NCLEX-RN
Part 4
QUESTION 601
A female client admitted to the labor and delivery unit thinks her bag of water "broke" approximately 2 hours ago. She is having mild
contractions 5 minutes apart.
The most immediate nursing intervention would be to:
A. Note the color and amount of fluid on her clothes.
B. Assess the FHR.
C. Notify the physician.
D. Place the nitrazine test paper at the cervical os and note the color change.
Answer: B
Explanation:
(A) Amniotic fluid is generally pale and straw colored. Meconium- stained amniotic fluid would indicate a previous hypoxic episode. This
intervention, though appropriate, is not the immediate priority.
(B) With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis. Assessing FHR ascertains fetal
well-being.
(C) More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician.
(D) Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This
intervention, though appropriate, is not the immediate priority.
QUESTION 602
A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives
the mother tells her, "Something is wrong. This is like my labor." Which reply by the nurse identifies the physiological response of the client?
A. "Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract."
B. "Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement."
C. "The same hormone that is released in response to the baby's sucking, causing milk to flow, also causes the uterus to contract."
D. "There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it."
Answer: C
Explanation:
(A) Mammary growth as well as milk production and maintenance in the breast occur in response to hormones produced primarily by the
hypothalamus and the pituitary gland.
(B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of breast-feeding.
(C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of the myoepithelial cells surrounding the
alveoli. In addition, it causes contractions of the uterus and uterine involution.
(D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are other symptoms that occur in response to
retained placental fragments.
QUESTION 603
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, "Why
did this happen to my baby?" is:
A. "It's God's will. It was probably for the best. There was something probably wrong with your baby."
B. "You're young. You can have other children later."
C. "I know your other children will be a great comfort to you."
D. "I can see you're upset. Would you like to see and hold your baby?"
Answer: D
Explanation:
(A) The mother and the father require support; the nurse should not minimize their grief in this situation.
(B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child.
(C) Attachment to this infant occurs during the pregnancy for both the mother and father.
Siblings will not replace their feelings or minimize their loss of this infant.
(D) Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the
infant appears ("she is bruised") and provide support.
QUESTION 604
A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:
A. In the immediate postpartum period
B. After the first trimester
C. At 28 weeks' gestation
D. Within 72 hours postpartum
Answer: A
Explanation:
(A) The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and
subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization.
(B) Rubella infection during the second trimester may result in permanent hearing loss for the fetus.
(C) RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine
during pregnancy.
(D) RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells.
QUESTION 605
A 24-year-old woman who is gravida 1 reports, "I can't take iron pills because they make me sick." She continues, "My bowels aren't moving
either." In counseling her based on these complaints, the nurse's most appropriate response would be, "It would be beneficial for you to eat . . .
A. prunes."
B. green leafy vegetables."
C. red meat."
D. eggs."
Answer: A
Explanation:
(A) Prunes provide fiber to decrease constipation and are an excellent source of dietary iron, as the prenatal client is not taking her supplemental
iron and iron deficiency anemia is common during pregnancy.
(B) Green leafy vegetables provide a source of fiber and iron; however, prunes are a better source of both.
(C) Red meat is a good iron source but will not address the constipation problem.
(D) Eggs are a good iron source but do not address the constipation problem.
QUESTION 606
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her
grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6
inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following
factors places her at risk for gestational diabetes?
A. Age>25 years
B. Maternal weight
C. Previous birth of an infant weighing>9 lb
D. Family history of heart disease
Answer: C
Explanation:
(A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there
is a familial history of diabetes.
(B) The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the
development of gestational diabetes.
(C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes.
(D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is
identified as a risk factor in the development of diabetes during pregnancy.
QUESTION 607
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3 4 minutes, lasting 6070 seconds; FHR baseline
134146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
A. Notify physician of no reassuring FHR pattern.
B. Turn the client to her left side.
C. Start IV for fetal distress and administer O2 at 68 liters by mask.
D. Evaluate to see if the monitor strip is reassuring.
Answer: D
Explanation:
(A) These indices are within normal parameters; therefore, the nurse does not need to contact the physician.
(B) The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no
indication that blood flow is compromised.
(C) These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse
should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2.
(D) Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120160 bpm. As the fetus moves, the
FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions
is every 24 minutes, with an appropriate duration of 60 sec.
QUESTION 608
Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must
emphasize the importance of:
A. Decreasing her sodium intake
B. Decreasing her fluids
C. Increasing her carbohydrate intake
D. Eating a moderate to high-protein diet
Answer: D
Explanation:
(A) Women with pregnancy-induced hypertension have a reduced plasma volume secondary to venous vessel constriction, not hypovolemia;
therefore, sodium restriction is not recommended. It is suggested that these women avoid extremely salty foods.
(B) Drinking six to eight glasses of water per day facilitates optimal fluid volume and renal perfusion, but it will not decrease the venous vessel
constriction of pregnancy-induced hypertension.
(C) Carbohydrate needs increase during pregnancy, specifically during the second and third trimesters, but they have not been linked to
pregnancy-induced hypertension.
(D) Loss of urinary protein (proteinuria) is associated with increased permeability of the large protein molecules with pregnancy-induced
hypertension. Additional dietary protein also helps increase the plasma colloidal osmotic pressure. Diets deficient in protein have been linked to
pregnancy-induced hypertension.
QUESTION 609
A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal
stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?
A. "It sounds as though you are coming down with a bad cold. I'll ask the doctor to prescribe a decongestant for relief of symptoms."
B. "A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side."
C. "These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them."
D. "This is most unusual. I'm sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist."
Answer: C
Explanation:
(A) Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated
during pregnancy.
(B) Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal
stuffiness or prevent epistaxis.
(C) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which
contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness.
(D) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts
associated with pregnancy.
QUESTION 610
A newborn girl's father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to
realize certain neurological patterns that characterize the newborn:
A. Mild hypotonia is expected in the upper extremities.
B. Purposeless, uncoordinated movements of the arms are indicative of neurological dysfunction.
C. Function progresses in a head-to-toe, proximal-distal fashion.
D. Asymmetrical movement of the extremities is not unusual and will disappear with maturation of the central nervous system.
Answer: C
Explanation:
(A) Term neonates are predominantly in a flexed position with strong active muscle tone that increases. Newborns are slightly hypertonic.
(B) Neonatal movements may be jerky and uncoordinated as the neonate works against gravity in contrast to the buoyancy of the amniotic fluid.
Jerky movements must be differentiated from the tremors of hypoglycemia, hypocalcemia, and neurological dysfunction.
(C) Growth of the newborn progresses in a cephalocaudal, proximal-distal fashion. Knowledge regarding infant development may facilitate
parental involvement and infant stimulation.
(D) Asymmetrical movements of the extremities are indicative of neurological dysfunction.
QUESTION 611
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The
immediate nursing response is to:
A. Administer methergine IM
B. Remove the retained placental fragments
C. Assist the client to the bathroom and provide cues to stimulate urination
D. Massage the fundus until firm
Answer: D
Explanation:
(A) Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered
in this clinical situation, but fundal massage would be the first response.
(B) Removal of retained placental fragments is done by the physician and is not the first response.
(C) If the fundus rises and is deviated, particularly to the right, the nurse should suspect bladder distention secondary to bladder and urethral
trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void.
(D) A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too
vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
QUESTION 612
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is
approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
A. Chadwick's sign
B. FHR by ultrasound
C. Enlargement of the uterus
D. Breast tenderness and enlargement
Answer: B
Explanation:
(A) Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other
situations that create Vaso congestion.
(B) FHR (movement) observed on ultrasound is a positive diagnosis of pregnancy.
(C) Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign.
(D) Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.
QUESTION 613
A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be:
A. Sulfa
B. Tetracycline
C. Hydralazine
D. Erythromycin
Answer: D
Explanation:
(A) Sulfa is a teratogen and will cause kernicterus.
(B) Tetracycline is a teratogen and will affect tooth development.
(C) Hydralazine is not an antibiotic but a calcium channel blocker.
(D) Erythromycin is safe during pregnancy and can be used when the client is allergic to penicillin.
QUESTION 614
A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?
A. Sitting with legs crossed at ankles
B. Wearing thromboembolic disease (TED) stockings
C. Wearing support pantyhose
D. Wearing knee-high stockings
Answer: D
Explanation:
(A) Sitting with the legs crossed at the ankles does not interfere with circulation or create pressure points.
(B) TED stockings will help to reduce the varicosity by supporting the vein. Stockings must be applied with legs elevated.
(C) Support pantyhose help to reduce the varicosity by supporting the vein. They also provide support to the uterus and allow for better return
circulation. Hose must be applied like TED stockings.
(D) Knee-high stockings create constriction and pressure points that interfere with circulation in the lower extremities.
QUESTION 615
A client at 9 weeks' gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first
pregnancy resulted in a spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This
information alerts the nurse to which of the following:
A. An increased risk in maternal adaptation to pregnancy
B. The need for anticipatory guidance regarding the pregnancy
C. The need for teaching regarding family planning
D. An increased risk for subsequent abortions
Answer: B
Explanation:
(A, D) There are no data to support this.
(B) Anticipatory guidance and health maintenance is a first-line defense in the promotion of healthy mothers and healthy babies.
(C) There are no data to support this at this time. This will be a concern later.
QUESTION 616
A client is pleased about being pregnant, yet states, "It is really not the best time, but I guess it will be OK." The nurse's assessment of this
response is:
A. Initial maternal-infant bonding may be poor.
B. Client may have a poor relationship with her husband.
C. This response is normal in the first trimester.
D. This response is abnormal, to be re-evaluated at the next visit.
Answer: C
Explanation:
(A) Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of "not now" in the first trimester. The statement still leaves
room for exploration.
(B) There are no data to support this. This statement by the mother still leaves room for exploration.
(C) Ambivalenceis normal during the first trimester. Reva Rubin addresses the issue of "not now." This fact should be shared with the mother
during further exploration of the comment.
(D) It is not abnormal. If it were, another month would also be too long to wait.
QUESTION 617
A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her
nutritional intake is assessed as sufficient. The most likely diagnosis is:
A. Iron-deficiency anemia
B. Physiological anemia
C. Fatigue due to stress
D. No problem indicated
Answer: A
Explanation:
(A) This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is
increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is <10.5 and the
hematocrit value falls below 35%. She needs increased iron supplements with follow-up.
(B) The client's values are below levels for physiological anemia.
(C) The client is fatigued because of a low hemoglobin level.
(D) Her hemoglobin level is low and will probably decrease even more when the blood volume peaks at 28 weeks.
QUESTION 618
In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as
a danger signal that should be reported immediately?
A. Backache
B. Leaking of clear yellow fluid from breasts
C. Constipation with hemorrhoids
D. Visual changes
Answer: D
Explanation:
(A) Backache is a common complaint during pregnancy. Proper body mechanics, pelvic rock, back rubs, and other comfort measures should
relieve the discomfort. In the presence of uterine contractions, the backache would radiate to the lower abdomen.
(B) Colostrum is normal and can be present anytime in the second half of pregnancy.
(C) Constipation and hemorrhoids are common and do need attention, but they do not constitute a dangerous situation.
(D) Visual changes are possibly related to PIH. The client should be assessed immediately to rule out or prevent worsening of PIH.
QUESTION 619
The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:
A. Empty her bladder
B. Lie on her left side
C. Place her arms over her head
D. Force fluids 1 hour prior to procedure
Answer: A
Explanation:
(A) A full bladder would cause discomfort and possible urinary incontinence during the exam.
(B) The left side-lying position would not accommodate the exam. The head of the exam table or bed can be slightly elevated to prevent supine
hypotension.
(C) Arms extended over the head would cause the abdomen to be tighter and less easily palpable.
(D) Forcing fluids would encourage a full bladder, which is not desired for the exam.
QUESTION 620
Before giving methergine postpartum, the nurse should assess the client for:
A. Decreased amount of lochial flow
B. Elevated blood pressure
C. Flushing
D. Afterpains
Answer: B
Explanation:
(A) Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease.
(B) Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given
oxytocin if necessary.
(C) Flushing is not a side effect of methergine.
(D) Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
QUESTION 621
A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of
infection. To relieve the discomfort, the nurse should first:
A. Assist her with a sitz bath
B. Administer the prescribed medication for pain
C. Teach her Kegel exercises
D. Apply an ice pack
Answer: A
Explanation:
(A) Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given.
(B) Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective.
(C) Kegel exercises facilitate sitting by decreasing tension on the episiotomy. They will not be effective for pain control or sustained comfort
level.
(D) Ice packs are appropriate to apply in the first 12 hours postdelivery to produce vasoconstriction and to reduce edema to the area.
QUESTION 622
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
A. Wear gloves for the procedure
B. Place and adjust the pad from back to front
C. Cleanse and wipe the perineum from front to back
D. Protect the outer surface of the pad from contamination
Answer: C
Explanation:
(A) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to
universal precautions.
(B) The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria.
(C) Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria.
(D) The inner surface of the pad should not be touched to maintain asepsis.
QUESTION 623
In teaching the client about proper umbilical cord care, the nurse recommends that:
A. Petrolatum be placed around the cord after the sponge bath
B. A belly binder be applied to prevent umbilical hernia
C. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage
D. The cord clamp be left on until the cord stump separates
Answer: C
Explanation:
(A) Petrolatum does not allow the cord to dry and will encourage infection.
(B) Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation.
(C) Frequent applications of alcohol will facilitate drying and discourage infection.
(D) The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.
QUESTION 624
A baby is circumcised. Immediate postoperative care should include:
A. Applying a loose diaper
B. Keeping the baby NPO for 4 hours to avoid vomiting
C. Changing the dressing frequently using dry, sterile gauze
D. Taking the baby to his mother for cuddling
Answer: D
Explanation:
(A) A pressure diaper should be applied to discourage hemorrhage.
(B) The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable.
(C) Dressing changes should not be dry. Dry dressing will stick.
(D) Cuddling after the procedure will hopefully quiet the baby. Feeding is also important if his feeding was withheld prior to the procedure or it
is time for a feeding.
QUESTION 625
A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks' gestation, all of the following observations are made.
Which would require intervention?
A. Weight gain of 2 kg in 4 weeks
B. Blood pressure of 128/78
C. Subjective data: shortness of breath after showering
D. Ankle edema reported present in late afternoon and evenings
Answer: C
Explanation:
(A) This is not an excessive weight gain indicative of fluid retention.
(B) The blood pressure is within normal range.
(C) Showering should not cause shortness of breath. This could be a sign of cardiac decompensation.
(D) Dependent ankle edema is normal late in the day among pregnant women. Progressive edema would be a dangerous development.
QUESTION 626
A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations
necessitates notifying the physician?
A. Contractions every 2 minutes, lasting 100 seconds
B. Fetal heart decelerations during a contraction
C. Beat-to-beat variability between contractions
D. Fetal heart decelerations at the beginning of contractions
Answer: A
Explanation:
(A) These are tetanic in nature and can cause rupture of the uterus.
(B) The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction.
(C) Beat- to-beat variability is a normal finding and demonstrates fetal well-being.
(D) The FHR may decrease at the beginning of a contraction owing to head compression.
QUESTION 627
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right
occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
A. Place her in knee-chest position during the contraction
B. Use effleurage during the contraction
C. Apply strong sacral pressure during the contraction
D. Have her push with each contraction
Answer: C
Explanation:
(A) This measure is inappropriate. The knee-chest position is employed to take pressure off the cord.
(B) Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position.
(C) Sacral pressure will counteract the pressure created by the position of the fetal head.
(D) The client is not completely dilated. Pushing is contraindicated until the second stage of labor.
QUESTION 628
The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a
monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client's diet?
A. Cream cheese
B. Fresh fruits
C. Aged cheese
D. Yeast bread
Answer: C
Explanation:
(A) Cream cheese does not contain tyramine, which might cause a hypertensive crisis.
(B) Fresh fruits do not contain tyramine, which might cause a hypertensive crisis.
(C) Aged or matured cheese combined with a monoamine oxidase predisposes the client to a hypertensive crisis.
(D) Bread products raised with yeast do not contain tyramine.
QUESTION 629
A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental
health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have
observed in the client to support this conclusion?
A. High fever, tachycardia, stupor, renal failure
B. Lip smacking, chewing, blinking, lateral jaw movements
C. Photosensitivity, orthostatic hypotension, dry mouth
D. Constipation, blurred vision, drowsiness
Answer: B
Explanation:
(A) These symptoms are found in clients with neuroleptic malignant syndrome.
(B) These symptoms are found in clients with tardive dyskinesia.
(C) These are normal side effects found in clients taking antipsychotic medications.
(D) These are also normal side effects found in clients taking antipsychotic medications.
QUESTION 630
On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and
exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
A. Administer her next dosage of lithium, and then call the physician.
B. Withhold her lithium, and report her symptoms to the physician.
C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
Answer: B
Explanation:
(A) The client has lithium toxicity, and the nurse must withhold further dosages.
(B) Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize
the client's lithium level.
(C) Ensuring adequate intake of sodium chloride will promote excretion of lithium and will assist in managing the client's lithium toxicity.
(D) A lithium blood level must be drawn immediately to determine the seriousness of the toxicity and to provide the physician with data for
medical orders.
QUESTION 631
In acute episodes of mania, lithium is effective in 12 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully.
Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement
and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?
A. Diazepam (Valium)
B. Haloperidol (Haldol)
C. Sertraline (Zoloft)
D. Alprazolam (Xanax)
Answer: B
Explanation:
(A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms.
(B) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect.
(C) Sertraline is an antidepressant and is used primarily to reduce symptoms of depression.
(D) Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms.
QUESTION 632
The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her
personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These
symptoms describe which of the following conditions?
A. Dementia
B. Parkinsonism
C. Delirium
D. Mania
Answer: A
Explanation:
(A) These changes are common characteristics of dementia.
(B) Parkinson's disease affects the muscular system. Progressive memory changes are not presenting symptoms.
(C) Delirium includes an altered level of consciousness, which is not found in dementia.
(D) Mania includes symptoms of hyperactivity, flight of ideas, and delusions of grandeur.
QUESTION 633
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic
for the nurse to use during the initial interaction with a family?
A. Always allow the most vocal person to state the problem first.
B. Encourage the mother to speak for the children.
C. Interpret immediately what seems to be going on within the family.
D. Allow family members to assume the seats as they choose.
Answer: D
Explanation:
(A) One will always hear what the most vocal person has to say. It is best to start with the quietest family member to encourage that person to
express emotions.
(B) All family members are encouraged to speak for themselves.
(C) In the initial family assessment, only data collection occurs; interpretations are made later.
(D) Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer
to whom.
QUESTION 634
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the
following interventions might be a primary prevention strategy?
A. Crisis intervention with an intoxicated teenager whose mother just committed suicide
B. Referring a client who has been on a detoxification unit to a rehabilitation center
C. Teaching fifth-grade children the harmful effects of substance abuse
D. Counseling a client with post-traumatic stress disorder
Answer: C
Explanation:
(A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention.
(B) The client must be sent to a rehabilitation unit, which requires tertiary prevention.
(C) Reducing the incidence of disease through education supports primary prevention.
(D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
QUESTION 635
While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
A. Politely tells the client, "Keep your hands off "
B. Ignores the remarks and hopes he will not try it again
C. Confronts the remarks but attempts not to reject the client
D. Leaves the room in order to compose herself
Answer: C
Explanation:
(A) This response does not recognize normal feelings of attraction and rejects the client.
(B) By ignoring the situation, the nurse has not set limits to discourage other remarks or perhaps more sexually aggressive behavior.
(C) By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their
nurse-client relationship.
(D) Leaving the room does not deal with setting limits for future interactions.
QUESTION 636
A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of
violence that she has been experiencing in her relationship with her husband of 5 years. In the "tension-building phase," the nurse might expect
the client to describe which of the following?
A. Promises of gifts that her husband made to her
B. Acute battering of the client, characterized by his volatile discharge of tension
C. Minor battering incidents, such as the throwing of food or dishes at her
D. A period of tenderness between the couple
Answer: C
Explanation:
(A) This description is characteristic of the "honeymoon" or "respite" phase.
(B) This description is characteristic of the "battering" phase.
(C) This description is characteristic of the "tension- building" phase prior to the volatile discharge of tension found in the battering phase.
(D) This description is characteristic of the "honeymoon" or "respite" phase.
QUESTION 637
Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
A. Fine hand tremor, headache, mental dullness
B. Vomiting, impaired consciousness, decreased blood pressure
C. Polyuria, polydipsia, edema
D. Gastric irritation, nausea, diarrhea
Answer: B
Explanation:
(A) These symptoms are acute, common, and usually harmless central nervous system side effects of lithium.
(B) These symptoms of lithium toxicity are usually dose related.
(C) These symptoms are acute, common, and usually harmless renal side effects of lithium.
(D) These symptoms are acute, common, and usually harmless gastrointestinal side effects of lithium.
QUESTION 638
A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications
and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is
which of the following?
A. Antipsychotic medications
B. Antidepressant medications
C. Antianxiety medications
D. Antimania medication
Answer: C
Explanation:
(A) Antipsychotic medications are also known as major tranquilizers.
(B) Antidepressants fall into different categories, such as the tricyclics or the MAO inhibitors.
(C) Antianxiety medications are also known as minor tranquilizers.
(D) Antimania medications are those such as lithium and lithium carbonate (Lithobid).
QUESTION 639
The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been
hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:
A. "I know it was my fault that it happened, because I shouldn't have been out so late."
B. "If I had not worn that sexy dress that night, he wouldn't have raped me."
C. "I know my date just had so much passion he couldn't handle me saying `no.' "
D. "I know now that it was not my fault, but I want to continue counseling after my discharge."
Answer: D
Explanation:
(A) This response does not show any insight; the client falsely assumes that she is responsible for the rape.
(B) The client continues to falsely assume responsibility for the rapist's behavior.
(C) The client believes falsely that rape is an act of passion, rather than one of violence, control, and domination.
(D) The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling
after discharge.
QUESTION 640
A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to
determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:
A. "I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group."
B. "I know that I can only drink one or two drinks at social gatherings in the future, but at least I don't have to continue AA."
C. "I really wasn't addicted to alcohol when I came here, I just needed some help dealing with my divorce."
D. "It really wasn't my fault that I had to come here. If my wife hadn't left, I wouldn't have needed those drinks."
Answer: A
Explanation:
(A) The client has insight into the severity of his alcohol addiction and has chosen one of the most effective treatment strategies to support him-Alcoholics Anonymous.
(B) The client is still using denial and is not dealing with his alcohol addiction.
(C) The client is exhibiting denial about his alcohol addiction and projecting blame on his divorce.
(D) The client is projecting blame onto his wife for being in the hospital while still denying his alcohol addiction.
QUESTION 641
Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how
such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what
caused her degenerative disorder?
A. "Some folks believe that aging causes this, Mother."
B. "Perhaps, it's the way your parents used those double- bind messages, Mother."
C. "I know some people who are having this problem and they were exposed to chemicals at work, Mother."
D. "It can be caused by lots of things, toxic agents and even alcohol, Mother."
Answer: B
Explanation:
(A) Aging is a factor in the cause of degenerative disorders.
(B) Double-bind messages may be found in the histories of families of individuals who develop schizophrenia, but they are not related to
degenerative disorders.
(C) Chemicals (toxic agents) in work environments are predisposing factors to degenerative disorders.
(D) Alcohol causes some degenerative disorders, such as Wernicke's syndrome.
QUESTION 642
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-yearold son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems
theory to this family, it is important for the nurse to remember which of the following principles?
A. The parts of a system are only minimally related.
B. Dysfunction in one part affects every other part.
C. A family system has no boundaries.
D. Healthy families are enmeshed.
Answer: B
Explanation:
(A) The parts of a system are interrelated.
(B) Any change in any part of the system affects all other parts.
(C) A family system, like any other system, has boundaries.
(D) Healthy families are neither enmeshed nor disengaged.
QUESTION 643
The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At
present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her
son's condition by which of the following statements?
A. "Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain."
B. "Has anyone in your family ever had schizophrenia?"
C. "If your son has a twin, he probably will eventually develop schizophrenia, too."
D. "Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship."
Answer: A
Explanation:
(A) The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms.
(B) This statement will only create anxiety in the mother, and the genetic theory is only one of the etiological factors.
(C) This statement will cause the mother much alarm, and nothing was mentioned about any other child.
(D) The mother child relationship is one of the previous theories examined, but it is not one to be emphasized, thereby causing a lot of anxiety
for the mother.
QUESTION 644
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take
his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most
therapeutic response will be:
A. "I don't see your mother in the room. Let's talk about how you're feeling."
B. "OK, I'll come back later when you're feeling more like taking your medicine."
C. "She may be here, but I can't see her."
D. "Why don't you finish talking to her, and I'll wait."
Answer: A
Explanation:
(A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize
his feelings.
(B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue
hallucinating.
(C) This response leaves room for doubt; the nurse is further confusing the client by this statement.
(D) This response reinforces the hallucination and implies that the nurse sees his mother, too.
QUESTION 645
A female client with major depression stated that "life is hopeless and not worth living." The nurse should place highest priority on which of the
following questions?
A. "How has your appetite been recently?"
B. "Have you thought about hurting yourself?"
C. "How is your relationship with your husband?"
D. "How has your depression affected your daily living activities?"
Answer: B
Explanation:
(A) Although eating habits are important to assess, they are less important than suicidal intent.
(B) Maintenance of the client's life is the priority; assessment of suicidal intent is imperative.
(C) Relationships and support systems are an important part of assessment, but they are less important than suicidal intent.
(D) Daily living activities will give additional information about the level of depression, and are less significant than suicidal intent, although
this information may give additional information about the actual plan for a suicidal attempt.
QUESTION 646
A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty
concentrating, repeated absences from work due to "fatigue," and not wanting to get dressed in the morning. She leaves her recorded message on
her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:
A. Deep depression
B. Psychotic depression
C. Severe anxiety
D. Severe depression
Answer: D
Explanation:
(A) A client in deep depression would have been brought to the mental health center and would not be physically able to seek help for herself.
(B) She is not manifesting psychotic symptoms in her behaviors.
(C) The client's symptoms are more indicative of depression than anxiety.
(D) Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with
activities of daily living indicate that she is severely depressed.
QUESTION 647
A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20- year history of alcohol abuse. The client is
diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the
following may cause the varices to rupture?
A. Lifting heavy objects
B. Walking briskly
C. Ingestion of barbiturates
D. Ingestion of antacids
Answer: A
Explanation:
(A) Lifting heavy objects will increase intrathoracic pressure, thus placing the client at risk for rupturing esophageal varices.
(B, C, D) This activity will not cause an increase in intrathoracic pressure.
QUESTION 648
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
A. Vitamin C and zinc
B. Folic acid and niacin
C. Vitamin A and biotin
D. Thiamine and pyroxidine
Answer: D
Explanation:
(A) Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine.
(B) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex.
(C) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex.
(D) Vitamins A, D, K, and B require bile salts to be absorbed from the gastrointestinal tract. A damaged liver does not form bile salts.
QUESTION 649
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from
the items below would be:
A. Liver and onions, macaroni and cheese, tea with sugar
B. Baked chicken, baked potato with bacon bits, milk
C. Waffles with butter and honey, orange juice
D. Cheese omelette with ham and mushrooms, milk
Answer: C
Explanation:
(A, B, D) These foods are high in protein, which needs to be restricted.
(C) Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and
low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.
QUESTION 650
A chronic alcoholic client's condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of
impending hepatic coma?
A. Hiccups
B. Anorexia
C. Mental confusion
D. Fetor hepaticus
Answer: C
Explanation:
(A) Hiccups are not a sign of impending hepatic coma.
(B) Anorexia is not a sign of impending hepatic coma.
(C) One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen.
(D) This sign is associated with the later stages of hepatic coma. Fetor hepaticus, a characteristic odor on the breath that smells like acetone, may
sometimes be noted when the liver fails.
QUESTION 651
The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma. Neomycin decreases serum ammonia
levels by:
A. Decreasing nitrogen-forming bacteria in the intestines
B. Acidifying colon contents by causing ammonia retention in the colon
C. Decreasing the uptake of vitamin D, thereby drawing more water into the colon
D. Irritating the bowel and promoting evacuation of stool
Answer: A
Explanation:
(A) Neomycin interferes with protein synthesis in the bacterial cell, causing bacterial death. Neomycin reduces the growth of the ammoniaproducing bacteria in the intestines and is used for the treatment of hepatic coma.
(B) This choice describes the action of lactulose, another drug commonly used to decrease systemic ammonia levels.
(C) Neomycin's action doesnotdecrease uptake of vitamin D to reduce serum ammonia levels.
(D) Bowel irritation with diarrhea is more likely to occur with administration of lactulose rather than of neomycin. Besides, diarrhea is a side
effect of a drug, not the action of the drug.
QUESTION 652
A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC),
fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulin dependent
diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following
should the nurse expect to administer in the ER?
A. D50W by IV push
B. NPH insulin SC
C. Regular insulin by IV infusion
D. Sweetened grape juice by mouth
Answer: C
Explanation:
(A) This action would further increase the client's blood sugar.
(B) NPH insulin is an intermediate-acting insulin, with an average of 46 hours before onset of action. The client needs insulin that will act
immediately. During a ketoacidotic state, the client is dehydrated, so any insulin administered SC will be poorly absorbed.
(C) Regular insulin is the fastest acting-insulin; when given IV, it will immediately act to decrease blood sugar. Regular insulin is given to
decrease blood glucose levels by promoting metabolism of glucose, inhibiting lipolysis and formation of ketone bodies.
(D) This action would further increase the client's blood sugar.
QUESTION 653
A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse
will monitor him closely for serum:
A. Chloride level of 99 mEq/L
B. Sodium level of 136 mEq/L
C. Potassium level of 3.1 mEq/L
D. Potassium level of 6.3 mEq/L
Answer: D
Explanation:
(A) The chloride level is within acceptable limits.
(B) The sodium level is within acceptable limits.
(C) This value indicates hypokalemia, rather than the hyperkalemia that occurs during diabetic ketoacidosis.
(D) When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus
increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is
transported back into the cells. Normal serum potassium levels range from 3.55.0 mEq/L.
QUESTION 654
An IDDM client's condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a
hypoglycemic reaction to occur that same day at:
A. 8:30 AM10:30 AM
B. 2:30 PM4:30 PM
C. 7:30 PM9:30 PM
D. 10:30 PM11:30 PM
Answer: B
Explanation:
(A) This time describes the time of onset of NPH insulin's action, rather than its peak effect.
(B) NPH insulin, an intermediate acting insulin, usually begins to lower serum glucose levels about 2 hours after administration. The action of
NPH insulin peaks 814 hours after administration. It has a 2030 hour duration.
(C) The time stated is not the time of peak action for NPH insulin administered at 6:30 AM.
(D) The time stated is not the time of peak action for NPH insulin administered at 6:30 AM.
QUESTION 655
After several days, an IDDM client's serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge.
The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can
substitute 1 oz of poultry for:
A. One frankfurter
B. One ounce of ham
C. Two slices of bacon
D. One-fourth cup dry cottage cheese
Answer: D
Explanation:
(A) A frankfurter is a high-fat meat on the diabetic exchange list.
(B) Ham is a medium-fat meat on the diabetic exchange list, unless it is a center-cut slice.
(C) One strip of bacon equals onefatexchange rather than ameatexchange. Dietary substitutions should occur within exchange lists and not
between exchange lists.
(D) Diabetic meat-exchange lists are categorized into lean meat foods, medium-fat meats, and high-fat meats. Cottage cheese (dry, 2% butterfat),
one- fourth cup, can substitute for one lean-meat exchange.
QUESTION 656
When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:
A. When exercise is increased, insulin needs are increased
B. When exercise is increased, insulin needs are decreased
C. When exercise is increased, there is no change in insulin needs
D. When exercise is decreased, insulin needs are decreased
Answer: B
Explanation:
(A) If the client's insulin is increased when activity level is increased, hypoglycemia may result.
(B) Exercise decreased the blood sugar by promoting uptake of glucose by the muscles. Consequently, less insulin is needed to metabolize
ingested carbohydrates. Extra food may be required for extra activity.
(C) This statement directly contradicts the correct answer and is inaccurate.
(D) When exercise is decreased, the client's insulin dose does not need to be altered unless the blood sugar becomes unstable.
QUESTION 657
A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and
hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint.
The most serious symptom that may accompany BPH is:
A. Acute urinary retention
B. Hesitancy in starting urination
C. Increased frequency of urination
D. Decreased force of the urinary stream
Answer: A
Explanation:
(A) Acute urinary retention requires urgent medical attention. If measures such as a warm tub bath or warm tea do not occur after 6 hours, the
client should go to the ED for catheterization.
(B, C, D) This choice is a symptom of BPH, but it is not serious or life threatening.
QUESTION 658
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal
saline in progress. The purpose of this bladder irrigation is to prevent:
A. Bladder spasms
B. Clot formation
C. Scrotal edema
D. Prostatic infection
Answer: B
Explanation:
(A) The purpose of bladder irrigation is not to prevent bladder spasms, but to drain the bladder and decrease clot formation and obstruction.
(B) A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other
debris will cause prostatic distention and hemorrhage.
(C) Scrotal edema seldom occurs after TURP. Bladder irrigation will not prevent this complication.
(D) Prostatic infection seldom occurs after TURP. Bladder irrigation will not prevent this complication.
QUESTION 659
Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual
functioning?
A. "You may resume sexual intercourse in 2 weeks."
B. "Many men experience impotence following TURP."
C. "A transurethral resection does not usually cause impotence."
D. "Check with your doctor about resuming sexual activity."
Answer: C
Explanation:
(A) Sexual activity should be delayed until cleared by the client's physician.
(B) Although many men experience retrograde ejaculation following prostate surgery, potency is seldom affected.
(C) Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse.
(D) Although the client should obtain clearance from his physician before resuming sexual activity, this statement does not give the client any
information or reassurance about future sexual activity or potency that could decrease his anxiety.
QUESTION 660
A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a
sonogram in this situation to be:
A. Determination of multiple gestations
B. Determination of gross anomalies
C. Determination of placental location
D. Determination of fetal age
Answer: C
Explanation:
(A) Sonography can be used to determine the presence of multiple gestation. In this question, the sonogram is used as a preparatory step for a
specific invasive procedure.
(B) Sonography can be used to determine the presence of gross anomalies. In this question, the sonogram is used as a preparatory step for a
specific invasive procedure.
(C) Prior to amniocentesis, the abdomen is scanned by ultrasound to locate the placenta, thus reducing the possibility of penetrating it with the
spinal needle used to obtain amniotic fluid.
(D) Sonography can be used to determine fetal age. In this question, the sonogram is used as a preparatory step for a specific invasive procedure.
QUESTION 661
A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to
be typical:
A. Thready pulse
B. Irregular pulse
C. Tachycardia
D. Bradycardia
Answer: D
Explanation:
(A) A thready pulse is indicative of hypotension and excessive blood loss and is often rapid.
(B) Pulse irregularities or dysrhythmias do not occur in the normal postpartal woman.
(C) Tachycardia occurs less frequently than bradycardia and is related to increased blood loss or prolonged difficult labor and/or birth.
(D) Puerperal bradycardia with rates of 5070 bpm commonly occurs during the first 610 days of the postpartal period. It may be related to
decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.
QUESTION 662
A client is being admitted to the labor and delivery unit. She has had previous admissions for "false labor." Which clinical manifestation would
be most indicative of true labor?
A. Increased bloody show
B. Progressive dilatation and effacement of the cervix
C. Uterine contractions
D. Decreased discomfort with ambulation
Answer: B
Explanation:
(A) Bloody show is considered a sign of imminent labor, which usually begins in 2448 hours. An increase in bloody show is an indication that
the cervix is changing.
(B) Contractions of true labor produce progressive cervical effacement and dilatation.
(C) Contractions of false labor may mimic those of true labor. However, the contractions of false labor do not produce progressive effacement
and dilatation of the cervix.
(D) In true labor, the discomfort is not relieved by ambulation; walking may intensify the discomfort.
QUESTION 663
In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4
toxicity?
A. A 31 patellar tendon reflex
B. Respirations of 12 breaths/min
C. Urine output of 40 mL/hr
D. A 21 proteinuria value
Answer: B
Explanation:
(A) Diminished (not accentuated) patellar tendon reflex is a sign of developing MgSO4 toxicity. A value of 21 is considered a normal tendon
reflex; 3+ is considered brisker than normal.
(B) MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity
may be developing.
(C) Urine output of 40mL/hr is enough to allow elimination of toxic levels of magnesium. Urinary output of <100 mL in a 4- hour period may
result in toxic levels of magnesium.
(D) Presence of protein in the urine is a symptom of pregnancy-induced hypertension (PIH), a clinical syndrome for which magnesium sulfate is
frequently used in medical management. Protein in the urine is not induced by magnesium sulfate intake.
QUESTION 664
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio
of 1:1. This is indicative of:
A. Lung immaturity
B. Intrauterine growth retardation (IUGR)
C. Intrauterine infection
D. Neural tube defect
Answer: A
Explanation:
(A) At about 3032 weeks' gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the
concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if
birth occurs at this time.
(B) IUGR is associated with compromised uteroplacental perfusion or with viral infections, chromosomal disorders, congenital malformations,
and maternal malnutrition. IUGR is not specifically assessed by analysis of the L/S ratio.
(C) Analysis of the L/S ratio is not an assessment used to confirm intrauterine infection.
(D) Elevated levels of _- fetoprotein in maternal serum or in amniotic fluid have been found to reflect open neural tube defects, such as spina
bifida and anencephaly.
QUESTION 665
On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and
deviated to the right. This is most likely an indication of:
A. Normal involution
B. A full bladder
C. An infection pain
D. A hemorrhage
Answer: B
Explanation:
(A) Immediately after expulsion of the placenta, the fundus should be in the midline and remain firm.
(B) A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full
bladder can displace the uterus.
(C) Symptoms of infection may include unusual uterine discomfort, temperature elevation, and foul- smelling lochia. The stem of this question
does not address any of these factors.
(D) While excessive bleeding is associated with a soft, boggy uterus, the stem of this question includes displacement of the uterus, which is more
commonly associated with bladder distention.
QUESTION 666
A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
A. Assess quantity of fluid.
B. Assess color and odor of fluid.
C. Document on fetal monitor strip and chart.
D. Assess fetal heart rate (FHR).
Answer: D
Explanation:
(A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well- being, but it does not take priority over
assessment of FHR.
(B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these
are important assessment data, but they do not take priority over possible life threatening compression of the umbilical cord.
(C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord.
(D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions.
The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly
against the cervix.
QUESTION 667
The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with
cigarette smoking there is increased risk that the baby will have:
A. A low birth weight
B. A birth defect
C. Anemia
D. Nicotine withdrawal
Answer: A
Explanation:
(A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus.
(B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal
anomalies.
(C) Smoking during pregnancy has not been directly linked to anemia in the fetus.
(D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn.
QUESTION 668
Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
A. Hemoglobin 17.2 g/dL
B. Platelets 250,000/mm3
C. Serum glucose 30 mg/dL
D. White blood cells 18,000/mm3
Answer: C
Explanation:
(A) The normal range for hemoglobin in the newborn is 1719 g/dL; 17.2 g/dL is within normal limits.
(B) A normal value range for platelets in the newborn is
150,000400,000 mm3; 250,000/mm3 is within normal range.
(C) A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention.
(D) On the day of birth, a white blood cell count of 18,00040,000/mm3 is normal in the newborn.
QUESTION 669
A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her
third attempt in 2 years. The highest priority intervention at this time is to:
A. Assess level of consciousness
B. Assess suicide potential
C. Observe for sedation and hypotension
D. Orient to her room and unit rules
Answer: B
Explanation:
(A) The client was stabilized in the ED and consequently would not be sent to the psychiatric unit if comatose.
(B) Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places
the client at high risk.
(C) The admission assessment should include observation for sedation and hypotension, but this is not in priority over suicide assessment.
(D) Orientation to room and unit rules is of low priority at this time.
QUESTION 670
A client's record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet
would be the most appropriate at this time?
A. High carbohydrate, low cholesterol
B. High protein, high carbohydrate
C. 1 g sodium
D. Tyramine-free
Answer: D
Explanation:
(A) There are no data to support the need for increased carbohydrates or decreased cholesterol in the diet.
(B) There is no data to support the need for increased protein or increased carbohydrates in the diet.
(C) There is no assessment or laboratory data indicating that sodium should be restricted in the diet.
(D) Tyramine is an amino acid activated by MAO in the liver and intestinal wall. It is released as proteins are hydrolyzed through aging,
pickling, smoking, or spoilage of foods. When MAO is inhibited, tyramine levels rise, stimulating the adrenergic system to release large amounts
of norepinephrine, which can produce a hypertensive crisis.
QUESTION 671
Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following
conditions, if present, would be a contraindication for ECT?
A. Brain tumor or other space-occupying lesion
B. History of mitral valve prolapse
C. Surgically repaired herniated lumbar disk
D. History of frequent urinary tract infections
Answer: A
Explanation:
(A) A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases. Therefore, ECT
would not be prescribed for a client whose intracranial pressure is already elevated.
(B) Any cardiac dysrhythmias or complications that arise during ECT are usually attributed to the IV anesthetics used, not to preexisting cardiac
structural conditions.
(C) Musculoskeletal injuries during ECT are extremely rare because of the IV use of centrally acting muscle relaxers.
(D) A history of any kind of infection would not contraindicate the use of ECT. In fact, concurrent treatment of infections with ECT is not
uncommon.
QUESTION 672
A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2- week period. Her husband asks, "Isn't that a lot?"
The nurse's best response is:
A. "Yes, that does seem like a lot."
B. "You'll have to talk to the doctor about that. The physician knows what's best for the client."
C. "Six to 10 treatments are common. Are you concerned about permanent effects?"
D. "Don't worry. Some clients have lots more than that."
Answer: C
Explanation:
(A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It also reinforces the husband's fears.
(B) This response is "passing the buck" unnecessarily. The information needed to appropriately answer the husband's question is well within the
nurse's knowledge base.
(C) The most common range for affective disorders is 610 treatments. This response confirms and reinforces the physician's plan for treatment. It
also opens communication with the husband to identify underlying fears and knowledge deficits.
(D) This response offers false reassurance and dismisses the husband's underlying concerns about his wife.
QUESTION 673
A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:
A. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment."
B. "Visitors are not allowed. We will telephone you to inform you of her progress."
C. "There's really no need to stay with her. She's going to sleep for several hours after the treatment."
D. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment."
Answer: D
Explanation:
(A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick.
(B) Visitors are allowed and encouraged, particularly family members.
(C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off.
(D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and
allay fears by explaining temporary side effects of the treatment.
QUESTION 674
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is
administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the
corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is:
A. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner."
B. "You'll probably see strange things for a while until the PCP wears off."
C. "Try to sleep. When you wake up, the devil will be gone."
D. "You're probably feeling guilty because you used illegal drugs tonight."
Answer: A
Explanation:
(A) The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and
reinforcing reality.
(B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation.
(C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces
delusional content.
(D) The nurse is making an incorrect assumption about the client's feelings by offering a nontherapeutic interpretation of the motivation for the
client's actions.
QUESTION 675
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
A. Give fluids if the client requests them.
B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
C. Measure vital signs at least every 4 hours.
D. Release restraints every 2 hours for client to exercise.
Answer: D
Explanation:
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not.
(B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are
applied and after they are removed.
(C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more
closely, perhaps every 12 hours.
(D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and
circulation.
QUESTION 676
After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue "pulling to
one side." These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:
A. Lorazepam (Ativan)
B. Benztropine (Cogentin)
C. Thiothixene (Navane)
D. Flurazepan (Dalmane)
Answer: B
Explanation:
(A) Lorazepam is an antianxiety agent that produces muscle relaxation and inhibits cortical and limbic arousal. It has no action in the basal
ganglia of the brain.
(B) Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by
displacing acetylcholine at the receptor site.
(C) Thiothixene is an antipsychotic known to block dopamine in the limbic system, thereby causing EPS.
(D) Flurazepan is a hypnotic that acts in the limbic system, thalamus, and hypothalamus of the CNS to produce sleep. It has no known action in
the vasal ganglia.
QUESTION 677
Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be
removed when:
A. The physician orders it
B. A therapeutic alliance has been established, and violent behavior subsides
C. The violent behavior subsides, and the client agrees to behave
D. The nurse deems that removal of restraints is necessary
Answer: B
Explanation:
(A) The physicianmayorder release of restraints, but prior to that, the client must meet criteria for release.
(B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue
between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to
violence.
(C) If the client only "agrees to behave" after violent behavior subsides, he has developed no insight into cause and effect of violence or his
response to stress.
(D) Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.
QUESTION 678
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her
mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two
of her best friends. The client is 5'4" and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial
intervention on admission is to:
A. Obtain an accurate weight
B. Search the client's purse for pills
C. Assess vital signs
D. Assign her to a room with someone her own age
Answer: C
Explanation:
(A) On admission, vital signs are the highest priority. Weight is not a vital sign.
(B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a high priority.
(C) Vital signs are a high priority when working with self-destructive clients.
(D) Room assignment is of low priority.
QUESTION 679
Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96
bpm, respirations
30, and temperature 97 F. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose
"just 5 more lb." Her symptoms are consistent with:
A. Pregnancy
B. Bulimia
C. Gastritis
D. Anorexia nervosa
Answer: D
Explanation:
(A) Presenting behaviors collectively are inconsistent with depression.
(B) A preillness weight loss of 30%, lanugo, and cessation of menses are inconsistent with bulimia.
(C) Symptoms and vital signs do not indicate the presence of infection.
(D) All symptoms and vital signs are consistent with anorexia nervosa.
QUESTION 680
Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa: hemoglobin 9.6 g/dL, hemocrit 27%,
potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is:
A. Hypoglycemia from low-carbohydrate intake
B. Possible cardiac dysrhythmias secondary to hypokalemia
C. Dehydration from vomiting
D. Anoxia secondary to anemia
Answer: B
Explanation:
(A) There is no lab data to support hypoglycemia.
(B) Hypokalemia, caused by vomiting and decreased dietary intake of potassium, can result in life-threatening dysrhythmias.
(C) Evidence of dehydration is not life threatening at this time, although fluid volume deficit does need to be addressed.
(D) The client's hemoglobin does not reflect a life threatening value sufficient to render the client anoxic.
QUESTION 681
A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the
results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification
plan is initiated. Three days after her transfer, the client tells the nurse, "I haven't exercised in 6 days. I won't be eating lunch today." This
statement by her most likely reflects:
A. Her lack of internal awareness about the outcome of the behavior
B. Increased knowledge about personal exercise plans
C. A manipulative technique to trick the nurse into allowing her to miss a meal
D. A true desire to stay fit while in the hospital
Answer: A
Explanation:
(A) Indirect self-destructive behavior such as that seen in anorexia nervosa is characterized by the client's lack of insight and the awareness that
the outcome of the dieting, exercising, and weight loss will ultimately result in death if uninterrupted.
(B) Although the client is knowledgeable about exercise, knowledge about the balance between nutrition, exercise, and rest is absent.
(C) The client's level of denial and lack of awareness disallow this behavior as a manipulative trick.
(D) The client's illness-maintaining behaviors are inconsistent with fitness.
QUESTION 682
A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
A. "Okay, missing one meal won't hurt."
B. "You'll have to eat lunch, or we'll force-feed you."
C. "It's not appropriate for you to try to manipulate the staff into granting your wishes."
D. "We will not allow you to starve yourself. You may choose to eat voluntarily or be fed."
Answer: D
Explanation:
(A) This response reinforces the client's maladaptive behavior, thereby contributing to the client's risk.
(B) Ultimatums are not therapeutic.
(C) This comment invites an argument because it puts the client on the defensive and stabs at her self-esteem, which is already compromised.
(D) Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client
an increased sense of control over her life and avoid an argument or power struggle.
QUESTION 683
A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in
monitoring her dietary compliance would be to:
A. Allow her privacy at mealtimes
B. Praise her for eating everything
C. Observe behavior for 12 hours after meals to prevent vomiting
D. Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes
Answer: C
Explanation:
(A) Eating alone is not recommended for anorexic clients because they tend to hoard food instead of eating it.
(B) The client should be praised for whatever she eats, which is usually a small portion or percentage of what is served. Praise should not be
withheld until she eats everything.
(C) The client should be observed eye to- eye for at least 1 hour following meals to prevent discarding food stashed in her clothing at mealtime
or engaging in self-induced vomiting.
(D) If offered these choices, the client would choose low-caloric foods, not a nutritious diet.
QUESTION 684
A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:
A. Be comforted when he is held
B. Cry
C. Not notice that his mother has left
D. Withdraw and become listless
Answer: B
Explanation:
(A) It will be difficult to comfort a 2 year old with a headache without his mother.
(B) This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait
until the baby is asleep may help.
(C) An awake 2 year old will notice when his mother leaves.
(D) An older child may withdraw when feeling afraid, but a 2 year old will probably show more aggressive behavior.
QUESTION 685
The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:
A. 900 mL/24 hr
B. 1300 mL/24 hr
C. 1600 mL/24 hr
D. 2000 mL/24 hr
Answer: C
Explanation:
(A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours.
(C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours.
QUESTION 686
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
A. Crying
B. Falling asleep
C. Rolling from his back to his tummy
D. Sucking his thumb
Answer: A
Explanation:
(A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure.
(B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury.
(C) This child is free to roll from his back to his abdomen.
(D) Thumb- sucking serves to reduce anxiety and should not be prevented at this time.
QUESTION 687
A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he
demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:
A. Encourage him to drink plenty of fluids
B. Expect him to have nausea with vomiting
C. Keep him awake for the next 12 hours
D. Wake him up every 12 hours during the night
Answer: D
Explanation:
(A) Fluid intake should be normal. Fluid intake may be restricted when there is a risk for increased ICP in a hospitalized client.
(B) Nausea is possible, but vomiting without nausea is more likely with increased ICP. Neither one should be expected, but the mother should
know to notify the physician or hospital if they occur.
(C) The child does not need to be kept awake. It is important that he can be aroused from sleep.
(D) If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an
ambulance right away.
QUESTION 688
A 14-year-old boy fell off his bike while "popping a wheelie" on the dirt trails. He has sustained a head injury with laceration of his scalp over
his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:
A. Ask the physician to order a sedative
B. Have the client describe his headache every 15 minutes
C. Increase his fluid intake to 3000 mL/24 hr
D. Offer diversionary activities
Answer: D
Explanation:
(A) CNS depressants are not given for headache due to head injury because they would mask changes in neurological status and because they
could further depress the CNS.
(B) The client should not be asked to think about his headache every 15 minutes.
(C) Fluid intake should be normal or restricted for a client with a head injury. Normal fluid intake for a 14 year old is about 20002400 mL daily.
(D) Diversion may help the child to focus on a pleasant activity instead of on his headache.
QUESTION 689
An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising
pulse rate and lowering blood pressure, the nurse would suspect that the client:
A. Has a sudden and severe increase in intracranial pressure
B. Has sustained an internal injury in addition to the head injury
C. Is beginning to experience a dangerously high level of anxiety
D. Is having intracranial bleeding
Answer: B
Explanation:
(A) Widening pulse pressure (high systolic and low diastolic) with compensatory slowing of pulse rate are late signs of increasing ICP.
(B) Rising pulse rate and lowering blood pressure are indicative of hypovolemia due to hemorrhage.
(C) High anxiety, in the absence of hemorrhage, would result in a high pulse rate and a high blood pressure.
(D) Intracranial bleeding results in increased ICP. A change in level of consciousness is an early sign of increasing ICP, and vital sign changes
are late signs of increasing ICP.
QUESTION 690
The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a
runny nose. The nurse should:
A. Call the doctor immediately
B. Help her to blow her nose carefully
C. Test the discharge for sugar
D. Turn her to her side
Answer: C
Explanation:
(A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak.
(B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose.
(C) Cerebrospinal fluid is positive for sugar; mucus is not.
(D) Turning her to her side will have no effect on her "runny nose." It is necessary to gather further assessment data.
QUESTION 691
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the
physician to report:
A. Evidence of perineal irritation
B. Pulse fell from 102 to 96
C. Pulse increased from 96 to 102
D. Temperature rose to 102_F rectally
Answer: D
Explanation:
(A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician.
(B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change.
(C) This rise in pulse rate is probably not significant, but it is important to monitor for continued change.
(D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
QUESTION 692
The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she:
A. Dorsiflexes her ankle
B. Flexes her spine
C. Plantiflexes her wrist
D. Turns her head to the side
Answer: B
Explanation:
(A) Discomfort with ankle dorsiflexion is not expected with meningitis.
(B) Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated.
(C) Discomfort with wrist flexion is not expected with meningitis.
(D) Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation.
QUESTION 693
The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:
A. Constipation
B. Hypothermia
C. Seizure
D. Sunken fontanelles
Answer: C
Explanation:
(A) Constipation may occur if the child is dehydrated, but it is not directly associated with meningitis.
(B) It is more likely the child will have fever.
(C) Seizure is often the initial sign of meningitis in children and could become frequent.
(D) It is more likely the child will have bulging fontanelles.
QUESTION 694
The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:
A. Give her a small soft blanket to hold
B. Give her good perineal care after each diaper change
C. Leave the door open to her room
D. Pick her up when she cries
Answer: D
Explanation:
(A) A soft blanket may be comforting, but it is not directed toward developing a sense of trust.
(B) Good perineal care is important, but it is not directed toward developing a sense of trust.
(C) An infant with meningitis needs frequent attention, but leaving the door open does not foster trust.
(D) Consistently picking her up when she cries will help the child feel trust in her caregivers.
QUESTION 695
A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse
how many baby aspirins her daughter can have for fever. The nurse should:
A. Advise the mother not to give her aspirin
B. Ask if the client is allergic to aspirin before giving further information
C. Assess the function of the client's cranial nerve VIII
D. Check the aspirin bottle label to determine milligrams per tablet
Answer: A
Explanation:
(A) Aspirin taken during a viral infection has been implicated as a predisposing factor to Reye's syndrome in children and adolescents. Children
and adolescents should not be given aspirin.
(B) Allergy to aspirin is not related to Reye's syndrome.
(C) Tinnitus, caused by damage to the acoustic nerve, occurs with aspirin toxicity, but this is not related to Reye's syndrome.
(D) A 6- year-old child should not be given any baby aspirin.
QUESTION 696
A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the
following play activities as most appropriate?
A. Assembling a puzzle with large pieces
B. Being taken for a wheelchair ride
C. Listening to a story about the Muppets
D. Watching Sesame Street on television
Answer: A
Explanation:
(A) A 2-year-old child is in the stage of autonomy, according to Erikson. Assembling a puzzle with large pieces enables her to "do it herself."
(B) A wheelchair ride would probably be fun, but it is not directed toward helping the child to achieve autonomy.
(C) Listening to a story may be fun and educational, but it is not directed toward helping the child to achieve autonomy.
(D) Watching television may be a favorite activity, but it does not foster autonomy.
QUESTION 697
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
A. Blood pressure increase from 100/80 to 115/85 after lunch
B. Headache that is unresponsive to acetaminophen (Tylenol)
C. Pulse rate ranges between 68 bpm and 76 bpm
D. Temperature rise to 102_F rectally
Answer: D
Explanation:
(A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is
important to continue to monitor for change in blood pressure.
(B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask
neurological signs and may depress the CNS.
(C) Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in
pulse rate, which is a late sign of increasing ICP.
(D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the
head injury, but CNS infection is serious and difficult to control.
QUESTION 698
The nurse is teaching a child's parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in
children is:
A. Dandelion leaves
B. Pencils
C. Old paint
D. Stuffing from toy animals
Answer: C
Explanation:
(A) Dandelion leaves are not a source of lead.
(B) Pencils are not a source of lead poisoning.
(C) Chewing on objects painted before 1960 is a common source of lead poisoning in children. Gasoline is another source.
(D) Stuffed animals are not a source of lead.
QUESTION 699
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:
A. Limit activities which require focusing (close vision)
B. Take more frequent naps
C. Use artificial tears
D. Wear a patch over one eye
Answer: D
Explanation:
(A) Limiting activities requiring close vision will not alleviate the discomfort of double vision.
(B) Frequent naps may be comforting, but they will not prevent double vision.
(C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia.
(D) An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a
person with an intact corneal reflex.
QUESTION 700
In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:
A. Becomes progressively debilitating without remission
B. Has unpredictable remissions and exacerbations
C. Is rapidly fatal
D. Responds quickly to antimicrobial therapy
Answer: B
Explanation:
(A) Multiple sclerosis eventually becomes debilitating, but it is characterized by remission of symptoms.
(B) Remissions and exacerbations are unpredictable with multiple sclerosis. The client experiences progressive dysfunction after each
exacerbation episode.
(C) Multiple sclerosis is usually slowly progressive.
(D) Multiple sclerosis is an autoimmune disease.
Antimicrobial therapy has no effect on its course.
QUESTION 701
A client with a head injury asks why he cannot have something for his headache. The nurse's response is based on the understanding that
analgesics could:
A. Counteract the effects of antibiotics
B. Elevate the blood pressure
C. Mask symptoms of increasing intracranial pressure
D. Stimulate the central nervous system
Answer: C
Explanation:
(A) Analgesic medication does not counteract the effects of antibiotics.
(B) Analgesic medication may lower blood pressure elevated due to anxiety.
(C) Analgesic medication, especially CNS depressants, is not given if there is danger of increasing ICP, because neurological changes may not be
apparent. Also, further depression of the CNS is contraindicated.
(D) Analgesics do not stimulate the CNS.
QUESTION 702
To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby's mother to:
A. Avoid touching the baby while in the room.
B. Stay outside of the baby's room.
C. Wear a gown and gloves and wash her hands before and after leaving the room.
D. Wear a mask while in the room.
Answer: C
Explanation:
(A) The mother should be allowed and encouraged to touch her baby.
(B) With care, transmission can be prevented. There is no need for the mother to stay outside the room.
(C) Everyone entering the baby's room should take appropriate measures to prevent transmission of pathogens.
(D) Wearing a mask will not protect against transmission of pathogens.
QUESTION 703
A client is scheduled for a magnetic resonance imaging (MRI) to locate a cerebral lesion. It is important for the nurse to find out if he has a(n):
A. Allergy to seafood
B. History of seizures
C. Movable metal implant
D. Pin or screw in any bone
Answer: C
Explanation:
(A) Iodine is not used as a contrast medium for MRI. It is important to inquire about allergy to seafood if the client is to have an arteriogram or
enhanced computer tomography.
(B) MRI is safe if seizures are under control. It is more important to inquire about movable metal implants.
(C) Clients with movable metal implants such as shrapnel or aneurysm clips or clients with permanent pacemakers or implanted pumps can be
traumatized during an MRI.
(D) Nonmovable metal prostheses or hardware will not cause trauma during an MRI.
QUESTION 704
A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be
more comfortable if the nurse:
A. Dims the lights in her room
B. Encourages her to breathe slowly and deeply
C. Offers sips of warm liquids
D. Places a large, soft pillow under her head
Answer: A
Explanation:
(A) The discomfort of photophobia is alleviated by dimming the lights.
(B) Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis.
(C) It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis.
(D) A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.
QUESTION 705
A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he
had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing:
A. Grandiose delusions
B. Paranoid delusions
C. Auditory hallucinations
D. Visual hallucinations
Answer: B
Explanation:
(A) There are no indications that the client's thoughts reflect special powers or talents characteristic of grandiosity.
(B) The client's thought content is fixed, false, persecutory, and suspicious in nature, which is characteristic of paranoid delusions.
(C, D) The client is not demonstrating a sensory experience.
QUESTION 706
A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having
difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this
time is:
A. Sensory-perceptual alteration: auditory command hallucinations
B. Alteration in thought processes: paranoid delusions
C. Potential for violence directed at others
D. Impaired verbal communication: loose associations
Answer: C
Explanation:
(A) Although the client is having command hallucinations, this is second in priority to real or potential violence, which can be a threat to life
itself.
(B) Although the client is experiencing delusions, this is also a lower priority than his potential or actual loss of control.
(C) Whether real or potential, violence directed at self or others is always high priority.
(D) There is no evidence of loosening of associations.
QUESTION 707
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and
kill her. The best verbal response to the client by the nurse at this time is:
A. "I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness."
B. "Just don't pay attention to the voices. They'll go away after some medication."
C. "You can't leave here. This unit is locked and the doctor has not ordered your discharge."
D. "We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that."
Answer: A
Explanation:
(A) This response validates the client's experience and presents reality to him.
(B) This nontherapeutic response minimizes and dismisses the client's verbalized experience.
(C) This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control.
(D) This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion
or restraints were indicated, the nurse should never confront the client alone.
QUESTION 708
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 12 hours if needed. The most likely
rationale for this order is:
A. The client will settle down more quickly if he thinks the staff is medicating him
B. The medication will sedate the client until the physician arrives
C. Haloperidol is a minor tranquilizer and will not over sedate the client
D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client
Answer: D
Explanation:
(A) If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients
frequently experience high levels of anxiety, which can contribute to delusions.
(B) The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him.
(C) Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer.
(D) Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.
QUESTION 709
Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing
symptoms consistent with:
A. Parkinsonism and dystonia
B. Dystonia and akathisia
C. Akathisia and parkinsonism
D. Neuroleptic malignant syndrome
Answer: B
Explanation:
(A) Stiff neck is consistent with a dystonic reaction, but the client has no symptoms of drooling, shuffling gait, or pill-rolling movements
characteristic of parkinsonism.
(B) Stiff neck is consistent with a dystonic reaction, and inability to sit still with varying degrees of psychomotor agitation is characteristic of
akathisia.
(C) The client has symptoms of dystonia but not of parkinsonism.
(D) The client has none of the characteristic symptoms of neuroleptic malignant syndrome: hyperpyrexia, generalized muscle rigidity, mutism,
obtundation, agitation, sweating, increased blood pressure and pulse.
QUESTION 710
The physician orders medication for a client's unpleasant side effects from the haloperidol. The most appropriate drug at this time is:
A. Lorazepam
B. Triazolam (Halcion)
C. Benztropine
D. Thiothixene
Answer: C
Explanation:
(A) Lorazepam is a benzodiazepine, or antianxiety agent, that potentiates the effects of aminobutyric acid in the CNS, which is not the CNS
neurotransmitter EPS.
(B) Triazolam is a benzodiazepine sedative-hypnotic whose action is mediated in the limbic, thalamic, and hypothalamic levels of the CNS by aminobutyric acid.
(C) Benztropine is an anticholinergic agent, and the drug of choice for blocking CNS synaptic response, which causes EPS.
(D) Thiothixene is an antipsychotic and neuroleptic drug that blocks dopamine neurotransmission at the CNS synapses, thereby causing EPS.
QUESTION 711
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the
following client statements?
A. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."
B. "If I have any side effects from my medicines, I will take an extra dose of Cogentin."
C. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now."
D. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway."
Answer: A
Explanation:
(A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts
him at the lowest risk for relapse.
(B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance.
(C) This statement reflects lack of insight into the importance of compliance.
(D) This statement reflects no insight into his illness or his responsibility in health maintenance.
QUESTION 712
The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical
mobility. Which alteration is most likely the etiology?
A. Hypernatremia
B. Hypocalcemia
C. Hypokalemia
D. Hypomagnesemia
Answer: C
Explanation:
(A) A deficit in sodium concentration results in muscular weakness and lethargy.
(B) Muscle fatigue and hypotonia are caused by hypercalcemia.
(C) Muscle weakness and fatigue are classic signs of hypokalemia.
(D) Hypermagnesemia can cause muscle weakness, paralysis, and coma.
QUESTION 713
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
A. Inspiration is longer than expiration
B. Breath sounds are high pitched
C. Breath sounds are slightly muffled
D. Inspiration and expiration are equal
Answer: D
Explanation:
(A) Inspiration is normally longer in vesicular areas.
(B) Highpitched sounds are normal in bronchial area.
(C) Muffled sounds are considered abnormal.
(D) Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
QUESTION 714
Discharge teaching for the client who has a total gastrectomy should include which of the following?
A. Need for the client to increase fluid intake to 3000 mL/day
B. Follow-up visits every 3 weeks for the first 6 months
C. B12 injections needed for the rest of the client's life
D. Need to eat three full meals with plenty of fiber per day
Answer: C
Explanation:
(A) There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem.
(B) Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized.
(C) With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral
injections of B12 will be needed on a monthly basis for the rest of the person's life.
(D) Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.
QUESTION 715
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
A. Urine output 22 mL/hr for 2 hours
B. Serum potassium level of 3.7
C. Small T wave of ECG
D. Serum glucose level of 180
Answer: A
Explanation:
(A) Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally.
(B) Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of
potassium are normal.
(C) A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate over infusion of potassium and
hyperkalemia.
(D) Glucose levels of <200 are desirable.
QUESTION 716
A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug
dependent?
A. The client requests pain medicine every 4 hours.
B. He is asleep 30 minutes after receiving the IV morphine.
C. He asks for pain medication although his blood pressure and pulse rate are normal.
D. He is euphoric for about an hour after each injection.
Answer: D
Explanation:
(A) Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery.
(B) Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved.
(C) A person may be in pain even with normal vital signs.
(D) A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain.
QUESTION 717
The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse's action
should be to:
A. Encourage coughing and deep breathing each hour
B. Obtain arterial blood gases
C. Increase O2 from 23 L/min
D. Remove the postoperative dressing to check for bleeding
Answer: A
Explanation:
(A) Decreased or absent breath sounds are frequently indicators of postoperative atelectasis.
(B) Arterial blood gases are not indicated because there is no other information indicating impending danger.
(C) Increasing O2 rate is not indicated without additional information.
(D) Removing the dressing is not indicated without additional information.
QUESTION 718
Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?
A. Nifedipine 10 mg SL for B/P 140/90
B. Furosemide 20 mg/PO for decreased urine output
C. Magnesium salicylate to decrease inflammation
D. Nitroglycerin gr 1/150 for chest pain
Answer: A
Explanation:
(A) It is important to maintain a normal to slightly lower pressure to prevent the graft from blowing and excessive pressure to surgical vascular
areas.
(B, C, D) None of these drugs is related to managing the problem at hand. Also, none of the problems for which these drugs would be indicated
is expected with this type of surgery, except if there is a prior history.
QUESTION 719
Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to:
A. Assess vital signs
B. Elevate the extremity
C. Perform a lower extremity neurovascular check
D. Remind the client that he has a client-controlled analgesic pump, and reinstruct him on its use
Answer: C
Explanation:
(A) Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but they should not be assessed before
checking the affected extremity.
(B) The extremity will be elevated if ordered by the doctor.
(C) Assessment of the postoperative area is important to determine if bleeding, swelling, or decreased circulation is occurring.
(D) Reinforcement of teaching on use of the client-controlled analgesic pump is important, but not the first action.
QUESTION 720
Goal setting for a client with Meniere's disease should include which of the following?
A. Frequent ambulation
B. Prevention of a fall injury
C. Consumption of three meals per day
D. Prevention of infection
Answer: B
Explanation:
(A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance.
(B) Vertigo resulting in balance problems is one of the most common manifestations of Meniere's disease.
(C) Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium.
(D) Infection is not an anticipated problem.
QUESTION 721
Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?
A. Neurovascular checks every 2 hours
B. Elevate legs on pillows
C. Arteriogram in the morning
D. No smoking
Answer: B
Explanation:
(A) Neurovascular checks are a routine part of assessment with clients having this diagnosis.
(B) Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised.
(C) Arteriogram is a routine diagnostic order.
(D) Smoking is highly correlated with this disorder.
QUESTION 722
A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the
room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for
discussion:
A. The risks of exposure of the visitor to infectious organisms is great.
B. Hospital regulations mandate that everyone in the facility adhere to appropriate codes.
C. The client is at extreme risk of acquiring infections.
D. Adherence to the guidelines are the latest Centers for Disease Control and Prevention recommendations on use of protective apparel.
Answer: C
Explanation:
(A) Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client.
(B, D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to
regulations.
(C) Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others.
QUESTION 723
The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the
husband realizes what has occurred he yells, "please save her!" The nurse's action would be:
A. Call the physician and inform him that the client has expired.
B. Remind the husband that the physician wrote an order not to resuscitate.
C. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.
D. Call a code and proceed with cardiopulmonary resuscitation.
Answer: D
Explanation:
(A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts.
(D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the
nurse should talk with the husband and notify the doctor.
QUESTION 724
The nurse is in the hallway and one of the visitors faints. The nurse should:
A. Sit the victim up and lightly slap his face
B. Elevate the victim's legs
C. Apply a cool cloth to the victim's neck and forehead until he recovers
D. Sit the victim up and place the head between the knees
Answer: B
Explanation:
(A) Sitting the client up defeats the goal of re-establishing cerebral blood flow.
(B) Elevating the legs anatomically redirects blood flow to the cerebral area.
(C) This strategy is a nice general comfort measure after the victim has regained consciousness.
(D) This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.
QUESTION 725
The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right
after showering. This statement is made by the nurse based on the knowledge that:
A. The client is more likely to remember to perform the TSE when in the nude
B. When the scrotum is exposed to cool temperatures, the testicles become large and bulky
C. The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate
D. The examination will be less painful at this time
Answer: C
Explanation:
(A) Nudity is not a trigger for reminding males to perform TSE.
(B) Testicles become more firm when exposed to cool temperatures, but not large and bulky.
(C) The testicles will be lower and more easily palpated with warmer temperatures. A protective mechanism of the body to protect sperm
production is for the scrotum to pull closer to the body when exposed to cooler temperatures.
(D) The examination should not be painful.
QUESTION 726
The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm
Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause
of the low blood pressure?
A. Pedal pulses 11 (weak)
B. Twenty-four-hour intake 1000 mL/day for past 2 days
C. Serum potassium 3.3
D. Pulse rate 150 bpm
Answer: B
Explanation:
(A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode.
(B) Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as
an action of the drug.
(C) A potassium level of 3.3 would not be associated with a significant drop in blood pressure.
QUESTION 727
A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action
when admitting the client will be to:
A. Obtain vital signs
B. Connect the client to the cardiac monitor
C. Ask the client if he is still having chest pain
D. Complete the history profile
Answer: B
Explanation:
(A) Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is
discharged from the emergency room.
(B) All are important, but the first priority is to monitor the client's rhythm.
(C) If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs.
(D) Completion of the history profile is the least important of the nursing actions.
QUESTION 728
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in
the client's chief complaint?
A. "I've been having a dull pain at the upper left shoulder."
B. "My legs have been numb for three months."
C. "I've only been urinating three times a day lately."
D. "I don't remember anything in particular, I just haven't felt well."
Answer: D
Explanation:
(A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the
aneurysm is expanding or rupture is imminent.
(D) Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
QUESTION 729
The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat
white chalk. When implementing a teaching plan, the nurse should explain that this practice:
A. Will bind calcium and therefore interfere with its metabolism
B. Will cause more premenstrual cramping
C. Interferes with iron absorption because the iron precipitates as an insoluble substance
D. Causes competition at iron-receptor sites between iron and vitamin B1
Answer: C
Explanation:
(A) Eating chalk is not related to calcium and its absorption.
(B) Poor nutritional habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop
eating chalk. Premenstrual discomfort has not been mentioned.
(C) Iron is rendered insoluble and is excreted through the gastrointestinal tract.
(D) There is no competition between the two nutrients.
QUESTION 730
Which of the following lab data is representative of a client with aplastic anemia?
A. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million
B. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000
C. White blood cells 3000, hematocrit 27, red blood cells 2.8 million
D. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000
Answer: D
Explanation:
(A, B, C) Although all of the lab data are abnormal and although these values are decreased in aplastic anemia, the disorder is defined by severe
deficits in red cell, white cell, and platelet counts.
(D) Aplastic anemia is typically defined in terms of abnormalities of red blood cell count, usually <1 million, white cell count <2,000, and
thrombocytes <20,000.
QUESTION 731
A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to
increase in the diet?
A. Cantaloupe
B. Rice
C. Chicken
D. Green beans
Answer: C
Explanation:
(A) Cantaloupe is a good source of carbohydrates, vitamin C, and vitamin A.
(B) Rice contains about 4 g of protein per 200 g.
(C) Chicken contains 35 g protein per breast. Chicken is a rich source of vitamin B6 (pyridoxine), which is needed for adequate protein
synthesis. As protein intake increases, vitamin B6 intake must also be increased. Vitamin B6 is a coenzyme in amino acid metabolism.
(D) Green beans only contain 2 g of protein per cup.
QUESTION 732
A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells."
Based on this information, which drug might the nurse expect to be discontinued?
A. Prednisone
B. Timolol maleate (Blocadren)
C. Garamycin (Gentamicin)
D. Phenytoin (Dilantin)
Answer: D
Explanation:
(A) Prednisone is not linked with hematological side effects.
(B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia.
(C) Gentamicin is ototoxic and nephrotoxic.
(D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplastic anemia is
chloramphenicol (Chlormycetin).
QUESTION 733
Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm
and facial twitching. The nurse needs to:
A. Report the findings to the physician
B. Assist the client to do range of motion exercises
C. Check the client's potassium level
D. Administer the as-needed dose of phenytoin (Dilantin)
Answer: A
Explanation:
(A) Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate.
Tetany can occur if the parathyroid glands were erroneously excised during surgery.
(B) Range of motion exercises are not appropriate to presenting symptoms.
(C) These characteristics are not usual signs of potassium imbalance, but of calcium imbalance.
(D) Phenytoin is indicated for seizure activity mainly of neurological origin.
QUESTION 734
The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the
client?
A. "Do you take aspirin on a regular basis?"
B. "Do you drink alcohol on a regular basis?"
C. "Do you eat red meat?"
D. "Have your stools been normal?"
Answer: B
Explanation:
(A) Aspirin does not affect folic acid absorption.
(B) Folic acid deficiency is strongly associated with alcohol abuse.
(C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources.
(D) Folic acid does not affect stool character.
QUESTION 735
An 18-month-old child has been playing in the garage. His mother brings him to a nurse's home complaining of his mouth being sore. His lips
and mouth are soapy and white, with small ulcerated areas beginning to form. The child begins to vomit. His pulse is rapid and weak. The nurse
suspects that the child has:
A. Inhaled gasoline fumes
B. Ingested a caustic alkali
C. Eaten construction chalk
D. Lead poisoning
Answer: B
Explanation:
(A, C, D) These agents would not cause ulcerations on mouth and lips.
(B) Strong alkali or acids will cause burns and ulcerations on the mucous membranes.
QUESTION 736
In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:
A. Measure adequacy of nutritional management
B. Check the accuracy of the fluid intake record
C. Impress the child with the importance of eating well
D. Determine changes in the amount of edema
Answer: D
Explanation:
(A) Weighing a child with nephrosis is to assess for edema, not nutrition.
(B, C) This is not the purpose for weighing the child.
(D) Weight and measurement are the primary ways of evaluating edema and fluid shifts.
QUESTION 737
The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse
explains that:
A. Alopecia is an unavoidable side effect.
B. There are several wig makers for children.
C. Most children select a favorite hat to protect their heads.
D. His hair will grow back in a few months.
Answer: D
Explanation:
(A) Alopecia has occurred, and knowing it is a side effect does not address their concern.
(B) Although true, it does not give them hope for the future.
(C) Although true, it does not provide them with information of the temporary nature of the situation.
(D) Knowing the hair will grow back provides comfort that the alopecia is temporary.
QUESTION 738
Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to:
A. Reinforce attempts to eat
B. Help the child gain weight
C. Increase his appetite
D. Make mealtimes pleasant
Answer: A
Explanation:
(A) Ignoring refusals to eat and rewarding eating attempts are the most successful means of increasing intake.
(B) This goal is not specific enough or related to the loss of appetite.
(C) This goal is not possible at this time based on his illness.
(D) This goal is helpful, but alone will not address his loss of appetite.
QUESTION 739
The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is
contraindicated, the next most effective cleansing and gingival stimulation technique would be:
A. Using a water pik
B. Rinsing with water
C. Rinsing with hydrogen peroxide
D. Rinsing with baking soda
Answer: A
Explanation:
(A) This technique provides effective rinsing and gingival stimulation.
(B) This technique does not provide gingival stimulation.
(C) This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child.
(D) This technique provides effective rinsing but not gingival stimulation.
QUESTION 740
When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a
brother who is terminally ill?
A. Open discussion and understanding
B. Play-acting out feelings in different roles
C. Storytelling
D. Drawing pictures
Answer: B
Explanation:
(A) When dealing with grief, siblings are usually most comfortable initially with open discussion.
(B) Assuming different roles allows children to act out their feelings without fear of reprisals and to gain insight and control.
(C) This method may be helpful, but having the child take an active part through role playing is more effective.
(D) This technique may be helpful, but being an active participant through role playing is more effective.
QUESTION 741
During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and
promoting healing by:
A. Putting all joints through full range-of-motion twice daily
B. Massaging the joints briskly with lotion or liniment after bath
C. Immobilizing the joints in functional position using splints, rolls, and pillows
D. Applying warm water bottle or heating pads over involved joints
Answer: C
Explanation:
(A) Any movement of the joint causes severe pain.
(B) Touching or moving the joint causes severe pain.
(C) Immobilization in a functional position allows the joint to rest and heal.
(D) Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.
QUESTION 742
The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:
A. Maintain contact with her parents
B. Provide for physical and psychological rest
C. Provide a nutritious diet
D. Maintain her interest in school
Answer: B
Explanation:
(A) This goal is helpful, but rest is essential during the acute phase.
(B) Rest is essential for healing to occur and for pain to be relieved.
(C) This goal is important, but rest is essential.
(D) This goal should be part of the plan of care, but it is not the priority during the acute phase.
QUESTION 743
During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of
sodium salicylate?
A. Tinnitus and nausea
B. Dermatitis and blurred vision
C. Unconsciousness and acetone odor of the breath
D. Chills and an elevation of temperature
Answer: A
Explanation:
(A) These are toxic symptoms of sodium salicylate.
(B, C, D) These are not symptoms associated with sodium salicylate.
QUESTION 744
Parents of a child with rheumatic fever express concern that she will always be arthritic. The nurse discusses their concerns and tells them the
joint pain usually:
A. Subsides in<3 weeks
B. Is relieved by aspirin
C. Is responsive to ibuprofen (Motrin)
D. Subsides in 36 days
Answer: A
Explanation:
(A) Joints usually remain inflamed and tender until the disease runs its course in 45 mm Hg, HCO3 >26
mEq/L.
(B) Respiratory acidosis would be reflected by the following: pH 45 mm Hg, HCO3 within normal limits (2226 mEq/L).
(C) Partially compensated metabolic alkalosis would be reflected by the following: pH > 7.45, PCO2 > 45 mm Hg, HCO3 > 26 mEq/L.
(D) Combined respiratory and metabolic acidosis would be reflected by the following: pH 45 mm Hg, HCO3 < 22 mEq/L.
QUESTION 808
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified
and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is
to:
A. Remove the potassium from the body by renin exchange
B. Protect the myocardium from the effects of hypokalemia
C. Promote rapid protein catabolism
D. Drive potassium from the serum back into the cells
Answer: D
Explanation:
(A) Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine
reducing the serum potassium.
(B) Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia.
(C) Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of
catabolism.
(D) The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.
QUESTION 809
The nurse writes the following nursing diagnosis for a client in acute renal failure--Impaired gas exchange related to:
A. Decreased red blood cell production
B. Increased levels of vitamin D
C. Increased red blood cell production
D. Decreased production of renin
Answer: A
Explanation:
(A) Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of
oxygen to the tissue and impairs gas exchange.
(B) The conversion of vitamin D to its physiologically active form is impaired in renal failure.
(C) In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas
exchange at the cellular level.
(D) The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention.
QUESTION 810
A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that
he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would
include:
A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position
B. Administering analgesics as ordered
C. Having the child turn, cough, and deep breathe every 12 hours
D. Remaining with the child and keeping as calm and quiet as possible
Answer: C
Explanation:
(A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if left unchanged, over time may
actually increase the atelectasis.
(B) Analgesics will not resolve the atelectasis and may contribute to it if proper nursing actions are not taken to help resolve the atelectasis.
(C) Having the client turn, cough, and deep breathe every 12 hours will aid in resolving the atelectasis. Surgery clients are at risk for
postoperative respiratory complications because pulmonary function is reduced as a result of anesthesia and surgery.
(D) Remaining with the client and keeping him calm and quiet will not affect the client's anxiety, restlessness, or help to resolve the atelectasis.
The cause (atelectasis) needs to be treated, not the symptoms (anxiety and restlessness).
QUESTION 811
A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to "Irrigate NG
tube with sterile saline q1h and prn." The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:
A. Water will deplete electrolytes resulting in metabolic acidosis.
B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.
C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.
D. Saline will increase peristalsis in the bowel.
Answer: A
Explanation:
(A) Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation.
(B) Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction.
(C) Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional
complications of surgery.
(D) A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well- functioning tube.
Irrigating with saline will not increase peristalsis.
QUESTION 812
A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in one-half normal saline infusing at 125
mL/hr and is receiving morphine sulfate 1015 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative
medication. In monitoring and promoting return of urinary function after surgery, the nurse would:
A. Provide food and fluids at the client's request
B. Maintain IV, increasing the rate hourly until the client voids
C. Report to the surgeon if the client is unable to void within 8 hours of surgery
D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention
Answer: C
Explanation:
(A) Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client.
(B) Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by
the physician.
(C) The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need
catheterization or medication. The physician must provide orders for both as necessary.
(D) Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with
uncontrolled pain will probably not be able to void.
QUESTION 813
A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection.
The rationale for giving antibiotics prior to surgery is to:
A. Provide cathartic action within the colon
B. Reduce the risk of wound infection from anaerobic bacteria
C. Relieve the client's concern regarding possible infection
D. Reduce the risk of intraoperative fever
Answer: B
Explanation:
(A) Cathartic drugs promote evacuation of intestinal contents.
(B) The client undergoing intestinal surgery is at increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines.
Administering antibiotics prophylactically can reduce the client's risk for infection.
(C) Antibiotics are indicated in the treatment of infections and have no effect on emotions.
(D) Antipyretics are useful in the treatment of elevated temperatures. Antibiotics would have an effect on infection, which causes temperature
elevation, but would not directly affect such an elevation.
QUESTION 814
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to
administering the medication, the nurse should:
A. Not give the digoxin if the pulse is_60
B. Not give the digoxin if the pulse is_100
C. Take the apical pulse for a full minute
D. Monitor for visual disturbances, a side effect of digoxin
Answer: C
Explanation:
(A) Digoxin should not be given to adults with an apical pulse 100 bpm. With a pulse < 100 bpm, the medication should be withheld and the
physician notified.
(C) Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute,
the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm.
(D) Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.
QUESTION 815
The family member of a child scheduled for heart surgery states, "I just don't understand this open-heart or closed-heart business. I'm so
confused! Can you help me understand it?" The nurse explains that patent ductus arteriosus repair is:
A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed.
B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.
C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.
D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.
Answer: B
Explanation:
(A) Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine.
(B) Patent ductus arteriosus is a ductus arteriosus that does not close shortly after birth but remains patent. Repair is a closed-heart procedure
involving ligation of the patent ductus arteriosus.
(C) Coronary artery bypass graft surgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts.
(D) Percutaneous transluminal coronary angioplasty is a closed heart procedure that improves coronary blood flow by increasing the lumen size
of narrowed vessels.
QUESTION 816
A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on
hand. How much atropine should be given?
A. 0.06 mL
B. 0.38 mL
C. 2.7 mL
D. Information given insufficient to determine the amount of atropine to be administered
Answer: B
Explanation:
(A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer.
(B) The answer is correct.
0.4 mg = 1 mL:0.15 mg 5 = mL 0.4 x = 0.15 x = 0.15/0.4 x = 0.375 or 0.38 mL
(D) Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of
atropine ordered is required to determine the amount of atropine to be given.
QUESTION 817
Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On
arrival at the postanesthesia care unit, the nurse should:
A. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations
B. Obtain pulse and blood pressure readings noting rate and quality of pulse
C. Reassure the client that his surgery is over and that he is in the recovery room
D. Review physician's orders, administering medications as ordered
Answer: A
Explanation:
(A) Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airway is the nurse's priority action.
(B) Obtaining the vital signs is an important action, but it is secondary to airway management.
(C) Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs.
(D) Airway management takes precedence over physician's orders unless they specifically relate to airway management.
QUESTION 818
A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained
temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her
surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered
preoperatively to reduce the risk or prevent:
A. Infection postoperatively
B. Malignant hyperthermia
C. Neuroleptic malignant syndrome
D. Fever postoperatively
Answer: B
Explanation:
(A, D) Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection.
(B) Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The
mortality rate for malignant hyperthermia is high.
(C) Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia.
QUESTION 819
A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain.
Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC
count. The nurse suspects that the client has developed:
A. Gastritis
B. Evisceration
C. Peritonitis
D. Pulmonary embolism
Answer: C
Explanation:
(A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort.
(B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision.
(C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and
fluid into the abdominal cavity. This causes infection and irritation.
(D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety
or panic, and wheezing and coughing often accompanied by blood-tinged sputum.
QUESTION 820
A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, "The
anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?" The best explanation for the nurse to give the client
would be that balanced anesthesia:
A. Is a type of regional anesthesia
B. Uses equal amounts of inhalation agents and liquid agents
C. Does not depress the central nervous system
D. Is a combination of several anesthetic agents or drugs producing a smooth induction and minimal complications
Answer: D
Explanation:
(A) Regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries.
(B) Varying amounts of anesthetic agents are used when employing balanced anesthesia. Amounts depend on age, weight, condition of the client,
and surgical procedure.
(C) General anesthesia is a drug-induced depression of the central nervous system that produces loss of consciousness and decreased muscle
activity.
(D) Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and
appropriate muscle relaxation with minimal complications.
QUESTION 821
A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept
well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a
tightness in her chest, a feeling of suffocation, light headedness, and tingling in her hands. Her respirations are rapid and deep. Assessment
reveals that the client is:
A. Having a heart attack
B. Wanting attention from the nurses
C. Suffering from complete upper airway obstruction
D. Hyperventilating
Answer: D
Explanation:
(A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and
vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms.
(B) Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention.
(C) Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are
absent.
(D) Tightness in the chest; a feeling of suffocation; light headedness; tingling in the hands; and rapid, deep respirations are signs and symptoms
of hyperventilation. This is almost always a manifestation of anxiety.
QUESTION 822
A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. The nurse expects that the physician
would order an appropriate antibiotic to treat P. aeruginosa such as:
A. Cefoperazone (Cefobid)
B. Clindamycin (Cleocin)
C. Dicloxacillin (Dycill)
D. Erythromycin (Erythrocin)
Answer: A
Explanation:
(A) Cefoperazone is indicated in the treatment of infection with Pseudomonas aeruginosa.
(B) Clindamycin is not indicated in the treatment of infection with P. aeruginosa.
(C) Dicloxacillin is not indicated in the treatment of infection with P. aeruginosa.
(D) Erythromycin is not indicated in the treatment of infection with P. aeruginosa.
QUESTION 823
A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take
her temperature:
A. Orally in the morning and at bedtime
B. Only one time during the day as long as it is always at the same time of day
C. Rectally at bedtime
D. As soon as she awakens, prior to any activity
Answer: D
Explanation:
(A) Monitoring temperature twice a day predicts the biphasic pattern of ovulation.
(B) Prediction of ovulation relies on consistency in taking temperature.
(C) Nightly rectal temperatures are more accurate in predicting ovulation.
(D) Activity changes the accuracy of basal body temperature and ability to detect the luteinizing hormone surge.
QUESTION 824
A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control
hyperventilating include:
A. Administering diazepam (Valium) 1015 mg po q4h and q1h prn for hyperventilating episode
B. Keeping the temperature in the client's room at a high level to reduce respiratory stimulation
C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur
D. Using distraction to help control the client's hyperventilation episodes
Answer: C
Explanation:
(A) An adult diazepam dosage for treatment of anxiety is 210 mg PO 24 times daily. The order as written would place a client at risk for
overdose.
(B) A high room temperature could increase hyperventilating episodes by stimulating the respiratory system.
(C) Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention.
(D) Distraction will not prevent or control hyperventilation caused by anxiety or fear.
QUESTION 825
A client delivered a stillborn male at term. An appropriate action of the nurse would be to:
A. State, "You have an angel in heaven."
B. Discourage the parents from seeing the baby.
C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time.
D. Reassure the parents that they can have other children.
Answer: C
Explanation:
(A) This is not a supportive statement. There are also no data to indicate the family's religious beliefs.
(B) Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say "good-bye."
(C) Parents need time to get to know their baby.
(D) This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child.
QUESTION 826
A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus
moves. The nurse explains that:
A. The test is inconclusive and should be repeated
B. Further testing is needed
C. The test is normal and the fetus is reacting appropriately
D. The fetus is distressed
Answer: C
Explanation:
(A) The test results were normal, so there would be no need to repeat to determine results.
(B) There are no data to indicate further tests are needed, because the result of the NST was normal.
(C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15minute period.
(D) The NST results were normal, so there was no fetal distress.
QUESTION 827
Which stage of labor lasts from delivery of the baby to delivery of the placenta?
A. Second
B. Third
C. Fourth
D. Fifth
Answer: B
Explanation:
(A) This stage is from complete dilatation of the cervix to delivery of the fetus.
(B) This is the correct stage for the definition.
(C) This stage lasts for about 2 hours after the delivery of the placenta.
(D) There is no fifth stage of labor.
QUESTION 828
On the third postpartum day, the nurse would expect the lochia to be:
A. Rubra
B. Serosa
C. Alba
D. Scant
Answer: A
Explanation:
(A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots.
(B) This discharge occurs from days 410. The lochia is brownish, serous, and thin.
(C) This discharge occurs from day 10 through the 6thweek. The lochia is yellowish white.
(D) This is not a classification of lochia but relates to the amount of discharge.
