Question 1

A. After amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary. Options 2, 3, & 4 are inappropriate to the child. Use therapeutic communication techniques. Note that the subject of the question relates to alleviating the child\'s fear. Options 2, 3, & 4 imply that this pain may be permanent. Review care of a child after amputation if you had difficulty with this question.

Accepted Answer

A 13-year-old child is diagnosed with Ewing\'s sarcoma of the femur. After a course of radiation and chemotherapy, it has been decided that leg amputation is necessary. After the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which nursing statement would be appropriate to assist in alleviating the child\'s fear? a) \"This aching and cramping is normal and temporary and will subside.\" b) \"This normally occurs after the surgery and we will teach you ways to deal with it.\" c) \"The pain medication that I give you will take these feelings away.\" d) \"This pain is not real pain, and relaxation exercises will help it go away.\"

Question 2

B. Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating. Use the process of elimination. Note the strategic words complete right-sided and focus on the subject: hemiparesis. Recalling that hemiparesis indicates weakness and focusing on the strategic words will direct you to option B. Review the description of hemiparesis and care of the client with hemiparesis if you had difficulty with this question.

Accepted Answer

The nurse is assigned to care for a client with complete right-sided hemiparesis. The nurse plans care knowing that in this condition: a) the client has complete bilateral paralysis of the arms and legs b) the client has weakness on the right side of the body, including the face and tongue c) the client has lost the ability to move the right arm but is able to walk independently d) the client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

Question 3

D. Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system.  Meningitis is an infection process of the CNS.  Encephalitis is an inflammation of the brain that occurs as a result of a viral illness or CNS infection.  Down syndrome is an example of a congenital condition that results in moderate to severe retardation. Use the process of elimination. Eliminate options 1&2 first, noting that they are comparable or alike. Next, note the relationship between the words \"palsy\" in the question and \"impaired muscle movement\" in D.

Accepted Answer

A nurse is caring for a child recently diagnosed with cerebral palsy, and the parents of the child ask the nurse about the disorder. The nurse bases her response on the understanding that cerebral palsy is:  a) An infectious disease of the central nervous system b) An inflammation of the brain as a result of a viral illness c) A congenital condition that results in moderately to severe retardation d) A chronic disability characterized by impaired muscle movement and posture

Question 4

A - Serum albumin levels help determine whether protein intake is sufficient. Proteins are broken down into amino acids during digestion. Amino acids are absorbed in the small intestine, and albumin is built from amino acids. The red blood cell count, bilirubin levels, and reticulocyte count do not indicate protein intake.

Accepted Answer

A 32-year-old woman recently diagnosed with Hodgkin\'s disease is admitted for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client\'s nutrition status the nurse should review the results of which of the following tests?   a) Albumin level.  b) Reticulocyte count.  c) Red blood cell count.  d) Direct and indirect bilirubin levels.

Question 5

C - Bulging fontanels in an infant may indicated increased intracranial pressure, a possible postoperative complication. Calming the infant, teaching the parent, and repositioning the infant will not address the underlying problem of increased intracranial pressure within the skull. Calling the healthcare provider is indicated.

Accepted Answer

An infant underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which of the following is the nurse\'s best action?    a) Calm the infant  b) Teach parent about procedure  c) Notify the healthcare provider  d) Reposition infant

Question 6

D - Weighing the diaper before applying it to the newborn, infant, or toddler, and then weighing it after micturition will help evaluate the urine output. The difference between the wet diaper and the dry one will give the amount of urine (1 g = 1 mL, so amounts may be recorded in milliliters). Weighing the child or measuring the formula will not give an indication of evaluating the urine output in this situation.

Accepted Answer

Which of the following is a common method of evaluating the urine output for newborns, infants, and toddlers who are not potty trained.   a) Monitoring the amount of time for breast feeding  b) Measuring the formula before the child ingests it  c) Weighing the child before and after feeds  d) Weighing the diaper before and after micturition

Question 7

A - Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day post-mature baby to have increased amounts of vernix. A discrepancy between EDC (estimated date of conception) and gestational age by physical examination must have occurred.

Accepted Answer

According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate?   a) \"The vernix indicates a different gestational age than expected.\"  b) \"The vernix is difficult and painful to remove from a newborn.\"  c) \"The presence of vernix affects the newborn\'s immune system.\"  d) \"The vernix should be a thicker coating for a newborn.\"

Question 8

VERNIX CASEOSA

Accepted Answer

a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy

Question 9

D - The nurse should respond with an open-ended statement that elicits further exploration of the client\'s feelings. Women with cancer may feel guilt or shame. Previous life decisions, sexuality, and religious beliefs may influence a client\'s adjustment to a diagnosis of cancer. The nurse should not contradict the client\'s feelings of punishment or offer advice such as confiding in the husband. A social worker referral may be beneficial in the future, but is not the first response needed to elicit exploration of the client\'s feelings.

Accepted Answer

During the postoperative period after a modified radical mastectomy, the client confides in the nurse that she thinks she got breast cancer because she had an abortion and she did not tell her husband. The best response by the nurse is which of the following?   a) \"You might feel better if you confided in your husband.\"  b) \"Cancer is not a punishment; it is a disease.\"  c) \"I can have the social worker talk to you if you would like.\"  d) \"Tell me more about your feelings on this.\"

Question 10

A - When caring for infants and newborns, the best nursing intervention is to encourage the parents to be present during the medical treatment. There is no need for the nurse to ask for a child specialist to be present during the treatment. Instead, the nurse should involve the parents in the caring process as the infant will feel more secure and comfortable in the presence of the parents. Providing the infant with toys, a feeding bottle, or trying to explain that it will be over soon will not pacify the child

Accepted Answer

A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants?   a) Encourage parents to be present during the treatment.  b) Tell the infant that it will be over within a minute.  c) Provide the infant with soft toys or a feeding bottle.  d) Ask a child specialist to be present during treatment.

Question 11

A - Many clients who undergo surgery for creation of an ileal conduit experience anxiety associated with changes in body image. The mental health practitioner can help the client cope with these feelings of anxiety. Mental health practitioners don\'t evaluate whether the client is a surgical candidate. None of the evidence suggests that urinary diversion surgery, such as creation of an ileal conduit, places the client at risk for suicide. Although evaluating the need for mental health intervention is always important, this client displays no behavioral changes that suggest intervention is necessary at this time.

Accepted Answer

A client is scheduled to undergo surgical creation of an ileal conduit. The primary nurse educates the client about surgery and the postoperative period. The nurse informs the client that many members of the health care team (including a mental health practitioner) will see him. A mental health practitioner should be involved in the client\'s care to:   a) help the client cope with the anxiety associated with changes in body image.  b) assess whether the client is a good candidate for surgery.  c) evaluate the client\'s need for mental health intervention.  d) assess suicidal risk postoperatively.

Question 12

C - Cancer clients report that the lifelong fear of recurrence is one of the most disruptive aspects of the disease. The trajectory of the disease is unpredictable and can be intertwined with many short- and long-term illnesses related to cancer and the treatment modalities. A diagnosis of cancer challenges the individual and the family with a series of crises rather than a time-limited episode. There are no data to indicate that the client has an underlying behavioral disorder.

Accepted Answer

A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior may be caused by:   a) The one-time crisis from learning of the diagnosis.  b) The usual trajectory of a short-term illness.  c) Uncertainty and an underlying fear of recurrence.  d) A history of a behavioral illness.

Question 13

C - Maintaining the therapeutic relationship is important, and some self-disclosure followed by refocusing on the client is therapeutic and may encourage engagement in the conversation. The other options are not helpful in assessing the student\'s response to the loss

Accepted Answer

A nurse works in a school with preadolescent students. One of the students has just returned to school after the death of a grandmother. The nurse tries to assess the student\'s response to the loss. Which statement is most appropriate for the nurse to use with the student?   a) \"Would you like to tell me about your grandmother? I bet she was very special.\"  b) \"I\'m here for you any time you need to talk to me about your grandmother.\"  c) \"When I lost my grandmother, I felt very sad. Is that how you are feeling?\"  d) \"I understand that you recently lost your grandmother. Is that correct?\"

Question 14

C - The client\'s resources for coping with the emotional and practical needs of herself and her family need to be assessed because usual coping strategies and support systems are often inadequate in especially stressful situations. The nurse may be concerned with the client\'s use of denial, decision-making abilities, and ability to pay for transportation; however, the client\'s support systems will be of more importance in this situation.

Accepted Answer

A 45-year-old single mother of three teenaged boys has metastatic breast cancer. Her parents live 750 miles (1,207 km) away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the client to consider high-dose chemotherapy. She is concerned about her children\'s welfare during the treatment. When assessing the client\'s present support systems, the nurse will be most concerned about the potential problems with:   a) Transportation and money for the boys.  b) Decision-making abilities.  c) Support systems and coping strategies.  d) Denial as a primary coping mechanism.

Question 15

D - When a client appears shocked by her appearance after surgery, such as after having a mastectomy, the nurse should help her express her feelings and offer the supportive care that she needs at this time. Telling the client that her disfigurement will not show when she is dressed dismisses her concerns and blocks expression of her feelings. Telling the client not to worry avoids the issues. Having the client meet someone who has had breast surgery is often helpful but is better done later, when the client is convalescing and accustomed to the appearance of the operative site. The client needs support now when the dressings are removed, not later.

Accepted Answer

On the third postoperative day after a radical mastectomy, the drainage tube is removed, and the dressings are changed. The client appears shocked when she sees the operative area and exclaims, \"I look horrible! Will it ever look better?\" Which of the following responses by the nurse would be most appropriate?    a) \"After it heals and you\'re dressed, you won\'t even know you had surgery.\"  b) \"Would you like to meet Ms. Paul? She looks just great and she had a mastectomy, too.\"   c) \"Don\'t worry. You know the tumor is gone, and the area will heal very soon.\"  d) \"You\'re shocked by the sudden change in your appearance as a result of this surgery, aren\'t you?\"

Question 16

B - The client is experiencing a precipitous birth. The nurse should remain calm during a precipitous birth. Explaining to the client what is happening as the birth progresses and how she can assist is likely to help her remain calm and cooperative. Maintaining eye contact is also beneficial. Telling the client that she is right and to just relax is inappropriate because the client may not be able to relax because of the strong urge to push the fetus out of the birth canal. Telling the client not to push because she may tear the cervix can instill fear, not cooperation. Saying that the primary health care provider will be there soon may not be an accurate statement and is not reassuring if the client is concerned about the birth.

Accepted Answer

A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, \"The baby\'s coming!\" To help the client remain calm and cooperative during the imminent birth, which of the following responses by the nurse is most appropriate?   a) \"You\'re right, the baby is coming, so just relax.\"  b) \"I\'ll explain what\'s happening to guide you as we go along.\"  c) \"Your doctor will be here as soon as possible.\"  d) \"Please don\'t push because you\'ll tear your cervix.\"

Question 17

C - The nurse shouldn\'t introduce new issues during the termination phase because doing so may confuse the client. This phase is a time for wrapping up the relationship. It\'s appropriate for the nurse to refer the client to support groups. Reviewing what\'s been accomplished during the relationship is a goal of the termination phase. The client may express sadness during the termination phase, but this is a normal response.

Accepted Answer

During the termination phase of a nurse-client relationship, which intervention may lead to client confusion?   a) Having the client express sadness that the relationship is ending  b) Reviewing what\'s been accomplished during the relationship  c) Introducing new issues to the client  d) Referring a client to support groups

Question 18

A - Most hospitalized persons are at risk for sleep disturbances. Psychological issues (such as anxiety and depression) and pain are related to sleep deprivation. Social, nutritional, and cultural issues are not necessarily associated with sleep disturbances.

Accepted Answer

The most common issue associated with sleep disturbances in the hospitalized client with cancer is:   a) Psychological.  b) Cultural.  c) Nutritional.  d) Social.

Question 19

C - Providing information can help to answer the client\'s questions and decrease anxiety. Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the procedure is common, or to follow her physician\'s orders will not necessarily decrease anxiety.

Accepted Answer

A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction?   a) Stressing the importance of following the physician\'s instructions after surgery.  b) Reassuring the client by telling her that surgery is a common procedure.  c) Providing the client with information about what to expect postoperatively.  d) Telling the client it is normal to be afraid.

Question 20

A - Strong social support enhances mental and physical health, providing a significant buffer against distress. Relationships of low-quality support are known to impact a person\'s coping effectiveness negatively.

Accepted Answer

A nurse is assessing available support systems for a client in the community mental health clinic. The client is divorced, has no siblings, and both parents died last year. The client has contact with once-supportive former in-laws; however, the client describes a strained relationship since the divorce. With regard to the relationship with the in-laws, what knowledge does the nurse use to plan care?   a) Low-quality support relationships often negatively affect coping in a crisis.  b) Strong social support is of relatively little importance as a coping factor.  c) The in-laws offer the only opportunity to obtain social support for the client.  d) The relationship with the in-laws can enhance the client\'s sense of control.

Question 21

A - Informed Consent protect\'s the client\'s right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, BUT, the MOST IMPORTANT function is to encourage shared decision making.   Informed consent does not help the client to make a living will.

Accepted Answer

A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent?  a) Protects the client\'s right to self-determination in health care decision making. b) Helps the client refuse treatment that he or she does not wish to undergo. c) Helps the client to make a living will regarding future health care required. d) Provides the client with in-depth knowledge about the treatment options available.

Question 22

d - chest x ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it\'s difficult to determine if the chest has re-expanded sufficiently.

Accepted Answer

a nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require:  a. monitoring of arterial oxygen saturation (SaO2) b. arterial blood gas (ABG) studies c. chest auscultation d. chest x ray

Question 23

a - an incident report, also termed a variance report or occurrence report, is a tool healthcare agencies use to document anything out of the ordinary that results in or has the potential to result in harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns and initiating in-service programs to prevent further problems. A nurse\'s shift report is given by a primary nurse to the nurse replacing him or her by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client\'s condition and care when transferring clients from one unit or institution to another. A telemedicine report can link healthcare professional immediately and enable nurses to receive and give critical information about clients in a timely fashion.

Accepted Answer

A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-services programs. This is an example of which type of report?  a. incident report b. nurse\'s shift report c. transfer report d. telemedicine report.

Question 24

c - birth may extend an episiotomy incision to the anal sphincter (a third degree laceration) or the anal canal (a fourth degree laceration). A first degree laceration involves the fourchette, perineal skin, and vaginal mucous membranes. A second degree laceration extends to the fasciae and muscle of the perineal body.

Accepted Answer

A client has an episiotomy to widen her birth canal. Birth extends the incision into the anal sphincter. This complication is called:  a. a first-degree laceration b. a second-degree laceration c. a third-degree laceration d. a fourth-degree laceration

Question 25

b - because the neonate is severely ill and needs to be placed in the neonatal intensive care unit, the client may have a nursing diagnosis of \'impaired parenting related to the neonate\'s transfer to the neonatal intensive care unit.\' (another pertinent nursing diagnosis may be \'compromised family coping related to lack the opportunity for bonding.) Rh isoimmunization isn\'t a socially unacceptable infection. This condition causes an excess fluid volume (not deficient) related to cardiac problems. Rh isoimmunization doesn\'t lead to loss of the neonate by statute.

Accepted Answer

A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe, generalized edema. The neonate is immediately transferred to the neonatal intensive care unit. Which nursing diagnosis is most appropriate for the client?  a. ineffective parenting related to the neonate\'s transfer to the intensive care unit b. impaired parenting related to the neonate\'s transfer to the intensive care unit c. deficient fluid volume related to severe edema d. fear related to removal and loss of the neonate by statute

Question 26

a - by 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a non-pregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle feeding mother).

Accepted Answer

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time?  a. firm fundus at the symphysis b. white, thick vaginal discharge c. striae that are silver in color d. soft breasts without milk

Question 27

c - lethargy in the neonate may be seen with hypoglycemia because of a glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia - not bradycardia - is seen with hypoglycemia. Jaundice isn\'t a sign of hypoglycemia.

Accepted Answer

The neonoate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:  a. peripheral acrocyanosis b. bradycardia c. lethargy d. jaundice

Question 28

b - the nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/ minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute - not 80 beats/minute, which is a normal pulse rate and doesn\'t warrant action. The client shouldn\'t take digoxin with meals; doing so slows the absorption rate.

Accepted Answer

Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)?  a. \"take an extra dose of digoxin if you miss one dose.\"  b. \"call the physician if your heart rate is above 90 beats/minute c. \"call the physician if your pulse drops below 80 beats/minute.\"  d. \"take digoxin with meals.\"

Question 29

a - an unconscious client is best positioned in a lateral or semiprone position because these positions allow the jaw and tongue to fall forward, facilitate drainage of secretions, and prevent aspiration. Positioning the client supine carries a major risk of airway obstruction from the tongue, vomit, or nasopharyngeal secretions. Trendeleburg\'s position, with the head lower than the heart, decreases effective lung volume and increases the risk of cerebral edema. The lithotomy position has no purpose in this situation.

Accepted Answer

the comatose victim of the car accident is to have a gastric lavage. Which of the following positions would be most appropriate for the client during this procedure?  a. lateral b. supine c. trendelenburg\'s d. lithotomy

Question 30

a - if the nurse administers the client\'s normal daily dose of insulin while he\'s on nothing-by-mouth status before surgery, he\'ll experience hypoglycemia. Therefore, the nurse should administer half the daily insulin dose as ordered. Oral antidiabetic agents aren\'t effective for type 1 diabetes I.V. insulin infusions aren\'t necessary to manage blood glucose levels in clients undergoing routine surgery.

Accepted Answer

A client with type 1 diabetes must undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of surgery?  a. administer half of the client\'s typical morning insulin dose as ordered b. administer an oral antidiabeteic agent as ordered c. administer an I.V. insulin infusion as ordered d. administer the client\'s normal daily dose of insulin as ordered

Question 31

head lower than the heart

Accepted Answer

Trendeleburg\'s position

Question 32

60- to 70-year-old age-group

Accepted Answer

Prostate cancer is predominant in what age group?

Question 33

prostate cancer

Accepted Answer

most common cancer in men

Question 34

B - The death of a fetus at any time during pregnancy is a tragedy for most parents. After a spontaneous abortion, the client and family members can be expected to suffer from grief for several months or longer. When offering support, a simple statement such as \"I\'m truly sorry you lost your baby\" is most appropriate. Therapeutic communication techniques help the client and family understand the meaning of the loss, move less stressfully through the grief process, and share feelings. Asking the client whether she is experiencing a great deal of uterine pain is inappropriate because this is a \"yes-no\" question and doesn\'t allow the client to express her feelings. Saying that the embryo was defective is inappropriate because this may lead the client to think that she contributed to the fetus\'s demise. This is not the appropriate time to discuss embryonic or fetal malformations. However, the nurse should explain to the client that this situation was not her fault. Telling the client that she should get pregnant again as soon as possible is not therapeutic and discounts the feelings of the expectant mother who had already begun to bond with the fetus.

Accepted Answer

On entering the room of a client who has undergone a dilatation and curettage (D&C;) for a spontaneous abortion, the nurse finds the client crying. Which of the following comments by the nurse would be most appropriate?   a) \"Commonly spontaneous abortion means a defective embryo.\"  b) \"I\'m truly sorry you lost your baby.\"  c) \"You should try to get pregnant again as soon as possible.\"  d) \"Are you having a great deal of uterine pain?\"

Question 35

C - Verbalizing feelings and concerns helps decrease anxiety and allows the wife to move on to understanding the current situation. Describing events or explaining equipment is appropriate when the person is not distraught and is ready to learn. Explaining the client\'s medical status is appropriate when the person is not distraught. Reassuring the family member does not allow verbalization of feelings and discounts her feelings.

Accepted Answer

A client who was involved in a motor vehicle accident is admitted to the hospital. His wife arrives on the unit 6 hours after her husband\'s accident, explaining that she has been out of town. She is distraught because she was not with her husband when he needed her. Which of the following nursing interventions is the most appropriate at this time?    a) Reassure her that the important fact is that she is here now.   b) Describe her husband\'s medical treatment since admission.   c) Allow her to verbalize her feelings and concerns.  d) Explain to her that her husband\'s condition is stable.

Question 36

D -  Asking if the client feels he\'ll have the same experience as his mother gives him an opportunity to vent underlying anxiety. There\'s nothing to indicate that his mother\'s diabetes wasn\'t under good control or that she had substandard care. Saying there\'s no guarantee about how diabetes will progress doesn\'t appropriately address the client\'s concerns and may increase his anxiety. After the nurse has addressed the client\'s anxiety, she can more easily address more-specific teaching needs.

Accepted Answer

A client concerned about being diagnosed with type 2 diabetes tells a nurse, \"My mother suffered with diabetes for many years and finally died of kidney failure in spite of treatment. Why should I try if I\'m going to go through the same thing?\" What is the nurse\'s most appropriate response?   a) \"There are no guarantees about how diabetes will progress.\"  b) \"It sounds like your mother\'s diabetes wasn\'t under very good control.\"  c) \"Your mother didn\'t get the proper treatment.\"  d) \"Are you worried that you\'ll have the same experience as your mother?\"

Question 37

ANSWER = 1 1. This client may or may not be stable. He may have \"no complaints\" at this time, but the nurse must assess this client first to determine that whatever the complaint was that brought him to the ED has stabilized. This client should be seen first. 2. It is important for the nurse to assess for pain relief in a timely manner, but this client has been medicated, and the nurse can evaluate the amount of pain relief after making sure that the ED admission is stable. 3. This client has been back from the procedure long enough to be allowed bathroom privileges; therefore, this client does not need to be seen first. 4. Psychological issues are important, but not more so than a physiologic issue, and the client admitted from the ED may have a physiologic problem. The test taker should use some tool as a reference to guide in the decision-making process. In this situation, Maslow\'s Hierarchy of Needs should be applied. PHYSIOLOGIC needs needs have priority over psychosocial ones.

Accepted Answer

The 7:00 P.M. to 7:00 A.M. nurse has received the shift report from the outgoing nurse. Which client should the nurse assess first?  1. The male client who has just been brought to the floor from the emergency department (ED) with no report of complaints. 2. The female client who received pain medication 30 minutes ago for pain that was a level \"8\" on a 1-to-10 pain scale. 3. The male client who had a cardiac catheterization in the morning and has been allowed to use the bathroom one time. 4. The female client who has been turning on the call light frequently and stating that her care has been neglected.

Question 38

ANSWER = 2  1. This is boundary crossing because the nurse does not have breast cancer. The nurse should assess what information the client is really seeking and then explain the treatment or refer the client, as appropriate. 2. The nurse must assess what information the client actually needs. To do this, the nurse must know what treatment options have been suggested to the client. Assessment is the first step in the nursing process. 3. This may be needed after the nurse further assesses the situation, but this is not the first intervention. 4. The client needs information about treatment options from a designated HCP; the significant other would not have such information/suggestions.

Accepted Answer

The client diagnosed with breast cancer who is positive for the BRCA gene is requesting advice from the nurse about treatment options. Which statement is the nurse\'s best response? 1. \"If it were me in this situation, I would consider having a bilateral mastectomy.\" 2. \"What treatment options has your health-care provider (HCP) discussed with you?\" 3. \"You should discuss your treatment options with your HCP.\" 4. \"Have you talked with your significant other about the treatment options available to you?\"

Question 39

ANSWER = 2 1. A typical sign of pneumonia is bilateral crackles; therefore, this client would not be seen first. 2. The client with calf pain could be experiencing deep vein thrombosis (DVT), a complication of immobility, which may be fatal if a pulmonary embolus occurs; therefore, this client should be assessed first. 3. The client experiencing low back pain when sitting in a chair should be assessed but not prior to the client with suspected DVT. 4. The nurse should address the client\'s concern about the food, but it is not a priority over a physiologic problem.  When deciding which client to assess FIRST, the test taker should determine whether the signs/symptoms the client is exhibiting are normal or expected for the client situation. After eliminating the expected options, the test taker should determine which situation is more life threatening.

Accepted Answer

The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? 1. The client diagnosed with pneumonia who has bilateral crackles 2. The client on strict bed rest who is complaining of calf pain 3. The client who complains of low back pain when sitting in a chair 4. The client who is upset because the food is cold all the time.

Question 40

ANSWER = 4 1. The nurse would expect the client diagnosed with a myocardial infarction to have an elevated troponin level; thus the nurse would not assess this client first. 2. Because the client\'s PTT of 68 seconds is 1.5 times the normal range, it is considered therapeutic and would not warrant the nurse\'s assessing this client first. 3. The nurse would expect a client with end-stage liver failure to have an elevated ammonia level. 4. The therapeutic range for Dilantin is 10-20 mg/dL. This client\'s higher level warrants intervention because the serum level is above the therapeutic range. The test taker must know normal laboratory data.

Accepted Answer

The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a myocardial infarction who has an elevated troponin level. 2. The client receiving the IV anticoagulant heparin who has a partial thromboplastin time (PTT) of 68 seconds. 3. The client diagnosed with end-stage liver failure who has an elevated ammonia level. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL.

Question 41

ANSWER = 3  1. A pain medication is important to administer in a timely manner, but its administration is not priority over a medication that must be administered on time to prevent respiratory complications. 2. For a client experiencing expected symptoms of a disease, such as pitting edema, administration of a loop diuretic has a 30-minute leeway - that is, it can be administered 30 minutes before to 30 minutes after the scheduled dosing time. 3. Anticholinesterase medications administered for myasthenia gravis must be administered on time to preserve muscle functioning, especially the functioning of the muscles of the upper respiratory tract. This is the priority medication. 4. Clients who have called for medications should be attended to, but this client would not receive an antacid for heartburn before the client diagnosed with myasthenia gravis or the client in pain.

Accepted Answer

The nurse is administering medications for clients on a medical unit. Which medication should the nurse administer first?  1. The narcotic pain medication to a client complaining that his pain is an \"8\". 2. A loop diuretic to a client diagnosed with heart failure who has 3+ pitting edema. 3. An anticholinesterase medication to a client diagnosed with myasthenia gravis. 4. An antacid to a client with pyrosis who has called several times over the intercom.

Question 42

ANSWER = 2 1. Placing a gait prior to ambulating is an appropriate action for safety and would not require the nurse to intervene. 2. Placing the client in a prone position helps promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures; therefore, this would not require the nurse to intervene. 3. This action is INAPPROPRIATE and would require IMMEDIATE intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the client\'s back or using a lift sheet. 4. the client should be encouraged and praised for attempting to perform activities independently, such as combing hair or brushing teeth.

Accepted Answer

The nurse and UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?  1. The assistant places the gait belt around the client\'s waste prior to ambulating. 2. The assistant places the client on the abdomen with the client\'s head to the side. 3. The assistant places her hand under the client\'s right axilla to help the client move up in bed. 4. The assistant praises the client for attempting to perform activities of daily living independently.

Question 43

ANSWER = 1. 1. Because the client is having an evolving stroke, the client is experiencing a worsening of signs and symptoms over several minutes to hours; thus, the client is at risk for dying and should be cared for by the most experienced nurse. 2. A transient ischemic attack by definition lasts less than 24 hours; thus, this client should be stable at this time.  When the test taker is deciding which client should be assigned to the most experienced nurse, the MOST critical and UNSTABLE client should be assigned to the most experienced nurse.

Accepted Answer

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?  1. The elderly client who is experiencing a stroke in evolution. 2. The client diagnosed with a transient ischemic attack 48 hours ago. 3. The client diagnosed with Guillain-Barre syndrome who complains of leg pain. 4. The client with Alzheimer\'s disease who is wandering in the halls.

Question 44

ANSWER = 1 1. This client should be referred to an inpatient rehabilitation facility for intensive therapy before deciding on long-term placement (home with home health care or a long-term care facility). The initial rehabilitation a client receives can set the tone for all further recuperation. This is the appropriate referral at this time. 2. A home health-care agency may be needed when the client returns home, but the most appropriate referral is to a rehabilitation center where intensive therapy can take place. 3. A long-term care facility may be needed at some point, but the client should be given the opportunity of regaining as much as lost ability as possible at this time. 4. The outpatient center would be utilized when the client is ready for discharge from the inpatient center.

Accepted Answer

The client diagnosed with a cerebrovascular accident (CVA) has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate at this time?  1. Inpatient rehabilitation unit 2. Home health-care agency 3. Long-term care facility 4. Outpatient therapy center

Question 45

ANSWER = 4 1. The client\'s lab work does not indicate an increased risk for infection. The client does not need to be placed in reverse isolation. 2. The lab work is within normal limits. The nurse does not need to notify the HCP. 3. The client is not at an increased risk for infection; therefore, the client may have flowers in the room. 4. This client\'s lab work is within normal limits. The nurse should continue to monitor the client.

Accepted Answer

The client diagnosed with lung cancer has a hemoglobin and hematocrit (H&H) of 13.4 mg/dL and 40.1, a WBC count of 7800, and a neutrophil count of 62%. Which action should the nurse implement?  1. Place the client in reverse isolation. 2. Notify the NCP. 3. Make sure no flowers are taken into the room. 4. Continue to monitor the client.

Question 46

A - A bedside commode should be near the client for easy, safe access. Measurement of urine output is also important in a client with heart failure. Putting diapers on an alert and oriented individual would be demeaning and inappropriate. Indwelling catheters are associated with increased risk of infection and are not a solution to possible incontinence. There is no reason to think that the client would not be able to use the bedside commode

Accepted Answer

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. Although the client is ambulatory, the unlicensed assistive personnel are concerned about urinary incontinence because the client is frail and in a strange environment. The nurse should instruct the unlicensed personnel to assist with implementing the nursing plan of care by   a) Placing a commode at the bedside and instructing the client in its use.   b) Ordering adult diapers for the client so she will not have to worry about incontinence.    c) Requesting an indwelling urinary catheter to avoid incontinence.    d) Padding the bed with extra absorbent linens.

Question 47

B - A bland, full-liquid diet may include some fruit juices and foods from all of the food groups. On this diet, the client should avoid gastric irritants, such as orange juice, coffee, tea, colas, cocoa, breads, bran (fiber), and highly seasoned foods.

Accepted Answer

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse\'s dietary teaching?   a) \"For breakfast I will choose pineapple juice, a bran muffin, and milk.\"    b) \"Today I can have apple juice, chicken broth, and vanilla ice cream.\"    c) \"I can have oatmeal, custard, and tea.\"    d) \"I will have orange juice, farina, and coffee.\"

Question 48

A - Hemiplegia refers to paralysis of one side of the body; therefore, the nurse should document that the client has left-sided hemiplegia. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; and quadriplegia, to paralysis of all four extremities and usually also the trunk.

Accepted Answer

A client has left-sided paralysis. The nurse should document this condition as left-sided: a) hemiplegia. b) paraplegia. c) quadriplegia. d) monoplegia.

Question 49

A - Sodium, the major ECF cation, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones.

Accepted Answer

A nurse is reviewing a client\'s laboratory test results. Which electrolyte is the major cation controlling a client\'s extracellular fluid (ECF) osmolality?   a) Sodium    b) Potassium    c) Chloride    d) Calcium

Question 50

C - The most important aspect is to ensure the client is hyperoxygenated to increase oxygen saturation levels. Then suctioning should be limited to 10-15 seconds. This helps to prevent desaturation so that breathing is not compromised. It is not enough to apply oxygen if desaturation occurs. Suctioning should be done when necessary, not as a routine. Fluid intake is increased to help liquefy the secretions.

Accepted Answer

Which of the following is the most important consideration when performing tracheotomy suctioning? a) Fluid intake should be limited to reduce the amount of secretions produced. b) Oxygen should be provided after each suctioning episode if desaturation occurs. c) The client should be hyperoxygenated, then suctioned for the duration of 10 to 15 seconds. d) Suctioning should be done routinely and frequently to prevent accumulation of secretions.

Question 51

B - Informed consent protects the client\'s right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.

Accepted Answer

A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent?   a) Helps the client to make a living will regarding future health care required.    b) Protects the client\'s right to self-determination in health care decision making.    c) Helps the client refuse treatment that he or she does not wish to undergo.    d) Provides the client with in-depth knowledge about the treatment options available.

Question 52

D - While it is important for the nurse and the other members of the care team to ensure that stereotypes or cultural imposition do not exist, the priority in all aspects of care is safety. Consequently, potential interactions between the complementary therapies and conventional hospital treatments are a priority. The family should not be required to forgo conventional treatment to pursue some aspects of culturally based, complementary care.

Accepted Answer

The children of an elderly male client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their father\'s bedside tomorrow to make recommendations for his care. Which of the following considerations should the nurse prioritize in light of the practitioner\'s planned visit?   a) Ensuring that the care team does not impose their beliefs on the family or the complementary practitioner.    b) Identifying whether the family would prefer to pursue alternative or conventional treatment for their father.    c) Taking measures to prevent cultural conflict when the practitioner comers to the hospital.    d) Ensuring any complementary therapies are safe when combined with his prescribed therapy.

Question 53

B - Clients with cancer may develop a tolerance to opioids, causing them to need higher doses to provide adequate pain relief. Although a nurse should always remain alert for adverse effects of opioids, clients may develop a tolerance for these effects. Therefore, it isn\'t likely that higher doses would cause respiratory depression. Administering pain medication around the clock maintains steady blood levels of opioids. Sleeping doesn\'t necessarily indicate pain relief, especially in a client who has chronic pain.

Accepted Answer

When planning pain control for a client with terminal gastric cancer, a nurse should consider that:   a) only low doses of opioids are safe; higher doses may cause respiratory depression.    b) clients with terminal cancer may develop tolerance to opioids.    c) a client who can fall asleep isn\'t in pain.    d) pain medication should be given only when a client requests it.

Question 54

â¢ It should be administered in the anterior area of the iliac crest. â¢ Use a 27G, 5/8-inch (1.6-cm) needle. â¢ Cephalosporin potentiates the effects of heparin. â¢ Double check the dose with another nurse.   Explanation:  Older adults may have little subcutaneous tissue, so the area around the anterior iliac crest is a suitable site for these clients. The nurse should use a 27G, 5/8-inch (1.6-cm) needle. Cephalosporin and penicillin potentiate the effects of heparin. Two nurses should check the dose because a dose error could cause hemorrhage. The onset of heparin is not immediate when given subcutaneously.

Accepted Answer

The nurse is to administer subcutaneous heparin to an older adult. What facts should the nurse keep in mind when administering this dose? Select all that apply.   a) Cephalosporin potentiates the effects of heparin.    b) Double check the dose with another nurse.    c) It should be administered in the anterior area of the iliac crest.    d) The onset is immediate.    e) Use a 27G, 5/8-inch (1.6-cm) needle.

Question 55

Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.

Accepted Answer

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)?   a) Turning.    b) Coughing.    c) Deep breathing.    d) Passive range-of-motion (ROM) exercises.

Question 56

â¢ Place the baby in a side-lying position avoiding flexion of the neck onto the chest â¢ Obtain a blood glucose level immediately before the procedure   Explanation:  For a lumbar puncture, the nurse should place the infant in an arched, side-lying position to maximize the space between the third and fifth lumbar vertebrae. The nurse\'s hands should rest on the back of the infant\'s shoulders to prevent neck flexion, which could block the airway and cause respiratory arrest. The infant should be placed at the edge of the bed or table during the procedure, and the nurse should speak quietly to calm the infant. Cerebrospinal fluid (CSF) blood glucose level is two-thirds that of the plasma level. In bacterial meningitis, the glucose level of the CSF will be lower than two-thirds of the plasma level as bacteria feeds on the glucose. There is no indication that the infant is in distress, as the respiratory rate and apical heart rate are within the normal ranges for the infant\'s age. There is not sufficient evidence to notify child protective services.

Accepted Answer

A parent brings an 8-month-old boy to the emergency department. The baby\'s vital signs are temperature 103.4Â° F (39.6Â° C), apical rate 122 beats per minute; respirations 30 breaths per minute. The baby is lethargic and difficult to arouse. A lumbar puncture is ordered. Which of the following actions should the nurse implement?    a) Administer 1.0 L of oxygen using a pediatric mask    b) Place the baby in a side-lying position avoiding flexion of the neck onto the chest    c) Give the baby 60 mL of glucose water 30 minutes before the procedure    d) Contact child protective services    e) Obtain a blood glucose level immediately before the procedure

Question 57

A - Avoidance of impending venous outflow.  Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase intracranial pressure. The other choices do not promote head trauma positioning and reduction/flow of cerebral fluid.

Accepted Answer

Which of the following is the nurse\'s best rationale for positioning a client with decreased level of consciousness related to a head injury?   a) Avoidance of impeding venous outflow    b) Prevention of flexion contractures    c) Decrease of cerebral arterial pressure    d) Prevention of aspiration of stomach contents

Question 58

â¢ Systolic blood pressure. â¢ Cerebral perfusion pressure.   Explanation:  The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.

Accepted Answer

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply.    a) Systolic blood pressure.    b) Level of pain.    c) Breath sounds.    d) Cerebral perfusion pressure.    e) Urine output.

Question 59

â¢ Wrist pronation. â¢ Stiff extension of the arms and legs. â¢ Plantar flexion of the feet. â¢ Opisthotonos.   Explanation:    Decerebrate posture, which results form damage to the upper brain stem, is characterized by adduction and stiff extension of the arms. These findings are accompanied by wrist pronation, finger flexion, opisthotonos, and stiff extension of the legs with plantar flexion of the feet.

Accepted Answer

A client who had a massive stroke exhibits decerebrate posture. What are the characteristics of this posture? Select all that apply.   a) Wrist pronation.    b) Flexion of the arms and wrists with internal rotation.    c) Opisthotonos.    d) Plantar flexion of the feet.    e) Stiff extension of the arms and legs.

Question 60

â¢ Turn the client on the right side. â¢ Apply a soft collar to keep the client\'s neck in a neutral position.   Explanation:  The client should be turned on the right side, because lying on the left side would cause the brain to shift into the space previously occupied by the tumor. A soft collar keeps the neck neutral, allowing for adequate perfusion and venous drainage of the brain. Placing a pillow under the head flexes the neck and impairs circulation to the brain. Flexion of the hip increases intracranial pressure and, therefore, is contraindicated. Exclusive use of the supine position is not indicated.

Accepted Answer

A client is admitted to the medical-surgical unit after undergoing intracranial surgery to remove a tumor from the left cerebral hemisphere. Which nursing interventions are appropriate for the client\'s postoperative care? Select all that apply.   a) Place a pillow under the client\'s head so that the neck is flexed.    b) Apply a soft collar to keep the client\'s neck in a neutral position.    c) Maintain the client in the supine position.    d) Turn the client on the right side.    e) Place pillows under the client\'s legs to promote hip flexion and venous return.

Question 61

â¢ Pain â¢ Coughing â¢ Agitation   Explanation:  Persistent and frequent coughing, pain, and agitation are all potential causes for increased intracranial pressure in the pediatric population. Sedation is used to reduce agitation and metabolic needs of the brain and therefore would not increase ICP in the pediatric population. Nausea may be a symptom of increased intracranial pressure, but does not cause it.

Accepted Answer

The nurse is caring for an 8-year-old child with a head injury. Which of the following symptoms are important for the nurse to control to prevent an increase in intracranial pressure? Select all that apply.   a) Pain    b) Nausea    c) Agitation    d) Coughing    e) Sedation

Question 62

D - The child is obtunded if he can be roused with stimulation.  If the child shows no motor or verbal response to noxious stimuli, he\'s comatose. If the child remains in a deep sleep and is responsive only to vigorous and repeated stimulation, he\'s stuporous. If the child has limited spontaneous movement and sluggish speech, he\'s lethargic.

Accepted Answer

When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which finding supports this level of consciousness?   a) Limited spontaneous movement; sluggish speech    b) Remains in a deep sleep; responsive only to vigorous and repeated stimulation    c) No motor or verbal response to noxious (painful) stimuli    d) Can be roused with stimulation

Question 63

B - It is very important to explore a client\'s past challenges and coping abilities. This information will help the nurse understand the client\'s resiliency and know how best to support the client. The client\'s emotional state would not be assessed by the other options.

Accepted Answer

A client is admitted to the rehabilitation unit after a cerebrovascular accident (or brain attack). The client is bedridden and aphasic. When assessing the client\'s emotional response to the illness, what would the nurse most want to explore?  a) Ability to understand the illness    b) Past experiences and coping abilities    c) Willingness to participate in rehabilitation    d) Frustration with changes in lifestyle

Question 64

â¢ Lifting causes the infant to cry  â¢ Reduction of movement in one of the infant\'s arms â¢ Loss of sensation in one the infant\'s arms   Explanation:  A reported neonatal complication from use of forceps is Erb\'s palsy. Symptoms that would alert the nurse to Erb\'s palsy include paralysis and reduced sensation of the affected limb. Crying while lifting could indicate that the infant\'s clavicle is broken, another complication of a forceps birth. Redness, areas of ecchymosis, and edema are all expected after a forceps birth.

Accepted Answer

The nurse assesses for complications in a newborn infant born with assistance of forceps. Which of the following findings would indicate a need for further assessment? Select all that apply.   a) Reduction of movement in one of the infant\'s arms    b) Loss of sensation in one the infant\'s arms    c) Redness and edema on the side of the infant\'s face    d) Lifting causes the infant to cry     e) Ecchymosis on the neck

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