is drawn. Question 15 Explanation: "ntibiotics must be started after the blood culture is drawn as they may interfere with the identi/cation of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. 0arental presence is important for the ad?ustment of the child but not for the administration of medication.

Question 16 WRONG #hich of the following conditions most commonly causes acute glomerulonephritis$ =iral infection of the glomeruli.

B

" congenital condition leading to renal dysfunction. 0rior infection with group " Streptococcus within the past 45-4H days.

 @ephrotic syndrome. Question 16 Explanation: "cute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group " Streptococcus. lomerular in7ammation occurs about 45-4H days after the infection resulting in scant dark urine and retention of body 7uid. 0eriorbital edema and hypertension are common signs at diagnosis. Question 1 CORRECT "n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$ The student experiences pain in the inferior aspect of the knee. The student is trying to avoid participation in physical education. The condition was caused by the student's competitive swimming schedule.


Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is

usually self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. !hadwick%s sign

B


!



A


C Spinal 7exibility.

 8eg length disparity. Question 3 Explanation: " check for scoliosis a lateral deviation of the spine is an important part of the routine adolescent exam. 9t is assessed by having the teen bend at the waist with arms dangling while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam. Question 4 CORRECT " 6 year old patient in the :th week of pregnancy has been hospitali;ed on complete bed rest for , days. She experiences sudden shortness of breath accompanied by chest pain. #hich of the following conditions is the most likely cause of her symptoms$

A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return

at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack

of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply. Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8 WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks 0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side.

Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Question ' WRONG " nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has ?ust been diagnosed with ?uvenile idiopathic arthritis. #hich of the following statements about the disease is most accurate$

A


C


A

&luid overload leading to compression of nerve tissue.

B 9n7ammation of the skin on the hands and feet. C Sensation distortion due to psychiatric disturbance. 9nadequate tissue perfusion leading to nerve damage. Question 1( Explanation: 0atients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. &luid overload is not characteristic of 0=<. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in 0=< are secondary to decreased decrease d tissue perfusion rather than primary in7ammation. Question 11 CORRECT The nurse is assessing assessing a child diagnosed diagnosed with a brain brain tumor. tumor. #hich of the following signs and symptoms would the nurse expect the child to demonstrate$Select demonstrate$Select all that apply. (ead tilt =omiting


!

9ncreased appetite


A B

1eferral to a surgeon for repair. Keeping the infant in a 7at supine position until the 7uid is gone. @o treatment is necessaryL the 7uid is reabsorbing

normally. >assaging the groin area twice a day until the 7uid is gone. Question 12 Explanation: " hydrocele is a collection of 7uid in the scrotum that results from a patent tunica vaginalis. 9llumination of the scrotum with a pocke pockett light demonstrates the clear 7uid. 9n most cases the 7uid reabsorbs within the /rst few months of life and no treatment is necessary. >assaging the area or placing the infant in a supine position would have no eEect. Surgery is not indicated.



Question 13 WRONG " patient who has been diagnosed with vasospastic disorder disorder 21aynaud's disease3 complains complains of cold and stiEness in the /ngers. #hich of the following descriptions is most likely to /t the patient$ "n elderly woman. " young woman.

C "n adolescent male.  "n elderly man. Question 13 Explanation: 1aynaud's disease is most common in young women and is frequently associated with rheumatologic rheumatologic disorders such as lupus and rheumatoid arthritis. Question 14 WRONG " clinic nurse interviews a parent who is suspected of abusing her child. #hich of the following characteristics is the nurse 8+"ST likely to /nd in an abusing parent$ Self-blame Self-blame for the in?ury to the child.

B 8ow self-esteem C )nemployment Single status Question 14 Explanation: The pro/le pro/le of a parent parent at risk of abusive abusive behavior includes includes a tendency to blame the child or others for the in?ury sustained. These

parents also have a high incidence of low self-esteem unemployment unemployme nt unstable /nancial situation and single status. Question 15 WRONG " child is admitted to the th e hospital several days after stepping on a sharp ob?ect that punctured her athletic shoe and entered the 7esh of her foot. The physician is concerned about osteomyelitis and has ordered order ed parenteral antibiotics. #hich of the following actions is done immediately immediate ly before the antibiotic is started$ " complete blood count with diEerential is drawn. parents arrive. B The parents are written. C The admission orders are " blood culture is drawn. Question 15 Explanation: "ntibiotics must be started after the blood culture is drawn as they may interfere with the identi/cation of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. 0arental presence is important for the ad?ustment of the child but not for the administration of medication. Question 16 WRONG #hich of the following conditions most commonly causes acute glomerulonephritis$ =iral infection of the glomeruli.

B


 @ephrotic syndrome. Question 16 Explanation: "cute glomerulonephritis glomerulonephritis is most commonly caused by the th e immune response to a prior upper respiratory infection with group " Streptococcus. Streptoc occus. lomerular in7ammation occurs about 45-4H days after the infection resulting in scant dark urine and retentio retention n of

body 7uid. 0eriorbital edema and hypertension are common signs at diagnosis. Question 17 CORRECT " patient in the cardiac unit is concerned about the risk factors fa ctors associated with atherosclerosis. atherosclerosis. #hich of the following f ollowing are hereditary heredit ary risk factors for developing atherosclerosis$ atherosclerosis$

A B

Smoking "ge &amily history of heart disease.

 Overweight Question 17 Explanation: &amily history of heart disease is an inherited risk factor that is not sub?ect to life style change. (aving a /rst degree relative relative with heart disease has been shown to signi/cantly increase risk. Overweight and smoking are risk factors that are sub?ect to life style change and can reduce risk signi/cantly. "dvancing age increases risk of atherosclerosis atheroscle rosis but is not a heredi hereditary tary factor Question 18 CORRECT The nurse is caring for a hospitali;ed hospitali;ed client who has chronic chronic renal renal failure. #hich of the following nursing diagnoses are most appropriate appropr iate for this client$ Select all that apply.

A B

0ain. 9mpaired as +xchange

"ctivity 9ntolerance 9mbalanced @utritionL 8ess than ody 1equirements +xcess &luid =olume Question 18 Explanation: "ppropriate "pprop riate nursing diagnoses for clients with chronic renal failure include excess 7uid volume related to 7uid and sodium retentionL imbalanced nutrition less than body requirements related to anorexia nausea and vomitingL and activity intolerance related to anorexia

fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure. Question 1' CORRECT " teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. #hich of the following /ndings is consistent with this diagnosis$ @ote* >ore than one answer may be correct. 2!hoose 6 answer3 )rine speci/c gravity of 4.5H5

B

enerali;ed edema

rown 2Mtea-coloredM3 urine )rine output of 6B5 ml in H hours. Question 1' Explanation: "cute glomerulonephritis is characteri;ed by high urine speci/c gravity related to oliguria as well as dark Mtea coloredM urine caused by large amounts of red blood cells. There is periorbital edema but generali;ed edema is seen in nephrotic syndrome not acute glomerulonephritis. /hrombolytic therapy is fre2uently used in the treatment of suspected stro0e. Which of the following is a significant complication associated with thrombolytic therapy?

A B

+xpansion of the clot "ir embolus.

!erebral hemorrhage 1esolution of the clot Question 23 Explanation: !erebral hemorrhage is a signi/cant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible often before the cause of stroke has been determined. "ir embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot but to resolution which is the intended eEect.

Question 1 CORRECT

"n adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. #hich of the following statements about the disease is correct$ The student experiences pain in the inferior aspect of the knee. The student is trying to avoid participation in physical education. The condition was caused by the student's competitive swimming schedule.



B


!


Question 2 Explanation: The probable signs of pregnancy include* -)terine +nlargement -(egar%s sign or softening and thinning of the uterine segment that occurs at week ,. -oodell%s sign or softening of the cervix that occurs at the beginning of the nd month -!hadwick%s sign or bluish coloration of the mucous membranes of the cervix vagina and

vulva. Occurs at week ,. -allottement or rebounding of the fetus against the examiner%s /ngers of palpation -raxton-(icks contractions -0ositive pregnancy test measuring for h!. 0ositive signs of pregnancy include* -&etal (eart 1ate detected by electronic device 2doppler3 at 45-4 weeks -&etal (eart rate detected by nonelectronic device 2fetoscope3 at 5 weeks "O -"ctive fetal movement palpable by the examiners -Outline of the fetus via radiography or ultrasound Question 3 CORRECT The clinic nurse asks a 46-year-old female to bend forward at the waist with arms hanging freely. #hich of the following assessments is the nurse most likely conducting$

A



A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis

Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply.

Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8 WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks 0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side. Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Question ' WRONG " nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has ?ust been diagnosed with ?uvenile idiopathic arthritis. #hich of the following statements about the disease is most accurate$

A C

0hysical activity should be minimi;ed. @onsteroidal anti-in7ammatory drugs are the /rst choice in treatment. The child has a poor chance of recovery without ?oint deformity. >ost children progress to adult rheumatoid arthritis.

Question ' Explanation: @onsteroidal anti-in7ammatory drugs are important /rst line treatment for ?uvenile idiopathic arthritis 2formerly known as ?uvenile rheumatoid arthritis3. @S"9


!

9ncreased appetite


A B


Keeping the infant in a 7at supine position until the 7uid is gone. @o treatment is necessaryL the 7uid is reabsorbing normally. >assaging the groin area twice a day until the 7uid is gone. Question 12 Explanation: " hydrocele is a collection of 7uid in the scrotum that results from a patent tunica vaginalis. 9llumination of the scrotum with a pocke pockett light demonstrates the clear 7uid. 9n most cases the 7uid reabsorbs within the /rst few months of life and no treatment is necessary. >assaging the area or placing the infant in a supine position would have no eEect. Surgery is not indicated.




C "n adolescent male.  "n elderly man. Question 13 Explanation:

1aynaud's disease is most common in young women and is frequently associated with rheumatologic rheumatologic disorders such as lupus and rheumatoid arthritis. Question 14 WRONG " clinic nurse interviews a parent who is suspected of abusing her child. #hich of the following characteristics is the nurse 8+"ST likely to /nd in an abusing parent$ Self-blame Self-blame for the in?ury to the child.

B 8ow self-esteem C )nemployment Single status Question 14 Explanation: The pro/le pro/le of a parent parent at risk of abusive abusive behavior includes includes a tendency to blame the child or others for the in?ury sustained. These parents also have a high incidence of low self-esteem unemployment unemployme nt unstable /nancial situation and single status. Question 15 WRONG " child is admitted to the th e hospital several days after stepping on a sharp ob?ect that punctured her athletic shoe and entered the 7esh of her foot. The physician is concerned about osteomyelitis and has ordered order ed parenteral antibiotics. #hich of the following actions is done immediately immediate ly before the antibiotic is started$ " complete blood count with diEerential is drawn. parents arrive. B The parents are written. C The admission orders are " blood culture is drawn. Question 15 Explanation: "ntibiotics must be started after the blood culture is drawn as they may interfere with the identi/cation of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. 0arental presence is important for the ad?ustment of the child but not for the administration of medication.

Question 16 WRONG #hich of the following conditions most commonly causes acute glomerulonephritis$ =iral infection of the glomeruli.

B


 @ephrotic syndrome. Question 16 Explanation: "cute glomerulonephritis glomerulonephritis is most commonly caused by the th e immune response to a prior upper respiratory infection with group " Streptococcus. Streptoc occus. lomerular in7ammation occurs about 45-4H days after the infection resulting in scant dark urine and retentio retention n of body 7uid. 0eriorbital edema and hypertension are common signs at diagnosis. Question 17 CORRECT " patient in the cardiac unit is concerned about the risk factors fa ctors associated with atherosclerosis. atherosclerosis. #hich of the following f ollowing are hereditary heredit ary risk factors for developing atherosclerosis$ atherosclerosis$

A B


 Overweight Question 17 Explanation: &amily history of heart disease is an inherited risk factor that is not sub?ect to life style change. (aving a /rst degree relative relative with heart disease has been shown to signi/cantly increase risk. Overweight and smoking are risk factors that are sub?ect to life style change and can reduce risk signi/cantly. "dvancing age increases risk of atherosclerosis atheroscle rosis but is not a heredi hereditary tary factor Question 18 CORRECT

The nurse is caring for a hospitali;ed client who has chronic renal failure. #hich of the following nursing diagnoses are most appropriate for this client$ Select all that apply.

A B


"ctivity 9ntolerance 9mbalanced @utritionL 8ess than ody 1equirements +xcess &luid =olume Question 18 Explanation: "ppropriate nursing diagnoses for clients with chronic renal failure include excess 7uid volume related to 7uid and sodium retentionL imbalanced nutrition less than body requirements related to anorexia nausea and vomitingL and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure. Question 1' CORRECT " teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. #hich of the following /ndings is consistent with this diagnosis$ @ote* >ore than one answer may be correct. 2!hoose 6 answer3 )rine speci/c gravity of 4.5H5

B

enerali;ed edema

rown 2Mtea-coloredM3 urine )rine output of 6B5 ml in H hours. Question 1' Explanation: "cute glomerulonephritis is characteri;ed by high urine speci/c gravity related to oliguria as well as dark Mtea coloredM urine caused by large amounts of red blood cells. There is periorbital edema but generali;ed edema is seen in nephrotic syndrome not acute glomerulonephritis. Question 2( CORRECT #hich of the following nursing interventions are written correctly$

A

!hange dressing once a shift.

B 0erform neurovascular checks. C "pply continuous passive motion machine during day. +levate head of bed 65 degrees before meals. Question 2( Explanation: 9t is speci/c in what to do and when. Question 21 WRONG " child has recently been diagnosed with
A



Question 22 CORRECT " 5-year old college student has been brought to the psychiatric hospital by her parents. (er admitting diagnosis is borderline personality disorder. #hen talking with the parents which information would the nurse expect to be included in the client%s history$ Select all that apply. Self-destructive behavior

B 1itualistic behavior C psychomotor retardation 9mpulsiveness 8ability of mood Question 23 WRONG Thrombolytic therapy is frequently used in the treatment of suspected stroke. #hich of the following is a signi/cant complication associated with thrombolytic therapy$

A B


!erebral hemorrhage 1esolution of the clot Question 23 Explanation: !erebral hemorrhage is a signi/cant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible often before the cause of stroke has been determined. "ir embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot but to resolution which is the intended eEect. Question 24 CORRECT " toddler has recently been diagnosed with cerebral palsy. #hich of the following information should the nurse provide to the parents$ @ote* >ore than one answer may be correct. 0arent support groups are helpful for sharing strategies and managing health care issues. 1egular developmental screening is important to avoid secondary developmental delays.
C



B

&etal heart rate detected by nonelectric device raxton (icks contractions )terine enlargement

allottement

!



A


C Spinal 7exibility.  8eg length disparity. Question 3 Explanation: " check for scoliosis a lateral deviation of the spine is an important part of the routine adolescent exam. 9t is assessed by having the teen bend at the waist with arms dangling while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Other choices are not part of the routine adolescent exam. Question 4 CORRECT

" 6 year old patient in the :th week of pregnancy has been hospitali;ed on complete bed rest for , days. She experiences sudden shortness of breath accompanied by chest pain. #hich of the following conditions is the most likely cause of her symptoms$

A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT #hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society

B

and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen. Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered.

" fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply. Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8 WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks 0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side. Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Question ' WRONG " nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has ?ust been diagnosed with ?uvenile idiopathic arthritis. #hich of the following statements about the disease is most accurate$

A


C



Question 11 CORRECT The nurse is assessing a child diagnosed with a brain tumor. #hich of the following signs and symptoms would the nurse expect the child to demonstrate$Select all that apply. (ead tilt =omiting


!

9ncreased appetite


A B






C "n adolescent male.  "n elderly man. Question 13 Explanation: 1aynaud's disease is most common in young women and is frequently associated with rheumatologic disorders such as lupus and rheumatoid arthritis. Question 14 WRONG " clinic nurse interviews a parent who is suspected of abusing her child. #hich of the following characteristics is the nurse 8+"ST likely to /nd in an abusing parent$ Self-blame for the in?ury to the child.


B The parents arrive. C The admission orders are written. " blood culture is drawn. Question 15 Explanation: "ntibiotics must be started after the blood culture is drawn as they may interfere with the identi/cation of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. 0arental presence is important for the ad?ustment of the child but not for the administration of medication. Question 16 WRONG #hich of the following conditions most commonly causes acute glomerulonephritis$ =iral infection of the glomeruli.

B


 @ephrotic syndrome. Question 16 Explanation: "cute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group " Streptococcus. lomerular in7ammation occurs about 45-4H days after the infection resulting in scant dark urine and retention of body 7uid. 0eriorbital edema and hypertension are common signs at diagnosis. Question 17 CORRECT " patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. #hich of the following are hereditary risk factors for developing atherosclerosis$

A B


 Overweight Question 17 Explanation: &amily history of heart disease is an inherited risk factor that is not sub?ect to life style change. (aving a /rst degree relative with heart disease has been shown to signi/cantly increase risk. Overweight and smoking are risk factors that are sub?ect to life style change and can reduce risk signi/cantly. "dvancing age increases risk of atherosclerosis but is not a hereditary factor Question 18 CORRECT The nurse is caring for a hospitali;ed client who has chronic renal failure. #hich of the following nursing diagnoses are most appropriate for this client$ Select all that apply.

A B



B

enerali;ed edema rown 2Mtea-coloredM3 urine )rine output of 6B5 ml in H hours.

Question 1' Explanation: "cute glomerulonephritis is characteri;ed by high urine speci/c gravity related to oliguria as well as dark Mtea coloredM urine caused by large amounts of red blood cells. There is periorbital edema but generali;ed edema is seen in nephrotic syndrome not acute glomerulonephritis. Question 2( CORRECT #hich of the following nursing interventions are written correctly$

A !hange dressing once a shift. B 0erform neurovascular checks. C "pply continuous passive motion machine during day. +levate head of bed 65 degrees before meals. Question 2( Explanation: 9t is speci/c in what to do and when. Question 21 WRONG " child has recently been diagnosed with
A



because they inherit one copy of the defective gene from the mother. The other G chromosome comes from the father who cannot be a carrier. Question 22 CORRECT " 5-year old college student has been brought to the psychiatric hospital by her parents. (er admitting diagnosis is borderline personality disorder. #hen talking with the parents which information would the nurse expect to be included in the client%s history$ Select all that apply. Self-destructive behavior


A B


!erebral hemorrhage 1esolution of the clot Question 23 Explanation: !erebral hemorrhage is a signi/cant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible often before the cause of stroke has been determined. "ir embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot but to resolution which is the intended eEect. Question 24 CORRECT

" toddler has recently been diagnosed with cerebral palsy. #hich of the following information should the nurse provide to the parents$ @ote* >ore than one answer may be correct. 0arent support groups are helpful for sharing strategies and managing health care issues. 1egular developmental screening is important to avoid secondary developmental delays.
C

Question 25 CORRECT A child is admitted to the hospital with a diagnosis of Wilm's tumor# stage 33. Which of the following statements most accurately describes this stage? The tumor has spread into the abdominal cavity and cannot be resected. The tumor extended beyond the kidney but was completely resected. The tumor is less than 6 cm. in si;e and requires no chemotherapy. The tumor did not extend beyond the kidney and was completely resected. Question 25 Explanation: The staging of #ilm's tumor is con/rmed at surgery as follows* Stage 9 the tumor is limited to the kidney and completely resectedL stage 99 the tumor extends beyond the kidney but is completely resectedL stage 999 residual nonhematogenous tumor is con/ned to the abdomenL stage 9= hematogenous metastasis has occurred with spread beyond the abdomenL and stage = bilateral renal involvement is present at diagnosis.

A

C 

Question 26 CORRECT A nurse is pro"iding discharge information to a patient with peripheral "ascular disease. Which of the following information should be included in instructions? )se antibacterial ointment to treat skin lesions at risk of infection. "void crossing the legs

A

C #alk barefoot whenever possible.  )se a heating pad to keep feet warm. Question 26 Explanation: 0atients with peripheral vascular disease should avoid crossing the legs because this can impede blood 7ow. #alking barefoot is not advised as foot protection is important to avoid trauma that may lead to serious infection. (eating pads can cause in?ury which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician.



Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused

by activities that require repeated use of the quadriceps including track and soccer. Swimming is not a likely cause. The condition is usually self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. !hadwick%s sign

B


!



A



A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT

#hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply. Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8 WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks

0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side. Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Question ' WRONG " nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has ?ust been diagnosed with ?uvenile idiopathic arthritis. #hich of the following statements about the disease is most accurate$

A


C

Question 1( CORRECT " nurse is caring for a patient with peripheral vascular disease 20=<3. The patient complains of burning and tingling of the hands

and feet and cannot tolerate touch of any kind. #hich of the following is the most likely explanation for these symptoms$



!

9ncreased appetite


A B







B

8ow self-esteem

C )nemployment Single status Question 14 Explanation: The pro/le of a parent at risk of abusive behavior includes a tendency to blame the child or others for the in?ury sustained. These parents also have a high incidence of low self-esteem unemployment unstable /nancial situation and single status. Question 15 WRONG " child is admitted to the hospital several days after stepping on a sharp ob?ect that punctured her athletic shoe and entered the 7esh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. #hich of the following actions is done immediately before the antibiotic is started$ " complete blood count with diEerential is drawn.


B


 @ephrotic syndrome.

Question 16 Explanation: "cute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group " Streptococcus. lomerular in7ammation occurs about 45-4H days after the infection resulting in scant dark urine and retention of body 7uid. 0eriorbital edema and hypertension are common signs at diagnosis. Question 17 CORRECT " patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. #hich of the following are hereditary risk factors for developing atherosclerosis$

A B



A B


"ctivity 9ntolerance 9mbalanced @utritionL 8ess than ody 1equirements +xcess &luid =olume Question 18 Explanation:

"ppropriate nursing diagnoses for clients with chronic renal failure include excess 7uid volume related to 7uid and sodium retentionL imbalanced nutrition less than body requirements related to anorexia nausea and vomitingL and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure. Question 1' CORRECT " teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. #hich of the following /ndings is consistent with this diagnosis$ @ote* >ore than one answer may be correct. 2!hoose 6 answer3 )rine speci/c gravity of 4.5H5

B

enerali;ed edema


planning another pregnancy. #hich of the following statements includes the most accurate information$ +ach child has a 4 in H 2BN3 chance of developing the disorder.
A





A B


C

Question 25 CORRECT " child is admitted to the hospital with a diagnosis of #ilm's tumor stage 99. #hich of the following statements most accurately describes this stage$

The tumor has spread into the abdominal cavity and cannot be resected. The tumor extended beyond the kidney but was completely resected. The tumor is less than 6 cm. in si;e and requires no chemotherapy. The tumor did not extend beyond the kidney and was completely resected. Question 25 Explanation: The staging of #ilm's tumor is con/rmed at surgery as follows* Stage 9 the tumor is limited to the kidney and completely resectedL stage 99 the tumor extends beyond the kidney but is completely resectedL stage 999 residual nonhematogenous tumor is con/ned to the abdomenL stage 9= hematogenous metastasis has occurred with spread beyond the abdomenL and stage = bilateral renal involvement is present at diagnosis.

A

C 

Question 26 CORRECT " nurse is providing discharge information to a patient with peripheral vascular disease. #hich of the following information should be included in instructions$ )se antibacterial ointment to treat skin lesions at risk of infection. "void crossing the legs

A

C #alk barefoot whenever possible.  )se a heating pad to keep feet warm. Question 26 Explanation: 0atients with peripheral vascular disease should avoid crossing the legs because this can impede blood 7ow. #alking barefoot is not advised as foot protection is important to avoid trauma that may lead to serious infection. (eating pads can cause in?ury which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician. Question 27 WRONG

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. #hich of the following statements indicates that the client has correctly understood the teaching$ Select all that apply. 9 can usually keep my ostomy pouch on for 6 to : days before changing it.P 9 should empty my ostomy pouch of urine when it is full.P 9 can place an aspirin tablet in my pouch to decrease odor.P 9f 9 limit my 7uid intake 9 will not have to empty my ostomy pouch as often.P 9 must use a skin barrier to protect my skin from urine.P Question 27 Explanation: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase 7uid intake to about 6555 ml per day and should not limit intake. "dequate 7uid intake helps to 7ush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 6 to : days and whenever a leak develops.

C 



Question 1 Explanation: Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps including

track and soccer. Swimming is not a likely cause. The condition is usually self-limited responding to ice rest and analgesics. !ontinued participation will worsen the condition and the symptoms. Question 2 CORRECT " nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. !hadwick%s sign

B


!



A



A


C "nxiety attack due to worries about her baby's health  >yocardial infarction due to a history of atherosclerosis Question 4 Explanation: 9n a hospitali;ed patient on prolonged bed rest he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. 0regnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. >yocardial infarction and atherosclerosis are unlikely in a :-year-old woman as is congestive heart failure due to 7uid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms the seriousness of pulmonary embolism demands that it be considered /rst. Question 5 CORRECT

#hen caring for a client with a central venous line which of the following nursing actions should be implemented in the plan of care for chemotherapy administration$Select all that apply. =erify patency of the line by the presence of a blood return at regular intervals. "dminister a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 9nspect the insertion site for swelling erythema or drainage. 9f unable to aspirate blood reposition the client and encourage the client to cough. !ontact the health care provider about verifying placement if the status is questionable. Question 5 Explanation: " ma?or concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology @ursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. 9n addition central venous lines may be longterm venous access devices. Thus diAculty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. (aving the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

B

Question 6 WRONG The nurse is caring for a client with a TB complete spinal cord in?ury. )pon assessment the nurse notes 7ushed skin diaphoresis above the TB and a blood pressure of 4,CD,. The client reports a severe pounding headache. #hich of the following nursing interventions would be appropriate for this client$ Select all that apply. "ssess for bladder distention and bowel impaction "dminister antihypertensive medication 0lace the client in a supine position with legs elevated +levate the (O to D5 degrees )se a fan to reduce diaphoresis 8oosen constrictive clothing

Question 6 Explanation: The client has signs and symptoms of autonomic dysre7exia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the (O to D5 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. ecause tactile stimuli can trigger autonomic dysre7exia any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction which may trigger autonomic dysre7exia and correct any problems. +levated blood pressure is the most life-threatening complication of autonomic dysre7exia because it can cause stroke >9 or sei;ures. 9f removing the triggering event doesn%t reduce the client%s blood pressure 9= antihypertensives should be administered. " fan shouldn%t be used because cold drafts may trigger autonomic dysre7exia. Question 7 WRONG !laudication is a well-known eEect of peripheral vascular disease. #hich of the following facts about claudication is correct$ 2!hoose 6 answers3 9t is a result of tissue hypoxia. 9t is characteri;ed by cramping and weakness. 9t is characteri;ed by pain that often occurs duing rest. 9t results when oxygen demand is greater than oxygen supply. Question 7 Explanation: !laudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic causing cramping weakness and discomfort. Question 8 WRONG The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client%s out7ow is less than the in7ow. Select actions that the nurse should take. (Select all that apply.) !heck the peritoneal dialysis system for kinks

0lace the client in good body alignment !ontact the physician !heck the level of the drainage bag 1eposition the client to his or her side. Question 8 Explanation: 9f out7ow drainage is inadequate the nurse attempts to stimulate out7ow by changing the client%s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with out7ow drainage. The drainage bag needs to be lower than the client%s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Question ' WRONG " nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has ?ust been diagnosed with ?uvenile idiopathic arthritis. #hich of the following statements about the disease is most accurate$

A


C

Question 1( CORRECT " nurse is caring for a patient with peripheral vascular disease 20=<3. The patient complains of burning and tingling of the hands

and feet and cannot tolerate touch of any kind. #hich of the following is the most likely explanation for these symptoms$



!

9ncreased appetite


A B







B

8ow self-esteem

C )nemployment Single status Question 14 Explanation: The pro/le of a parent at risk of abusive behavior includes a tendency to blame the child or others for the in?ury sustained. These parents also have a high incidence of low self-esteem unemployment unstable /nancial situation and single status. Question 15 WRONG " child is admitted to the hospital several days after stepping on a sharp ob?ect that punctured her athletic shoe and entered the 7esh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. #hich of the following actions is done immediately before the antibiotic is started$ " complete blood count with diEerential is drawn.


B


 @ephrotic syndrome.

Question 16 Explanation: "cute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group " Streptococcus. lomerular in7ammation occurs about 45-4H days after the infection resulting in scant dark urine and retention of body 7uid. 0eriorbital edema and hypertension are common signs at diagnosis. Question 17 CORRECT " patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. #hich of the following are hereditary risk factors for developing atherosclerosis$

A B



A B


"ctivity 9ntolerance 9mbalanced @utritionL 8ess than ody 1equirements +xcess &luid =olume Question 18 Explanation:

"ppropriate nursing diagnoses for clients with chronic renal failure include excess 7uid volume related to 7uid and sodium retentionL imbalanced nutrition less than body requirements related to anorexia nausea and vomitingL and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure. Question 1' CORRECT " teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. #hich of the following /ndings is consistent with this diagnosis$ @ote* >ore than one answer may be correct. 2!hoose 6 answer3 )rine speci/c gravity of 4.5H5

B

enerali;ed edema


planning another pregnancy. #hich of the following statements includes the most accurate information$ +ach child has a 4 in H 2BN3 chance of developing the disorder.
A





A B


C

Question 25 CORRECT " child is admitted to the hospital with a diagnosis of #ilm's tumor stage 99. #hich of the following statements most accurately describes this stage$

The tumor has spread into the abdominal cavity and cannot be resected. The tumor extended beyond the kidney but was completely resected. The tumor is less than 6 cm. in si;e and requires no chemotherapy. The tumor did not extend beyond the kidney and was completely resected. Question 25 Explanation: The staging of #ilm's tumor is con/rmed at surgery as follows* Stage 9 the tumor is limited to the kidney and completely resectedL stage 99 the tumor extends beyond the kidney but is completely resectedL stage 999 residual nonhematogenous tumor is con/ned to the abdomenL stage 9= hematogenous metastasis has occurred with spread beyond the abdomenL and stage = bilateral renal involvement is present at diagnosis.

A

C 


A

C #alk barefoot whenever possible.  )se a heating pad to keep feet warm. Question 26 Explanation: 0atients with peripheral vascular disease should avoid crossing the legs because this can impede blood 7ow. #alking barefoot is not advised as foot protection is important to avoid trauma that may lead to serious infection. (eating pads can cause in?ury which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician. Question 27 WRONG

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. #hich of the following statements indicates that the client has correctly understood the teaching$ Select all that apply. 9 can usually keep my ostomy pouch on for 6 to : days before changing it.P 9 should empty my ostomy pouch of urine when it is full.P 9 can place an aspirin tablet in my pouch to decrease odor.P 9f 9 limit my 7uid intake 9 will not have to empty my ostomy pouch as often.P 9 must use a skin barrier to protect my skin from urine.P Question 27 Explanation: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase 7uid intake to about 6555 ml per day and should not limit intake. "dequate 7uid intake helps to 7ush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 6 to : days and whenever a leak develops. " skin barrier is essential to protecting the skin from the irritation of the urine. "n aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

C 

Question 28 WRONG #hen assessing a client diagnosed with impulse control disorder the nurse observes violent aggressive and assaultive behavior. #hich of the following assessment data is the nurse also likely to /nd$ Select all that apply. The client has no remorse about the inability to control his anger. The client has a history of parental alcoholism and chaotic abusive family life. The degree of aggressiveness is out of proportion to the stressor.

 The violent behavior is most often ?usti/ed by the stressor. The client functions well in other areas of his life. Question 28 Explanation:

" client with an impulse control disorder who displays violent aggressive and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life and often verbali;es sincere remorse and guilt for the aggressive behavior.




B

&etal heart rate detected by nonelectric device raxton (icks contractions

)terine enlargement allottement

!



A




A



B




A


C



Question 11 CORRECT The nurse is assessing a child diagnosed with a brain tumor. #hich of the following signs and symptoms would the nurse expect the child to demonstrate$Select all that apply. (ead tilt =omiting


!

9ncreased appetite


A B









B


 @ephrotic syndrome. Question 16 Explanation: "cute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group " Streptococcus. lomerular in7ammation occurs about 45-4H days after the infection resulting in scant dark urine and retention of body 7uid. 0eriorbital edema and hypertension are common signs at diagnosis. Question 17 CORRECT " patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. #hich of the following are hereditary risk factors for developing atherosclerosis$

A B



A B



B



A





A B



C

Question 25 CORRECT " child is admitted to the hospital with a diagnosis of #ilm's tumor stage 99. #hich of the following statements most accurately describes this stage$ The tumor has spread into the abdominal cavity and cannot be resected. The tumor extended beyond the kidney but was completely resected. The tumor is less than 6 cm. in si;e and requires no chemotherapy. The tumor did not extend beyond the kidney and was completely resected. Question 25 Explanation: The staging of #ilm's tumor is con/rmed at surgery as follows* Stage 9 the tumor is limited to the kidney and completely resectedL stage 99 the tumor extends beyond the kidney but is completely resectedL stage 999 residual nonhematogenous tumor is con/ned to the abdomenL stage 9= hematogenous metastasis has occurred with spread beyond the abdomenL and stage = bilateral renal involvement is present at diagnosis.

A

C 


A

C #alk barefoot whenever possible.  )se a heating pad to keep feet warm. Question 26 Explanation: 0atients with peripheral vascular disease should avoid crossing the legs because this can impede blood 7ow. #alking barefoot is not advised as foot protection is important to avoid trauma that may lead to serious infection. (eating pads can cause in?ury which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician. Question 27 WRONG The nurse is evaluating the discharge teaching for a client who has an ileal conduit. #hich of the following statements indicates that the client has correctly understood the teaching$ Select all that apply. 9 can usually keep my ostomy pouch on for 6 to : days before changing it.P 9 should empty my ostomy pouch of urine when it is full.P 9 can place an aspirin tablet in my pouch to decrease odor.P 9f 9 limit my 7uid intake 9 will not have to empty my ostomy pouch as often.P 9 must use a skin barrier to protect my skin from urine.P Question 27 Explanation: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase 7uid intake to about 6555 ml per day and should not limit intake. "dequate 7uid intake helps to 7ush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 6 to : days and whenever a leak develops. " skin barrier is essential to protecting the skin from the irritation of

C 

the urine. "n aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin. Question 28 WRONG #hen assessing a client diagnosed with impulse control disorder the nurse observes violent aggressive and assaultive behavior. #hich of the following assessment data is the nurse also likely to /nd$ Select all that apply. The client has no remorse about the inability to control his anger. The client has a history of parental alcoholism and chaotic abusive family life. The degree of aggressiveness is out of proportion to the stressor.

 The violent behavior is most often ?usti/ed by the stressor. The client functions well in other areas of his life. Question 28 Explanation: " client with an impulse control disorder who displays violent aggressive and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life and often verbali;es sincere remorse and guilt for the aggressive behavior. Question 2' CORRECT " two-year-old child has sustained an in?ury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower aEected leg. #hich of the following does the nurse suspect is the cause of the child's symptoms$

A

0ossible fracture of the radius. 0ossible fracture of the tibia.

C ruising of the gastrocnemius muscle. @o anatomic in?ury the child wants his mother to carry  him.

Question 2' Explanation: The child's refusal to walk combined with swelling of the limb is suspicious for fracture. Toddlers will often continue to walk on a muscle that is bruised or strained. The radius is found in the lower arm and is not relevant to this question. Toddlers rarely feign in?ury to be carried and swelling indicates a physical in?ury




B

&etal heart rate detected by nonelectric device raxton (icks contractions

)terine enlargement allottement

!



A




A



B




A


C



Question 11 CORRECT The nurse is assessing assessing a child diagnosed diagnosed with a brain brain tumor. tumor. #hich of the following signs and symptoms would the nurse expect the child to demonstrate$Select demonstrate$Select all that apply. (ead tilt =omiting


!

9ncreased appetite


A B


Keeping the infant in a 7at supine position until the 7uid is gone. @o treatment is necessaryL the 7uid is reabsorbing normally. >assaging the groin area twice a day until the 7uid is gone. Question 12 Explanation: " hydrocele is a collection of 7uid in the scrotum that results from a patent tunica vaginalis. 9llumination of the scrotum with a pocke pockett light demonstrates the clear 7uid. 9n most cases the 7uid reabsorbs within the /rst few months of life and no treatment is necessary. >assaging the area or placing the infant in a supine position would have no eEect. Surgery is not indicated.




C "n adolescent male.  "n elderly man. Question 13 Explanation: 1aynaud's disease is most common in young women and is frequently associated with rheumatologic rheumatologic disorders such as lupus and rheumatoid arthritis. Question 14 WRONG " clinic nurse interviews a parent who is suspected of abusing her child. #hich of the following characteristics is the nurse 8+"ST likely to /nd in an abusing parent$ Self-blame Self-blame for the in?ury to the child.

B 8ow self-esteem C )nemployment Single status Question 14 Explanation: The pro/le pro/le of a parent parent at risk of abusive abusive behavior includes includes a tendency to blame the child or others for the in?ury sustained. These parents also have a high incidence of low self-esteem unemployment unemployme nt unstable /nancial situation and single status. Question 15 WRONG " child is admitted to the th e hospital several days after stepping on a sharp ob?ect that punctured her athletic shoe and entered the 7esh of her foot. The physician is concerned about osteomyelitis and has ordered order ed parenteral antibiotics. #hich of the following actions is done immediately immediate ly before the antibiotic is started$ " complete blood count with diEerential is drawn.

parents arrive. B The parents are written. C The admission orders are " blood culture is drawn. Question 15 Explanation: "ntibiotics must be started after the blood culture is drawn as they may interfere with the identi/cation of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. 0arental presence is important for the ad?ustment of the child but not for the administration of medication. Question 16 WRONG #hich of the following conditions most commonly causes acute glomerulonephritis$ =iral infection of the glomeruli.

B


 @ephrotic syndrome. Question 16 Explanation: "cute glomerulonephritis glomerulonephritis is most commonly caused by the th e immune response to a prior upper respiratory infection with group " Streptococcus. Streptoc occus. lomerular in7ammation occurs about 45-4H days after the infection resulting in scant dark urine and retentio retention n of body 7uid. 0eriorbital edema and hypertension are common signs at diagnosis. Question 17 CORRECT " patient in the cardiac unit is concerned about the risk factors fa ctors associated with atherosclerosis. atherosclerosis. #hich of the following f ollowing are hereditary heredit ary risk factors for developing atherosclerosis$ atherosclerosis$

A B



A B



B



A





A B



C

Question 25 CORRECT " child is admitted to the hospital with a diagnosis of #ilm's tumor stage 99. #hich of the following statements most accurately describes this stage$ The tumor has spread into the abdominal cavity and cannot be resected. The tumor extended beyond the kidney but was completely resected. The tumor is less than 6 cm. in si;e and requires no chemotherapy. The tumor did not extend beyond the kidney and was completely resected. Question 25 Explanation: The staging of #ilm's tumor is con/rmed at surgery as follows* Stage 9 the tumor is limited to the kidney and completely resectedL stage 99 the tumor extends beyond the kidney but is completely resectedL stage 999 residual nonhematogenous tumor is con/ned to the abdomenL stage 9= hematogenous metastasis has occurred with spread beyond the abdomenL and stage = bilateral renal involvement is present at diagnosis.

A

C 


A

C #alk barefoot whenever possible.  )se a heating pad to keep feet warm. Question 26 Explanation: 0atients with peripheral vascular disease should avoid crossing the legs because this can impede blood 7ow. #alking barefoot is not advised as foot protection is important to avoid trauma that may lead to serious infection. (eating pads can cause in?ury which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician. Question 27 WRONG The nurse is evaluating the discharge teaching for a client who has an ileal conduit. #hich of the following statements indicates that the client has correctly understood the teaching$ Select all that apply. 9 can usually keep my ostomy pouch on for 6 to : days before changing it.P 9 should empty my ostomy pouch of urine when it is full.P 9 can place an aspirin tablet in my pouch to decrease odor.P 9f 9 limit my 7uid intake 9 will not have to empty my ostomy pouch as often.P 9 must use a skin barrier to protect my skin from urine.P Question 27 Explanation: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase 7uid intake to about 6555 ml per day and should not limit intake. "dequate 7uid intake helps to 7ush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 6 to : days and whenever a leak develops. " skin barrier is essential to protecting the skin from the irritation of

C 

the urine. "n aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin. Question 28 WRONG #hen assessing a client diagnosed with impulse control disorder the nurse observes violent aggressive and assaultive behavior. #hich of the following assessment data is the nurse also likely to /nd$ Select all that apply. The client has no remorse about the inability to control his anger. The client has a history of parental alcoholism and chaotic abusive family life. The degree of aggressiveness is out of proportion to the stressor.

 The violent behavior is most often ?usti/ed by the stressor. The client functions well in other areas of his life. Question 28 Explanation: " client with an impulse control disorder who displays violent aggressive and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life and often verbali;es sincere remorse and guilt for the aggressive behavior. Question 2' CORRECT " two-year-old child has sustained an in?ury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower aEected leg. #hich of the following does the nurse suspect is the cause of the child's symptoms$

A

0ossible fracture of the radius. 0ossible fracture of the tibia.

C ruising of the gastrocnemius muscle. @o anatomic in?ury the child wants his mother to carry  him.

prometric review

Recommend Documents