CorrectAnswers and Rationale
The letters in parentheses following the rationale identify
the step of the nursing process (A, 0, P, I, E), client needs
(I, 2, 3, 4, 5, 6, 7, 8, 9, lO),and nursing care area (0, Y,M,
X). S.:e the inside front cover for the key.
1. 4. Heartburn is caused when stomach content:;enter
the distal end of the esophagus, producing a bJrning
sensC\tion.To avoid heartburn during eregnancy, the
client should avoid spicy foods; eat smaller, more frequent meals; and avoid lying down after eating. Peristalsis usually decreases during the latter half of
pregnancy. Displacement of the stomach by the
uterus, not the diaphragm, may contribute to heartburn. Increased, not decreased, secretion of
hydrochloric acid also contributesto heartburn during
pregnancy.(I,3, 0)
2. 2. Acknowledgingthe anger and its sourceencourages
i;il~~t~i;~UW~~I~'~V!,&e~1rf~"\~~N
directly.Tellingthe client that the mlscarrlagewas an
accident or that she is a strong person and will get
through this ignores the client's feelings of anger and
loss, thereby cutting offcommunication.(I,5, X)
3. 4. Asking the client to speak abot.:t his concerns
encourages open discussion. Telli.1gthe cUent that
he is making a mistake is judgmental of the client's
wishes and eliminates opportunities for the client to
explore the situation and discuss various treatment
options. Saying that herbal treatments have not been
approved by the FDA or that they have not been
researched is irrelevant, places a value judgment on
the client's wishes, and provides no opportunity for
discussion. (I, I, M)
"
4. 3. The most important aspect of teaching a preSchooler
is to have the family members there for support.
Preschoolers are able to understand information that is
individualized to their level. Including a plastic model
of the heart and a catheter as part" of the preoperative
preparation may be helpful. The other family members
will understand the heart" model and catheter better
than the preschooler will. lP' 9, Y}
5. 4. Massaging a area that is reddened due to pressure is
contraindicated because it further reduces blood flow to
the area. In the past, massaging reddened areas was
thought to improve blood flow to the area, and some
n~lI ;ing personnel may still believe that massaging the
area is effective in preventing pressure ulcer formation.
(I, I, M)
6. 3. Asking the mother to talk about her concerns
acknowledges"the mother's rights and encourages
open discussion..The other responses negate the par.
ent's concerns.(I, I, '.,t1> .'
'i. 3. The Meals on Wheels program delivers mealsto
clients once a day in their home. In addition to the
improved nutrition, it is often valued as a meansto
check on eJderlypersons who live alone. Hospicecare
involves daily needs for the terminally ill at home.
VNA,providesskilled nursing care to clientsat home.
AARPis a national organization for retired people,not
a health care organization.(P,I, M)
8. 1. The cardiovascular status of the client is the first
information documented. This information willvali.
date the effectiveness of the temporary pacemaker.
Tht! client's emotional state and the type of sedation
are importantbut not a high priority.Thenursewill
needto .documentJ~~, p"cemakf~ information '91,
.
uf1nf,HJ"Wf1.MM1l1mUJt\"~\1UI11Inl'\\\~II~r~'~
4"tI
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. J. 3. Using a speci~l feeding table or modified high chair
is \he best method for an; infant who is used to si~
up for feedings. The child should not be flat becau;;eof
the danger of aspiration. Raising the child's head will
not work as well as usin~ a feeding table because the
child is not used to lying'down to eat. Two people an:
not necessary. (E, 7, Y)
.'
10. 4. Ventricular tachycardia is recognized by a wide QRS
. complex; the rhythm may be regular or irregular. TheP
waves, if observed, are not related to the QRS complex.
Ventricular tachycardia is a major dysrhythmia and
must be treated immediately. (A, 10, M)
11. 3. Although coordinating documentation, resolving negative feelings, and caIming down are goals of debriefing
after a restraint, the ultimate outcome is 'to improve
restraint procedures. (E, I, X)
12. 3. ARDS frequently develops after a major insult to the
body. The major diagnostic indicator is low arterial
oxygen levels that are not responsive to the administration of high concentrations of oxygen. Early recognition of ARDS is important to increase the client's
chances of recovery. The oxygen levels of clients with
hypostatic pneumonia, hypovolemic shock, or asthma
would,be expe~ed to improve with oxygen administration. (0, IO,'M)
13. 2. By federal law;'aUclientsentering a'hospital or hospice program are offered the chance to make an
advance directive, so that their wishes will beknown
_ _. .
.
wo "', '\ ."fI"
.1\." "URlfre
\
and followed in an emergency. The directive ISnot a
substitute for informed discussion with the phY3iciano Worry about extraordinary means being taken
can be discussed ,,,,ith the client later, but the client
needs to be informed that the di.ective is a federal
requirement to protect the client's autonomy. (I, 1,
M)
h4. 4. The role of the nurse in witnessing the signing of
.
the consent is not to witness that the client is fully
aware of the rehabilitation. The nurse's role is to witness that the client is informed of the procedure,
understands the information, and is signing of his or
her own free will. (I, 1, M)
~
fi15. 1. Temporal arteritis, often seen in the elderly, can
t result in blindness if not treated quickly with steroids.
~
The dose is individualized and depends on the elevation of the sedimentation rate. The client may need to
;:,
i.~ 16. 4.takeDoxycycline
steroids for several weeks to months. (I, 8, M)
is contraindicated
in pregnancy
~
because it can stain the teeth and affect the bones of
the developing fetus. The nurse should hold the drug
and notify the physician to change the order. All
neonates are given prophylactic ophthalmic ointment
for the prevention of ophthalmic neonatorum, con-
~
x
f
t
,'
t
junctivitis caused by gonorrhea. (I, 8, M)
; 17, 3. The contraction stress test simulates labor and
determines the fetal response to the labor process and
~ the mother's contractions. Therefore, determining
that contractions have ceased after the test is important. Although spontaneous rupture of membranes is
a possibility after a contraction stress test, it is not a
t
.
typical occurrence. The test should not affect the viability of the fetus. Fetal viability is reiated to gestational age. A fetus of at least 23 weeks' gestation is
considered viable, or capable of extrauterine life. A
negative contraction stress test should not affect or
alter fetal heart rate variability.(A, 9, 0)
.
~8. 1. A postoperative ileus is a functional obstruction of
the bowel. Assessment of bowel sounds, the first
stool, and the amount of gastric output provide information about the return of gastric function. Measurement of urine specific gravity provides information
.
.
about fluid and electrolyte status. (A,9, Y)
9. 2. Salmeterol is a 13~-agonist,a maintenance drug that
the asthmatic client uses twice daily, every 12 hours.
... Albuterol (Proventil) is used as the "rescue inhaler"
for bronchospasms. Serevent can be used to prevent
exercise-induced
bronchospasms, but it should be
~
taken 30 to 60 minutes before exercise. If the client is
taking Serevent twice daily, it should not be used in
,..
additional doses before exercise; twice daily is the maximum dose. Indications for Serevent incluae only
asthma and bronchospasm induced by chronic
obstructive pulmonary disease. (I, 8, M)
f
~
f
~
20. 4. Because cIozapine can cause tachycardia, the nurse
should hold the medication if the pulse rate is greater
than 140bpm and notify the physician. Giving the drug
or telling the client to go exercise could be detrimental
to the client. (I, 8, X)
21. 1. Valproic acid is the treatment of choice for absence
seizures. Dilantin is used for major motor seizures.
Neurontin is indicated for partial seizures..Paxil is indicated for depression and panic disorders. (0, 8, M)
22. 2. The best approach by the mother is not to interfere.
The children need to learn how to solve disagreements
on their own. If the parent always intervenes, then the
children do not learn how to do this. SibliT''}swm disagree and argue as part of normal development. Punishment, including telling the children that they wiJ]
not go oul to lunch, is not warranted. (E, 3, Y)
23. 4. Hyperventilation causes the excessive loss of carbon dioxide. This results in a decreased carbonic acid
content of the blood. The kidneys will try to compensate by eliminating bicarbonate to maintain a normal
ratio of carbonic acid to bicarbonate, but this takes
several days. If compensatory efforts are insufficient
the client will develop respiratory alkalosis. H:'perventilation does deplete oxygen levels. Arterial blood
gas studies do not ev.aluate sodium or potassium k'vels. (E, 9, M)
24. 2. Managing stressful life events can decrease the
incidence of outbreaks of HSV-2. Occlusive ointments
should not be applied. Antiviral therapies will not cure
herpes, but they can manage symptoms an,-l decrease
the incidence of outbreaks. Clients with H5V-2 should
use condoms to prevent HSV transmission. Cells can
be shed at other times, not only when the \'esicles are
weeping. (I, 7, M)
25. 2. Tmnitus or a ringing in the ears is a clinical manifestation of altered function of the auditory branch of the
eighth cranial nerve, not the vestibular branch. Ototoxic side effects affecting the vestibular brarlch of the
acoustic nerve include vertigo, nausea and vomiting
with motion, and ataxia. (A, 8, M) .
26. 1. Tetanus toxoid is indicated, since there has been no
booster in the last 5 years. Tetanus is not administered
intravenously. With a human bite there is a potential of
severe infection. The closure of the wound should be
delayed until it is determined that there is no infection,
in approximately 24 to 48 hours. (I, 8, M)
27. 3. One of the advantages of subdermal hormonal
implants for contraception is that this form Carlbe used
by a client who is breast-feeding 6 weeks after delivery
without adverse effects on the neonate. Subdermal hormonal implants are progesterone based. Therefore, the
same side effects as those associated 'with progesterone
..."'...
i
II
.!
therapy may occur. After subdermal hormo!lal
implants are discontinued (removed), fertility returns
rapidly because ovulation resumes quickly. Subdermal
hormonal implants do not offer p:otection against sexually transmitted diseases. Only condoms or abstinence offers such protection. (E, 8, 0)
28. 3. Diuretics and digoxin are first-line therapy for
symptom control and management of heart failure.
SSRI are used to treat depression. (A, 8, M)
.
29. 3. With a parent who is visibly upset, it is best to try to
determine what the cause is. Therefore, asking the
mother about why she wants to take the child home
can provide insight into what the problem is. The nurse
cannot stop tne mother from taY.ingher child hon- ~.
However, the physician should be notified about the
mother's decision and efforts are needed to explain the
ramifications of taking the child home. It is inappropriate for the nurse to say "I know how you feel" or "I can
imagine how hard this is" unless the nurse has had the
same experience. (I, 5, Y)
30. 2. Prolonged inactivity causes the body to excrete
excessive calcium. This leads to breakdown of bone tissue; as a result, the bones become brittle and fracture
easily, a condition known as osteoporosis. The excessive calc;,um excretion that occurs during bed rest also
predisposes the client to formation of renal calculi. Prolonged bed rest does not increase sodium retention,
insulin use, or red blood cell production. (A, 10, M)
31. 1. Normal urine output for an infant is 1 to 2
mL/kg/hour. (A, 10, Y)
32. :L.Based on the data given, the most appropriate nur-ing diagnosis is Activity Intolerance related to severe
left leg pain. The other diagnoses are not supported by
the data presented. There is no clinical indication that
the leg will need to be amputated or that the client is
experiencing a disturbance in body image. A temperature of 101°F (38.3°C) would be unlikely to produce a
fluid volume deficit in this client. (D, 10, M)
33. 3. After vasectomy, a sperm analysis will be performed
every 4 to 6 weeks. A sperm-free analysis is necessary
before the man can be considered sterile. Sperm gradually disappear from the ejaculate. Clients must be
informed that conception is possible in the immediate
postvasectomy perioa. (I, 9, M)
34. 3. Garamycin is ototoxic; therefore, the client should
have a vestibular and auditory check 3 to 4 weeks after
discontinuing the drug. This is the most likely time for
deafness to occur. It is not necessary to check the
client's hemoglobin level, white blood cell count, or
serum potassium level solely on the basis of having
been taking gentamycin. The blood urea nitrogE:nlevel
and the creatinine level will be checked to assess renal
function, if necessary. (I, 9, M)
"~n
35. 2. Coughing and deep-breathing
.
are more
when r .:inis minimal. A client in severe pain tenas
limit movement and to breathe shallowly to d . "
the pain. En?ugh. pain medicati~n should be given"
decrease pam without depressmg respirations' iii
allows the clie~t to co~gh e~fectively.Administraticnier _._~"
oxygen or forcmg flUids wIll not prevent atelectasis ~j~.~
pneumonia. Deep-breathing exercises should be r:.1.-:y-
formed at least every 2 hours. (I, 10,M)
36. 2. A child who has had rheumatic fever is likely to
develop the illness again after a future streptocOcat
infection. Therefore, it is advised that such a child
receive antibiotic prophylaxis for at least 5 years. and
sometimes even longer after the acute attack to prevCrtt
recurrence. (I, 8, Y)
37. 4. Crowning occurs when the fetal head is visible.
Anterior-posterior slit occurs as the perineum flattens
and is followed by an oval opening. As labor progresses, the perineum takes on a circular shape, fol.
lowed by crowning. (A, 10, 0)
38. 1. The first action is to increase the oxygen flow ralc
from 2 to 4 L/minute to help ensure adequate 0)(\'genation for the client. A1th~ugh it is important to
notify the physician for additional orders and to obtain
further assessment data such as arterial blood gas
measurements, it is a priority to support the client's
cardiopulmonary system. It would be appropriate to
reassure the client while these other interventions arc
occurring. (1,9, M)
39. 2. Although a cool air vaporizer may be recommended
to humidify the enviiOnment, using saline nose drops
and then a bulb syringe before meals and at nap and
bed times will.allow the child to brea~e. more easily.
Saline helps to loosen secretions and keep the mucous
membranes moist. The bulb syringe then gently aids in
removing the loosened secretions. BlowiIJ.g into the
child"'smouth to clear the nose introduces more organisms to the child. A nonprescription vasoconstrictive
nasal spray is not recommended for infants, because if
the spray is used for longer than 3 days a rebound
effect with increased inflammation occurs. (I, 9, Y)
40. 3. Voice hoarseness may indicate metastatic disease to
the recurrent laryngeal nerve and is most often noted
with left upper !obe lung tumors. Diarrhea and constipation are not associated with lung cancer. Weight loss
can be a symptom of extensive disease. (A, 10, M)
41. 1. A client with metabolic alkalosis may exhibit confusion, nervousness, or irritability, which can be the result
of hypoventilation and increased carbon dioxide retention. Hyperventilation is a clinical manifestation of respiratory alkalosis. Diarrhea is a possible clinical finding
in metabolic acidosis. Edema is not specifically associated with an acid-base imbalance. (a, 10, M)
.
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~
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.,...
12. 2. An initial sign of hemorrhaging after a tonsillectomy
is swaJ10wing frequently as mucus and blood combine
. ,:-Jo
increase secretions. Increased pulse rate is a later
. sign of hemorrhage. Mouth breathing is expected after
surgery because the child's mouth is very dry and the
throat is sore. Because the child has been without fluids
for a period of time, the child usually is thirsty and asks
for a drink. (A, 9, Y)
1. The nurse should not restart a new intravenous
catheter at a different site. The nurse should keep the
catheter patent at the original blood transfusion site so
that a normal saline drip can be started immediately in
case of hypotension and the need for emergency intra"'t. venous medication. (I, 8, M)
.
,"44. 3. The flow rate is determined by the rate of infusion
and the number of drops per milliliter of the fluid
j~
being administered: drops/mL X mL/rninute = IV
flow rate (drops/minute). Therefore, 10 gtt/mL X 100
mL/30 minutes = 33 gtt/ minute. (I, 8, M)
.t 45. 4. Delusions of grandeur provide the client with an
.~~ exaggerated sense of self-esteem that is unrelated to the
client's actual achievements. Other, less grandiose, religious delusions may provide comfort or meaning for
the client. Delusions of persecution are frequently
related to safety issues. Delusions may also be related
to
sexual issues. (D, 6, X)
..
~46. 3. Loss of electrolytes from the gastrointestinal tract
through vomiting, diarrhea, or nasogastric suction is a
common cause of potassium loss, resulting in
hypokalemia. Hypermagnesia does not result from
excessive loss of gastrointestinal fluids. Common
causes of hypernatremia are water loss (as in diabetes
insipidus or osmotic diuresis) and excessive sodium
intake. Common causes of hypocalcemia include
chronic renal failure, elevated phosphorus concentration, and primary hypoparath~roidism. (P, 10, M)
7. 3. It is a normal variation fo~ women to have long~ term, bilateral nipple inversion. A woman who has a
_.
unilateral nipple .inversion that is a new change is at
risk for a tumor; the weight of the tumor cause",pulling
on the nipple. A pronounced unilateral venous pattern,
peau d' orange breast tissue, and breast tissue darker
than the areolae are definite warning signals for breast
cancer that must be reported to the physician immediately. (0, 4, M)
.~. 1. It is important
for children with sickle cell disease to
lop" drink lots of fluids to help prevent a crisis. Dehydration
precipitat~s sickling and a crisis. Although taking the
child's temperature may provide information about the
child's status, it will do nothing to prevent a crisis, nor
would weighing the child daily, Offering the child a
high-protein diet will not prevent a crisis, nor is it recommended. (I, 10, Y)
~,~:t..
49. 1. T;le nurse notifies the pediatrician because a short,
webbed neck is associated with genetic deviations,
such as chromosomal disorders. Cleft palate is associated with embryonic developmental failures and an
abnormal opening in the palate. Potter's syndrome
(renal agenesis) is characterized by an atypical facial
appearance consisting of a flat nose, recessed chin, epicanthal folds, low-set abnormal ears, limb abnormalities" and pulmonary hypoplasia. Neural tube defects
are associated with spina bifida or myelomeningocele.
(0, 9, 0)
-;-j
,
50. 3. Clinical manifestation of hypokalemia include an
irregular pulse, fatigue, muscle weakness, flabby muscles, decreased reflexes, nausea, vomiting, and ileus.
Muscle spasms are not seen in hypokalemia. Thirst is a
symptom of hypernatremia. Confusion can be seen in
hyponatremia and hypocalcemia. (E, 10, M)
51. 2. Pruritus, or skin itching, is not one of the clinical
manifestations of a superinfection, which is a new
infection caused by microorganisms different from the
ones causing the initial infection. A black, hairy tongue;
glossitis; and anal itching are clinical manifestations of
a superinfection. (A, 8, M)
52. 2. The clie~' s self-report of pain is the most reliable
ind:cator of the existence and intensity of the pain.
Client respon:>c to pain is highly individualized and
subjective. The nurse must respect the client's self-
report. (A, 10,M)
.-..~
.
~:.J
53. 2. Excessive milk consumption can often lead to the
displacement of iron-rich foods in the diet. This can
resul~ ;n iron-deficiency anemia. (A, 4, M)
54. 2. Although all the symptoms listed can manifest in
cases of fat embolism syndrome, confusion is the earliest symptom noted. The confusion is caused by a low
arterial oxygen level. (A, 10, M)
55. 1. An idea of reference is a person's view that other
people recognize that she has an important characteristic or power. Thought insertion refers to a person's
belief that others, or a specific other, can put thoughts
into her mind. Visual hallucinations involve seeing
objects or persons not based in reality. A neologism is a
word or phrase that has meaning only to the person
using it. (D,6, X)
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.
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.
56. 3. To test the hearing ability of a neonate, the nurse
should position himself or herself approximately 12
inches away from the neonate and make a loud noise,
such as clapping the hands. (A, 9, 0)
57. 4. The equianalgesic dose of oral meperidine hydrochloride is up to four times the 1M dosage. Meperidine hydrochloride can be given orally, but it is
much more effective when given by the 1M route. (D,
8, M)
~~
\
58. 1. In order to prevent disuse osteoporosis, it is important to implement weight-bearing activities as soon as
medically allowed. Increasing the client's calcium will
not prevent the development of osteoporosis without
the inclusion of weight-bearing activity. Passive rangeof-motion exercises and isometric exercises do not provide the bone stress necessary to reduce the risk of
osteoporosis. (I, 9, M)
59. 3. Toddlers have temper tantrums in their attempt to
.
develop autonomy. Toddlers should be left alone as
long as they are safe during a tantrum. Moving the
child to a "time-out" chair or punishing the child reinforces the behavior and is to be avoided. Attempting to
talk to the toddler also reinforces the behavior. Additionally, at this cognitive level, toddlers do not understand as well as older children do. (I, 3, Y)
60. 1. When a nurse has been stuck by a used needle and
has not completed the hepatitis B vaccination, he or
she should receive both active and passive immunization. (I, 4, M)
61. 2. Daily skin inspection is essential in preventing pressure ulcers. Hot water is irritating to skin and should
be avoided. Massaging bony prominences is contraindicated and may actually promote skin breakdown. Prolonged, uninterrupted chair sitting should
be avoided; the client's position should be adjusted at
least every hour. (I, 9, M)
62. 3. Skeletal pins should not be loose and able to move.
Any pin loosening should be reported immediately.
Slight serous drainage is normal and may crust around
the insertion site or be present on the dressing. The pin
insertion site should be cleansed with aseptic technique according to institution policy. Pin insertion
.-'.. sites are typically not painful; pain may be indicative
&:1w
of an infection and should be reported.
(E, 9, M)
~~
..
~63~.4. Acknowledging the basic feeling that the client
:i, . expressed and asking an open-ended question allows
I
';~. the client to explain her fears. Saying, "It's normal to
;"be scared. We'll help you through it," does not focus
..Ion the client's feelings; rather, it gives reassurance.
i7 Asking if the client feels guilty for having smoked
{- assumes guilt, which might be present, but additional
'~ information is needed to confirm. Telling the client not
.
to be so hard on herself does not ackno'vledge the
client's feelings at all. (I, 5, M)
64. 3. It is important that clients with rheumatoid arthritis
maintain proper posture and body alignment to-support joints and decrease pain and stiffness. Clients
with hip pain will be most comfortable when sitting in
a straight-back chair with an elevated seat. Elevated
seats avoid excessive hip flexion and place less stress
on the hip joints. (E, 9, M)
---
~
65. 3. Giving away p~rso.nal items has consistenU .~,
showr to be an mdlcator of suicidal plans ~. -, ;.
depressed and suicidal individual. The other
indicate
a return of interest in normal adolescent _ _
..
ctc:tiv.'c.f
6 X
lties. (I, , )
{...~
~
~
66. 3. When a neonate dies, the mother should be allowed ~..;~
to stay with the baby as long as she wants and say am'. .~,~
"
thing she wants. She is grieving and needs time \\ith
the neonate. A photograph should be taken in case ~
mother wants ~ photograph at. a.later time. Telling ~
mother that thIs ISfor the best ISmappropriate beca~
such a .statement discounts the mother's feeling~.
Advising the mother to get pregnant again to get O\'cr
the loss is not helpful because the mother needs time to
grieve and be with the neonate. The nurse should
remain near the mother and not delegate this responsibility to the hospital's chaplain. A chaplain or other
religious member can be contacted if the mother
desires. (I, 5, 0)
67. 4. 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
ac'is. The red blood cell count, bilirubin levels, and
reticulocyte count do not indicate protein intake. (A. .;,
M) .
.
68. 2. The client who is taking desmopressin (DDA\'Pj
nasal spray should not use the same nares for administration each time. The client should alternate nares
every dose. The client should observe for and report
promptly signs of nasal ulceration, congestion, or respiratory i~ection. (I, 8, M)
69. 3. 500 mg/mL = 250 mg / x mt; x = 0.5 ~L. (I, 8, M)
70. 3. Common clinical manifestations of hypokalemia
include ventricular dysrhythmias, weak and irregular
pulse, soft and flabby muscles, and decreased deep tendon reflexes. Hypercalcemia causes confusion and
decreased memory, bone pain, polyuria, ane;.nausea,
vomiting, and constipation. Hypernatremia causes
signs of fluid volume deficit. Hypomagnesemia is manifested by tremors, confusion, hyperactive deep tendon
reflexes, and seizures. (A, 10, M)
71. 3. As with other contraceptives that are progestin
based, heavy menstrual bleeding may ocCUr.Other side
effects include rash, acne, alopecia, fluid retention,
edema, and sudden loss of vision. Depression and
weight gain have been reported. For clients taking this
drug, the risk of endometrial or ovarian cancer is
decreased. Amenorrhea has been reported after recei\'ing four injections 3 months apart for 1 year. Depression
and loss of energy have been reported. (P, 8, 0)
72. 4. Clients with burns are susceptible to the development of Curling'~ ulcer, a gastroduodenal ulcer that is
Ircaused
by a generalized stress response. The stress
~ response results in increased gastric acid secretion and
~- . abestdecreased
production of mucus. Prevention is the
treatment, and clients are frequently treated pro-
,,
.
."
.
phylacticallywith antacids and H2histamine blockers
such as cimetidine.(P,9, M)
13~2. Fever is a cardinal manifestation of infection in peo~' pIe with AIDS. Because the major physiologic alteration in AIDS is generalized immune system dysfunction, typical indicators of the body's response to
infection (eg, erythema, warmth, tenderness) may be
absent. (I, 10, Y)
t
44. 2. To care effectively for clients with depression, the
nurse would teach the importance of demonstrating
empathetic concern. Caregivers must accept clients as
they are even though many will be angry and negative,
acknowledge their emotional pain, and offer to help
them work through their pain. For the client who is
depressed, using a cheerful demeanor or a humorous,
lighthearted approach may be overwhelming because
the client will be unable to meet the caregiver's expectations, subsequently leading to decreased self-worth.
A serious, t "Isiness-like affect may threaten the client
and inhibit the development of trust. (I, 1, X)
.
;. 4. When a child is ready to take fluids by mouth postoperatively, clear liquids are given initially. If clear liquids a~ tolerated, the concentration and amount of
oral feedings are gradually increased. This means
advancing to half-strength and then to full-strength
formu'" while increasing the amount given with each
feeding. (I, 7, Y)
,. 2. The nurse would monitor the client taking paroxetine
(paxil), an SSRI, for sexual problems such as decreased
libido, impotence, and ejaculatory disturbances, because
these side effects can occur frequentl¥ and lead to medication noncompliance. Sleep disturbances can occur
with an SSRIsuch as paroxetine. However, this client is
taking the drug every morning, which would not affect
nighttime sleep. A hypertensive crisis is associated with
the ingestion of foods rich in tyramine when a client is
taking a monoamine oxidase inhibitor (MAOI). Orthostatic hypotension is a potential side effect with tricyclic
antidepressants (TCAs). (I, 8, X) .
J. 1. This diet is based on experimental research indicating that diets low in potassium are often associated
with hypertension. Higher-potassium diets appear to
prevent and correct hypertension. Magnesium deficiency causes artery walls and capillaries to constrict
and therefore raises blood pressure. Magnesium intake
within the normal range lowers blood pressure. Vitamin C helps to normalize blood pressure. Calcium lowers blood pressure in healthy people and in those with
hypertension. (D, 4, M)
78. 2. In the pro~ressive stage \)f shock, the client can display listlessness or agitation, confusion, and slowed
speech. Restlessness occurs in the compensatory stage.
Incoherent speech and unconsciousness are clinical
manifestation£ 'Jf the irreversible stage. (A, 10, M)
79. 1. When the crash cart arrives, ECG electrodes are
applied to the client's chest. If the client is fOU11dto be
in ventricular fibrillation, the immediate priority is to
defibrillate the client. Pulse oximetry is not an immediate priority. The client's oxygenation is evaluated in a
code situation using arterial blood gas analysis. The
client's blood pressure is evaluated after the ECG
rhythm has been established. A portable Doppler ultrasound unit may be needed to check for the presence of
a pulse or to check the"blood pressure in a code situation. (0, 10, M)
80. 2. Heroin causes pupils to be pinpoints. Marijuana
causes the eyes to appear red and bloodshot. Cocaine
use causes pupils to dilate. Drooping of the eyelids is
not typically associated with th~ use of any substance.
(I, 6, Y)
81. 3. A typical sign of pediculosis capitis (head lice) is frequent scratching of the scalp, because the condition
causes severe itching. Scratch marks are usually easily
visible. Because head lice are easily transmitted to others, the child's family members and peers also should
be examined for infestation. Spotty baldness, wheals,
and scaly lesions are often allergic in nature. (A, 10, Y)
82. 1. Passing flatus indicates the return of peristalsis, as
does active bowel sounds. Hunger is not the best indicator of peristaltic return. Hypoactive bowel sounds
indicate that there is some peristaltic activity but it is
limited and not yet normal. Palpitation is not an appropriate method of assessing bowel activity. (E, 10, M)
83. 3. The pH of 7.24 indicates that the client is acidotic.
The pC02 value of 49 mm Hg is elevated.
The HC03
-
value of 24 mEq/L is normal. The client. is in uncompensated respiratory acidosis. Hypoventilation and a
flushed appearance are additional clinical manifestations of respiratory acidosis. (0, 10,M)
84. 2. It is essential for the nurse to evaluate the effects of
pain medication after it has had tinie to act. Although
other interventions may be appropriate, continual
reassessment is most important to determine effectiveness and the need for additional intervention, if any.
Repositioning could provide some comfort, but assessment of the client's pain level is essential. Reassuring
the client is important, but it will be of no value unless
the nurse evaluates the client's pain level. To readjust
pain dosage is appropriate only if titration is prescribed
by the physician. (E, 10, M)
85. 1. Barrier contraceptives must be used to protect
against STDs. Birth control pills and douching are not
i
effective for pre\-ention of STDs. Prophylactic antibiotics are not used to prevent the acquisition of STDs. (E,
2,M)
86. 2. A purplish-blue discoloration of the vagina and
cervix is termed Chadwick's sign; it is caused by
increased vascularity of the vagina during pregnancy.
It is considered a !Jrobable sign of pregnancy. Goodell's
sign, o::msidered a probable sign of pregnancy, refers to
a softening of the cervix during pregnancy. Hegar's
sign, also a probable sign of pregnancy, refers to a softening of the lower uterine segment. Melasma, the mask
of pregnancy, refers to the pigmentation of the skin on
the face during pregnancy. Melasma is considered a
presumpth'e sign of pregnancy. (A, 3, 0)
87. 3. Initially, the nurse would tell the client to seek out
staff when feeling agitated or upset to prevent violent
episodes. Doing so helps the client to redirect negative
feelings in an appropriate manner (eg, talking). Encouraging the client to stay in his room is inappropriate
because it does not help the client to deal with his feelings. Secluding the client at the first sign of agitation is
not indicated and may be perceived by the client as
punishment. Instructing the client to ask for medication
when agitateo woulG not be the initial course of action.
The nurse woulc', interact with the client and direct the
client to an activity to decrease his anxiety before intervening with any PRN medicati~m. (I, 6, X)
88. 3. The nurse should use short words, sentences, and
paragraphs and avoid medical jargon. Correct terminology should be used when appropriate (eg, type 1
diabete5, not "sugar diabetes"). The format should bE
as simple as possible; charts are not necessary and may
be confusing to some clients. Information should be
prepared at a fifth-grade reading level. The information
should be presented in large-sized type. (P,5, M)
89. 4. It is normal for the client to feel pressure on the
palms of the hands whell walking with crutches. The
client should move her affected (right) leg forward first
as she swings forward with the crutches. Leaning on
,
.
the crutches can apply pressure to the axillae,leading
to neurovascular impairment. If the client's arms are
tingling after she uses her crutches, she is probably
applying pressure on her axillae when walking. (E, 7,
M)
,
90. 2. Because clients are discharged as soon as possible
from the hospital, it is essential to evaluate the support
for assistance and self-care at home. (0, I, M)
91. 3. If the client begins breast-feeding early and often
after delivery, the breasts begin to fill with milk within
48 to 96 hours, or 2 to 4 days. The breasts secrete
colostrum for the first 24 to 48 hours, which is beneficial to the neonate because of the immunoglobulins'
contained in colostrum. (I, 3, 0)
,
92. 3. Thl!predominant clinicalfinding in e1d-'
itated cli~n~s i.ldica~g th~t they have ~~
pneumoma IS confusIOn, which results from;"'"
Fever and chills, productive cough, and pl--~"
pain could be present, but confusion is the
nant development. (A, I, M)
.
.
93. 1. It is important for !he chil.d and family to ~~
stand that chorea assocIated WIth rheumatic fC\ ' cr .~~
.
.
'. ,-
'~
permaf1e~t. T?erefore, the nu.rse would explain that tbt~
chorea WIll dIsappear over time. It is not necessary to
assess the child's neurologic status, because the ch~
;~
is self-limited and nonprogressive. Because the child ..~
has cardiac involvement, ambulation is contraindi_ .~
cated. Aspirin is used primarily as an anti-inflammatory drug and secondarily for pain relief. A slightl\' coot
environment is unnecessary. Environmental te~pera.
ture does not affect the child's polyarthritis and cho~a.
(P, 10, Y)
l~
94. 1. When the gestation is les3 than 13 weeks. a thera.
peutic abortion is usually performed by the dilation .md
curettage method. Menstrual extraction. or suction
evacuation, is the easiest method, but it is used onh
when the client is between 5 and 7 "'eeks' gestatio~
Dilatatic and vacuum extraction is used when clicn:~
are betwee:1 12 and 16 weeks' gestation. Saline induction, used for clients between 16 and 2-1Wl'l.'\...'
gestation, involves instillation of a hypertonic saJinl'
solution into the amniotic sac to initiate expulsion.
Oxytocin infusion may also be used with saline induction. (I, 3, 0)
95. 1. A pleural effusion is a collection of fluid between the
pleural layers of the lung. The effusion decreases chest
wall movement on the affected side: The nurse WQuld
expectthe breath sounds to be decreased or diminis:1ed.
over the affected area. Because of the presence of fluid.
percussion would elicit dullness, not hyperresonance.
Fever may be present if emphysema has developed.
but not in the case of a nonpurulent pleural effusion.
(A, 10, M)
96. 1. An expected client outcome relative to the nursing
diagnosis of Pain related to cramping is that the client
exhibits no manifestations of discomfort, such as crying
or drawi!1g the legs to the abdomen. Being very still
may indicate either a pain state or a state of relaxation.
(P, 10, Y)
97. 2. 40 mg/mL = 25 mg / x mL; x = 0.6 mL. (I, 8, M)
98. 4. The client is exhibiting symptoms of herpes genitalis.
which include painful blisters or vesicles that appear 2
to 20 days after transmission of the disease. The client
was most likely exposed from her new partner. Vulvar
pain, dyspareunia, dysuria, and flu-like symptoms also
may be present. HIV infection is commonly manifested
by numerous signs and symptoms such as persistent
. canUIOlaslS,anogenital condyloma, and herpes simplex
infections. Chlamydia trac1lOI1latis
infection is asymptomatic, often going undetected by affected women.
Symptoms, when present, include a grayish-white
discharge and '\.1lvar itching. Syphilis typically is
manifested by chancre occurring about 10 days after
exposure. The chancre is usually deep but painless. (A,
'Co 9, 0)
99: 2. It has been found that parents are more grieved
,
when optimism is followed by defeat. The nurse
~. should recognize this when planning various ways to
help the parents ~a dying child. It is not necessarily
true that knowing about a poor prognosis for years
helps prepare parents for a child's death, that trust in
health personnel is destroyed when a death is
untimely, or that it is more difficult for parents to
accept the death of an older child than that of a
younger child. (P, 5, Y)
f
100. 1. A client who has an allergy to penicillin may have a
cross-sensitivity to cefazolin (Ancef), a first-generation
cephalosporin, and the drug should be given with caution. The nurse should ask the client whether he has
taken cefazolin before. The nurse should inform the
pharO''Icy of the client's allergy after asking the client
about prior use of cefazolin. The medication should not
be admir:istered until the nurse first inquires about the
client's exposure to cefazolin and then consults with
the pharmacist or physician. Observing the client for
urticaria is appropriate but is not an initial response.
(D, 2, M)
01. ~ Clients with chronic renal failure are susceptible to
uremia, an accumulation of nitrogenous waste products in the blood. Clinical manifestations include dry,
itchy skin that can be severe in nature. Because of the
irritation of the skin and the inclination to scratch,
clients are prone to impaired skin .integrity. The pruritus is not a result of poor hygiene. Chronic pain is not
a likely result of the pruritus and is not a priority nursing diagnosis. The data do not support the nursing
diagnosis of Ineffective Coping. (0, 7, M)
)2. 1. The nurse would teach the client taking lithium and
his family about the importance of maintaining adequate sodium intake to prevent lithium toxicity. Because
lithium is a salt, a reduced scdium intake could result in
lithium retention with subsequent toxicity. Increasing
sodium in the diet is not recommended and may be
harmful. Increased sodium levels result in lower
lithium levels. Therefore, the drug may not reach therapeutic effectiveness. (P, 8, X)
~. 3. Mucositis is a inflammation of the oral mucosa
caused by radiation therapy. It is important that the
client with mucositis receive meticulous mouth care,
including flossing, to prevent the development of an
infection. Mouth care should be provided before and
after each meal, at bedtime, and more frequently as
needed. ..;xtremes of temperature should be avoided in
food and drink. Half-strength hydrogen peroxide is too
harsh to use on irritated tissues. (I, 9, M)
104. 2. The first treatment for ingestion of nonprescription medication is to empty the stomach. This can be
achieved by giving syrup of ipecac and water. If the
child does not vomit in 30 minutes, then the dose
should be repeated. It is important that the parent
attempt to empty the child's stomach before or during
transport to the emergency department. (I, 8, Y)
105. 1. The best approach by the nurse is to determine why
the parent thinks the child is hyperactive. Some children are very active but do not have the necessary
defining characteristics of hyperactivity. Asking what
the parent thinks needs to be done or how the child
behaves normally would be an appropriate follow-up
question once more information is gathered from the
parent to determine whether the child indeed is hyperactive. TeJling the parent to wait for the physician
ignores the parent's concern and does not deal with the
parent's issue. (I, 10, Y)
106. 2. Dilation at the anastomosis sitP.is .'1ceded during the
first years of childhood in about 50% of children who
have had corrective surgery for TEE Recurrent mild
diarrhea with dehydration is not likely to develop with
this surgery. Speech problems can occur if other abnorm~lities are present to produce them; the larynx and
structures of speech are not ~~ected by TEE Dysphagia
and strictures may decrease food intake, and poor
weight gain may be noted, but gastric ulcers should not
develop from surgery to repair TEE (Y,1,.9)
107. 1. Terminally ill clients most often describe feelings of
isolation because they feel ignored. The terminally ill
client may sense any discomfort that family and friends
feel in the client's presence. Nursing interventions
include spending time with the client, encouraging discussion about feelings, and answering questions openly
and honestly. Reducing fear of pain or fear of more
aggressive therapies is secondary to lessening the
client's feelings of isolation. Reducing feelings of social
inadequacy is not relevant to the terminally ill client. (P,
5,M)
108. 2. When the fetus is in a breech position, the fetal heart
rate most often is located above the umbilicus, because
the fetal heart is near the top of the mother's uterus.
The heart of a fetus in the cephalic position is typically
located on either the left or the right side of the client's
uterus. Also, because the fetal heart typically is located
in the lower portion of the mother's uterus, the sounds
would be heard below the umbilicus. With a face presentation, fetal heart sounds are typically located on
L
i':"7i'
either the l~ft or the right side of the client's uterus; in
addition, because the fetal heart typically is located in
the lower portion of the mother's uterus, the sounds
would be heard below the umbilicus. When the fetus is
in a trdnsverse position, the fetal heart sounds typically
would be located below the umbilicus and in the midline. (0, 3, 0)
109. 4. Clients who have been diagnosed with pernicious
anemia are lacking adequate amounts of the intrinsic
factor (IF) that is secreted by the gastric mucosa. IF is
necessary for the absorption of cobalamin (vitamin Bu)
in the jistal ileum. Without the presence of IF, dietary
intake of vitamin B12is useless because it cannot be
absorbed. Treatment of pernicious anemia includes
intramuscular injections of cobalamin, at first daily for
2 weeks, then weekly until the anemia is corrected. A
maintenance schedule of montWy injections IS then
impiemented. The injections will need to be continued
for the rest of the client's life. (E, 10,M)
110. 2. The nurse should first take orange juice to the client,
because a hypoglycemic reaction is likely to occur. The
nurse (charge nurse or otherwise) should notify the
physician for orders to prevent or treat severe hypoglycemia. The nurse could consult with the clinical
pharmacist until able to contact the physician. The
nurse should ask for assistance so that the client can be
monitored by. a nurse while someone prepares a
longer-acting carbohydrate or protein. (0, 7, M)
111. 4. Safety is the priority in caring for this infant. Infants
adapt easily, increasing mobility even with a splint in
place. Therefore, the mother needs to ensure that the
;'
area in which the infant is mobile is safe. There is no
need to contact the physician to alter the treatment
~~
plan. Confining the infant to one room may not allow
t
~;..,
...
~
f'
the child to achieve normal development. The child
needs different envir0IlII!.ents for maximum development. The infant needs to wear the splint as ordered by
. the physician to ensure optimal healing. (I, 2, Y)
~'112. .1. Anxiety in a preoperative client may be caused by
many different fears, such as fear of the effects 0' anesff .thesia, the effects of surgery on body image, separation
.
~
i'
.
from family and friends, job loss, disability,pain, or
death. However, fear of the unknown is mostlikely to
be the greatest fear, because the client feels helpless.
Therefore, an important part of preoperative nursing
care is to assess the client for anxieties and explore possible causes. Emotional support can then be offered, so
that the client is in the best possible psychologica! condition for surgery. (A, 5, M)
113. 1. An important nursing responsibility is preoperative
teaching. The recommended guide for teaching is to tell
the client as much as she wants to know and is able to
understand. Delaying discussion of issues or concerns
"'"'111
,,'.ill most l~kelyincreas~ the client's anxiety. Teii~""
chent to dIscuss questions with the phv~id"
acknowledging the client's concerns. (I, 5, M:n ff:;i;.
114. 3. Th~eclient ~ust have adequate disclosure of the :'"", ..
~ssoC1at~dwIth the .s~rg;ry before signing the ~).JI:'
'
.1._1."'-:,
torm. It IS the physloan s responsibility. to expJam
U1I:'
*--"!6:~is~s of any, proce?ures and to obtain the dient'I'~j~~
mtormed consent. I.t the nurs: s.uspects that the client .,t-;
has not been truly informed, It IS the responsibilit 0( ~!
the nurse to act as a client ad,'ocate and contact t.heY. . :'.\1
geon to provide additional information to t.hl,c1ien~~' 'Z
is not appropriate to have the client sign the consen;
form if the cliel1t has questions. The nurse should r\l~
minimize the procedure or dismiss the client's COn.
cerns. (I, 1, M)
.
115. 4. In right occipital anterior lie, the occiput faces ~
right anterior segment of the ,\'oman's peh'is. In Iclt .1
occipital transverse lie, the occiput faces left the
~
woman's left hip. In left occipital anterior lie. t..'-Il" .,
occiput faces the left anterior segment of the wum.ln....
pelvis. In right occipital trans\"erse lie, the occiput ia,,-'S
the woman's right hip. (0, 10, 0)
.
116. 2. Urinary tract infe ''ions in infants are a bit kmi to
diagnose because symptoms may be subtle, such .1"
loss C'fappetite and fussiness. Dysuria and fever m.1\'
aiso occur, but dysuria is harder to recogni7t' in a~
infant. Increased urine output may occur, but it would
be very difficult for the parent to actually det('rminl'
this. Typically, urine is cloudy in appearance in an
infant with a urinary tract infection. Feeding problems
may occur, but jaundice would be a late sign. (I, 10,Y)
117. 3. A positive Babinski's reflex in a neonate is a norma!
finding demonstrating the immaturity of tIl(' central
nervous system in corticospinal pathways. A neonate's
muscle coordination is immature, but the Babinski's
reflex does not help determine this immaturity. A positive Babinski's reflex does not indicate a defect in the
spinal cord or an injury to nelyeS that innervate th('
legs. There is no evidence to suggest partial paralysis.
A pJsitive Babinski's reflex in arl adult indicates disease. (0, E, 3)
118. 2. The nurse should instruct the client who is taking dexamethasone (Oecadron) and furosemide (Lasix) to observe for signs of hypokalemia, such as malaise, muscle
weakness, vomiting, and a paralytic ileus, because both
dexamethasone and, furosemide deplete the serum
potassium. (P, 8, M)
119. 2. After a bronchoscopy with a biopsy, the nurse should
monitor the client for signs of pneumothorax as well as
hemorrhage. The client should not gargle with oral
lidocaine; this will not allow th~ gag reflex to return.
The client should not have an\' mediastinal discomfort
after a bronchoscopy; if pain does occur it sho111r1
hp rp-
..
''
ported promptly to the rhysician. It is not necessary to
tell the client not to tal:; until the gag reflex returns. (I, 9,
: M)
.
[
·
:..
.
I.
,.
. 2. i"he number of drops the client should receive each
minute is d~termined as follows:500mL / 12hours =
between 41 and 42 mL to be infused each hour; 42 mL
X60(drop factor)= 2520drops to be infused eachhour;
2520drops / 60minutes = 42 drops to be infused every
t
minute. (I, 8, Y)
\'21.2. Subcutaneous injections are administered at an
angle of 45 to 90 degrees, depending on the size of the
I
client. Surrutaneous needles are typically 3/8 to
5/8
inches in length. The skin should be pinched up at the
injection site to elevate the subcutaneous tissue. Air is
not drawn into the syringe for a subcutaneous injection. (I, 8, M)
122.3. Acute Pain is a priority nursing diagnosis for the
client with pelvic inflammatory disease because the
disease is associated with severe pain. Imbalanced
Nutrition, Self-Care Deficit, and Impaired Skin
Integrity are not priority nursing diagnoses associated
with pelvic inflammatory disease. (0, 10, M)
23. 3. Children with difficult temperaments do better in
structured environments than in environments with
daily changes. This helps to teach them what to expect.
Easy children do well with flexible feeding times. Childr~n with easy temperaments do not cry often, and
parents need to remember to feed them. Children with
high activity levels, another type of temperament, who
are always on the go, need to be watched more closely
and need extra safety precautions taken around the
house. (P,3, Y)
24. 4. The position of the tube should be verified before
the feeding is implemented. Warming the solution is
not necessary or desirable because it can encourage
bacterial growth. The client should.be lying down with
the head elevated or sitting upright during administration of the feeding. Gastric residual should be aspirated
and then reinstilled to prevent electrolyte losses. (I, 9,
M)
25. 4. The cramping is caused by the baby's sucking and
subsequent stimulation for the release of oxytocin. This
cramping is normal. With each subsequent pregnancy,
the uterus becomes "stretched" and the release of oxytocin causes the uterus to contract, resulting in the feeling of cramping. Continued moderate to large amounts
of lochia rubra is indicative of retained placental fragments. Cramping indicates that the uterus is contracting and most likely firm. A boggy uterus, continued
moderate to heavy lochia, mild vasoconstriction, and
restlessness and anxiety suggest delayed postpartum
hemorrhage due to subinvolution of the placental site,
retained placental tissue, or infection. Most clients
receive a stand arc dose of oxytocin (Pitocin) after
delivery. Oxytocin has a duration of action of 60 minutes. Therefore, the effects of the drug would have
worn off by 24 hours postpartum. (I, 3, 0)
126. 4. The current recommendations for children experiencing mild to moderate diarrhea are to continue the
child's regular diet. With this diet plan, children seem
to get well faster. Clear liquids, such as juices, colas,
and gelatin, are high in carbohydrates but low in electrolytes, as are foods such as bananas, rice, applesauce,
and toast. Foods low in fat also typically lack the electrolytes that the child needs. (I, 9, Y)
127. 2. When performing tracheostomy care, it is important
that the tracheostoL.y ties be securely tied to prevent
dislodgment of the tube. It is not necessary to remove
the inner cannula every 2 hours for cleaning. Routine
cleansing is usually performed every 8 hours. The
nurse should use precut tracheostomy dressings under
the neck plate to protect the skin surrounding the
stoma. Cutting and using a gauze dressing can cause
loose gauze fibers to enter the ainvay. The inner cannula should be suctioned before cleansing, not afterward. (I, 7, M)
128. 2. The nurse should sen~: the sealed container of IV
50% dextrose found in the catch-all bin to the pharmacy. A concentrated medica'tion such as 50% dextrose
could be lethal if inadvertently administered and
should be not be stored outside the pharmacy. An incident report is not necessary in this situation. The
sharps container is not the appropriate method for disposal of this medication. (0, 1, M)
129. 3. The client who is wheelchair-bound with a spinal
cord injury should be taught to make small weight
shifts, lifting off the sacral area every 15 minutes. This
decreases the risk of pressure ulcer formation. Bathing
daily promotes skin cleanliness, but by itself it will not
p.revent pressure ulcer formation. Eating a well-balanced diet that includes proteins and carbohydrates
promotes good skin integrity. Moving from the bed to
the wheelchair every 2 hours is not desirable because
the clieut should not spend excessive amounts of time
in bed. Pressure sores can develop in less than 2 hours.
(I, 10, M)
130. 1. Anatomically, the squatting position enlarges the
pelvic outlet and uses the force of gravity during pushing. The mother should curve her body into a C shape
for the greatest effectiveness. (I, 3, 0)
131. 2. Saying, "If you punch people out, you'll get arrested," helps the client by pointing out the negative
consequences of his behavior. Clients with antisocial
personality disorder are aggressive, impulsive, and
reckless; engage in illegal activities; and lack guilt or
remorse. The nurse teaches the client that there are con-
I
I
4I
sequences to his irresponsible behavior and that the
way to stay out of trouble is to change his behavior. Saying, IIIt's wrong to punch others," is not helpful since
the client does not feel guilt or remorse. Saying, "I
wouldn't do that again if I were you" or 1I0on't ever do
that again," is authoritative and scolds the client without helping him. (I, 6, X)
132. 3. Self-mutilation is a way to express anger and rage,
commonly seen in clients with borderline personality
disorder. It typically is a cry for help, an expression of
intense anger, helplessness, or guilt. When a client is
experiencing numbness or feelings of unreality, selfmutilation induces physical pain which validates the
person's being alive because of the ability to feel the
physical pain. Self-mutilation is not a means of getting
what the person wants. It is not used as a form of
manipulation, although it is often misinterpreted as
such. Self-mutilation is a serious behavior that is harmful to the self and cannot be ignored. (E, 6, X)
133. 3. Hepatitis C is transferred by percutaneous exposure,
such as tattooing. Hepatitis A is acquired through contaminated water, exposure in underdeveloped countries, or shellfish in contaminated waters. (A, 9, M)
134. 1. Lorazepam (Ativan), a benzodiazepine, is commonly used to decrease the symptoms of central nervous system irritability in the client who is experiencing
symptoms of alcohol withdrawal. Diazepam (Valium)
and chlordiazepoxide (Librium), also benzodiazepines,
may be used in some instances. Naltrexone (ReVia) is
an opioid-receptor antagonist that interferes with opioid functioning and reduces the craving for alcohol and
narcutics. It is used as an adjunct for treating alcohol or
narcotic dependence. Methadone (Oolophine) is an
opioid similar to morphine. It is used to treat opioid
dependence. Imipramine (Tofranil) is a tricyclic antidepressant used to treat major depression. It also may be
used as a substitute for heroin'and narcotics in clients
who want to terminate drug use. (P, 8, X)
135. 3. After surgery, the nurse's initial assessment is the
surgical site dressing to determine whether there is any
bleeding or drainage. Once this assessment is completed, then the nurse would assess the other areas
such as the intravenous access site, pain, and nasogastric tube function. (A, 10, Y)
136. 1. The nurse should use the radial artery to obtain
blood gas samples, because it is easier to maintain firm
pressure there than on the femoral artery. Nursing
interventions to protect the client who has received tPA or alteplase recombinant (Activase) therapy include
maintaining arterial pressure for 30 seconds, because it
takes longer for coagulation to occur with the thrombolytic agent onboard. Intramuscular injections are
contraindicated during thrombolytic therapy. The
nurse should prevent physical manipulati
of
client, which ca:1cau"e bruisin~ (I, 10, M) on
the
137. 3. Experim~ntal and epidemiologic research indiate$.
that approximately 50% of all patients with h
sion can I"wer their blood pressure through
sodiumreduction.(0,4, M)
~---,
138. 4. Serum amylase and lipase are increased in ~
atitis, as is the ~rinary amylase. Other abnormallaboratory values mclude hypocalcemia, hypergh'cenu.",
and hyperlipidemia. (A, 10, M)
.
139. 2. For the client with an alcohol or drug pro.r-:m1..
group se~"ions are helpful in dealing with emotl~
and concerns about alcohol and drugs. Clients with
substance abuse problems identify wi~h each Otlwr'~
similar experiences and can best help each other dt.'al
with these feelings and emotions. Additionallv ttw
members of the group are able to support and Comron!
each other. Individual therapy is not as hl'lpful 3!">
group sessions because group members offer peer support and confrontation when needed. Solitary acti,'itll":>
and recreation lead to increased avoidance of the 15$U('<;
that must be faced and dealt with by the client. Tht.~.
are often areas that the client must learn to dewlop and
manage while in recovery. (I, 9, X)
140. 4. Foul-smelling urine is indicative of cystitis. Otlw~
symptoms include dysuria, frequency, and urg'.:;."
Flank pain, nausea, and vomiting indicate pydl"
nephritis. (A, 10, M)
141. 4. By saying, "You couldn't have prevented the tornado, it just happened," the nurse helps the client to
develop an objective perspective and promotes a ~!1('r
understanding of the event. The other statements tl'lI
the client how to feel, possibly causing resistance and
thus delay therapeutic healing. Guilt and self-blamt'
will not be decreased. (I, 6, X)
142. 3. In many Asian cultures, the 30 days after the birth of
.the 'neonate is a time for the mother to heal from the
delivery. The appropriate action by the nurse is to
determine whether this is a cultural practice for this
client and her family. If so, then the client is beha\'ing
within her cultural practices. Teaching should be provided to both the mother and her mother-in-law. There
is no indication that bonding is not taking place. Lack
of bonding might be indicated if the client did not
show any interest in the neonate. Documenting the
client's maternal behavior in her chart is a routine task.
However, the nurse should not assume that this behav'
ior is unusual, because it may be reflective of the
client's cultural framework.. A home visit is not warranted unless there is evidence of infant neglect or the
family needs additional follow-up or teaching. (I, 3, 0)
143. 1. A creatinine clearance test is a 24-hour urine test that
measures the degree of protein breakdown in the body.
I The
collection is not maintained in a sterile container.
There is no need to insert a Foley catheter as long as the
I
clientis a:"leto control urination. It is not necessaryto
I force fluids. (A, 7, M)
t.".4. The statement, "Your eyes look dark," is the least
sensitive statement because it points out an obvious
difference for no real purpose. The nurse has a reason
to ask the client about favorite foods and needs to
know about past health problems. Also, it is appropriate for the nurse to ask the client how she wishes to be
addressed. (0, 6, M)
S. 2. Insight into the illness is demonstrated when the
client recognizes the relationship between the chemical
imbalance and his illness and symptoms. Stating that
the olanzapine is the best medicine or that the client's
mother is proud of him for staying on his medicines
reflects awareness about the effect of medications and
the need for compliance. Stating that he may be able to
get a part-time job indicates an awareness of his
increased capacity for work. (E, 6, X)
16.3. Carpallunnel syndrome is a condition in which the
median nerve becomes compressed in the wrist. The
brachial nerve is not affected. Carpal tunnel syndrome
may be the result of a systemic Jisease such as rheumatoid arthritis or diabetes mellitus, or it may be an occupational hazard for people whose jobs require repetitive hand movements. It is not a condition resulting
~
~
from disuse. The wrists do not develop flexioncontractures with carpal tunnel syndrome. (I, 9, M)
V. 1. Se:enty-five percent of all food allergies are caused
~' by mIlk, eggs, or peanuts. (A, 9, M)
j8. 3. Clients who have undergone a TURP need to be
instructed to maintain an adequate fluid intake despite
urinary dribbling or incontinence. The client should be
advised to drink at least 8 glasses of water a day to
dilute the urine and help prevent urinary tract infections. Maintaining a voiding schedule of every 2 hours
! can help decrease incidents of incontinence. Teaching
I the client Kegel exercises is also beneficial for strength-
i
~
~"
ening sphincter tone. The nurse should not encourage
the client to -decreasefluids. It is not necessarily true
that a decreased intake will cause renal calculi. Threatening the client with a catheter is not beneficial, and it
is not the treatment of choice for a client who is experiencing incontinence from a TURF. (I, 10, M)
-19.1. Risk for Infection would be a priority nursing diagnosis after surgery. With any type of incision, the
immediate concern is preventing infection at the site.
Pain is also a diagnosis of concern and would be next
in order of priority. The infant would be partially
restrained to prevent disturbance of the IV infusion
and nasogastric tube. Bowel elimination should begin
in a few days. (0, 10, Y)
150. 4. Risk factors for TSS include the use of tampons at
night, when the tampon would be in p~ace for 7 to 9
hours. TSS can occur in other situations, but it is most
often associated with women during menses, particularly women who use tampons. The longer the tampon
is left in place, the greater ~:1erisk for TSS. Changing
tampons every 3 hours or more frequently, avoiding
use of deodorized tampons, and alternating tampons
with sanitary pads are actions that decrease the risk for
TSS. (I, 4, M)
151. 4. Costovertebral tenderness occurs on the side of the
affected kidney in pyelonephritis. Dysuria, suprapubic
pain, and urinary retention TYlayoccur in pyelonephritis
but do not specifically support a diagnosis of pyelonephritis. Dysuria, suprapubic pain, and urinary retention are symptoms of cystitis, which can lead to
pyelonephritis if not treated. (A, 10, M)
152. 2. Broad-spectrum antibiotics can cause decreased efficacy of contraceptives, placing the client at risk for an
unplanned pregnancy. When a client is prescribed a
course of antibiotics, a back-up method of contraceptive should be used. Antihypertensives, diuretics, and
antihistamines do not interfere with oral contraceptive
efficacy. (I, 8, M)
153. 1. Side effects of danazol (Danocrine) include
headaches, dizziness, irritability, and decreased libido.
Masculinization effects such as deepened voice, facial
hair, and weight. gqin may occur. (I, 8, 0)
154. 2. The nurse should assign the male client of Mexican
American descent who needs complete morning care to
Joe. Modesty is a high priority for this client. The nurse
must also consider case load, and Joe has the lightest
assignment. (I, 5, M)
155. 4. CNS changes include such symptoms as apathy,
lethargy, and decreased concentration. Seizures and
coma can also occur. The nurse should assess the
cli~nt's level of consciousness at regular intervals and
maintain client safety. Allowing the client to express
feelings related to body image changes and restricting
foods high in potassium and fluid intake are all appropriate activities, but they are not related to the CNS
changes. (I, 10, M)
156. 3. Elderly individuals have less subcutaneous tissue.
An elderly, emaciated client will require a short needle
and a shallow angle to avoid hitting an underlying
bone. The nurse should choose the shortest subcutaneous needle available, at the least angle. (P, 8, M)
157. 3. This situation describes the classic symptoms of urinary tract infection. Urinalysis and culture c:mdsensitivity studies would be helpful information for this
diagnosis. Pelvic inflammatory disease is manifested
by severe suprapubic pain and vaginal discharge.
Renal calculi are accompanied by severe, colicky flank
"~'!o':II"
pain and hematuria. Renal failure is manifested by
hypertension, pruritus, anorexia, nausea, and vomiting. (P, 10, M)
158. 1. Scant dark vaginal bleeding, abdominal pain, and
frequent low-amplitude uterine activity are associated
with abruptioplacenta.The clientneeds a cesareandelivery to prevent hypovolemic shock. Placentaaccretais an
unusually deep attachment of the placenta to the
myometrium and usually is not discovered until delivery. Hysterectomy is usually the treatment. Placentaprevia refers to an abnormal implantation of the placenta.
Typically, painless, bright red vaginal bleeding is seen.
Battlr:doreplacentaoccurs when the cord is inserted marginally rather than centrally, and it is of no clinical significance. (0, 9, 0)
159. 3. Flagyl can cause an Antabuse-like reaction if it is
taken with alcohol. Tachycardia, nausea, vomiting, and
other serious interaction effects can occur. Flagyl will
make the urine a darker color. Oral contraceptives
should never be discontinued with trichomoniasis. The
partner also requires treatment to prevent retransmission of infection. (I, 8, M)
,
160. 1. In the advanced stages of osteoarthritis, pain can
OCLJrwith minimal activity or even when the client is
at rest. Crepitation can be present at any stage of the
disease and does not exacerbate pain. Joints are not
symmetrically affected by the disease. Symmetric joint
involvement and fatigue are characteristics of rheumatoid arthritis. (A, 10, M)
161. 3. The traditional belief of Vietnamese Americans is
that the family can provide more comfort for their
loved one at home. It is not seen as being disloyal if
their loved one dies in the hospital.'The request is not
based on a feeling that the hospital cannot be trusted.
The Vietnamese Americans accept death as a part of life
and do not think that reincarnation is prevented in the
hospital.(1,5,M)
.
162. 2. It is important for the daughter to know that there
is an underlying cause for what her mother is experiencing and that it is treatable. Telling her not to worry
is a useless cliche and does nothing to inform the
daughter. Talking about care after discharge implies
that the delirium is irreversible. Delirium is a
reversible condition. Although not arguing with hallucinations is valid, this response ignores the daughter's concern. (I, 6, X)
163. 2. The client with dementia should not have access to
toiletries that could be swallowed (eg, aftershave)
unless closely supervised. Putting special locks on all
the doors is appropriate to prevent wandering, thus
maintaining the r:lient's safety. Placing the client in a
room that has nothing to trip over is appropriate to
reduce the client's risk for falling. Taking the knobs off
~~1
-
of
the stove is appropriate to prevent POSSible.
~~~
.
..
164. 3. It i:, important that the client force fluids to
;... ~;
mLI day to avoid the development of renal ~
I
when taking allopurinol. Allopurinol must becaJadi
consistently
~
to be effective in the treatment of gOUt.
dru? sho~ld be taken after mea~s to avoid 8astrointestmal dIstress. Although the clIent can take aspirin
when taking allopurinol, both drugs can cause
trointestinal irritation and the practice is not rec::
mended if the client is sensitive to the medications. <Eo
8,M)
165. 2. A white, cottage cheese-like discharge accompanied
by severe itching is characteristicof Candidainfection
Trichomonas has a yellow-green discharge. Bacteria!
vaginosis often has a positive, fishy odor. A purulent
discharge should be investigated, cultured, and treated
immediately. (A, 4, M)
166. 3. The best advice for the nurse to give the child'~
mother is to run cool water over the burned area to stop
the burning process. Then the area should be wrapped
in a clean cloth. Once these initial actions are com.
pleted, the mother can call the child's doctor. Packing
the arm in ice may cause "')ore damage to the burned
area, because cold can cause burns just as heat can. For
most burns, it is not advised to apply any ointm\.'n~
until the area has been evaluated. (I, 9, Y)
167. 4. The priority nursing diagnosis for this client is R,sk
for Injury. The goal in this situation is to prevent falling.
Impaired Physical Mobility contributes to the risk for
injury and is an applicable diagnosis but does not
address the client's safety needs, which are the priority.
Impaired Skin Integrity and Ineffective Coping are not
applicable diagnoses at this time. (0, 9, M)
168. 3. Chills and headache are signs of a febrile, nonhemolytic blood transfusion reaction and the nurse's
. first action should be to discontinue the transfusion as
soon as possible and then notify the physician.
Antipyretics and antihistamines may be ordered. The
nurse would not administer acetaminophen without an
order from the physician. The client's blood pressure
should be taken after the transfusion is stopped.
Checking the infusion rate of the blood is not a pertinent action; the infusion needs to be stopped regardless
of the rate. (0, 8, M)
169. 3. Resolving grief and having increased energy and
activity convey good mental health, indicating that
counseling is not necessary at this time. Taking an antidepressant or having less energy and involvement with
grandchildren reflects possible depression and the
need for counseling. Wanting to be with her dead husband suggests possible suicide ideation that warrants
serious further assessment and counseling. (A, 5, X)
~
~
i
::
;
.0
. .~ 3. Common!side effectsof isosorbideare lightheaded...
nesS,dizziness, and orthostatic hypotension. Clients
should be instructed to change positions slowly to preveQt these side effects and to avoid fainting. Ankle
swelling is not related to the isosorbide. The client's
t,~ pulse does not need to be taken before taking the med-
i
I,
ication. The medication does not need to be taken with
food. (E, 8, M)
.171.3. ValproiC'acid (Depakote) and propranolol (Inderal)
are often prescribed to help manage explosive anger.
Recognizing the need for medications indicates readiness for discharge. Not ever getting angry is difficult,
impractical, and unrealistic without specific anger
management strategies. Drinking does not address
anger control and suggests a risk for continued drinking. Blaming others, such as the client's mother, does
not address anger control and indicates a lack of
responsibility for the client's own behavior. (E, 6, X)
172.3. The nurse should first help the client into a position
of comfort even though the primary purpose for entering the room was to administer medication. After
attending to the client's basic care needs, the nurse can
proceed with the proper identification of the client,
such as asking the client his name and checking his
armband, so that the medication can be administered.
(1,7, M)
173.4. During the first 24 hours after an abdominal hysterectomy, the client is at risk for development of
thrombophlebitis because of potential interference with
pelvic and leg circulation. Leg exercises are essential to
promote circulation and prevent a thrombus. Bowel
sounds may not be heard immediately after surgery. It
may take up to 48 hours for peristalsis to return. Perineal pads are used after a vaginal hysterectomy, not an
abdominal hysterectomy. In the early phases of recovery, the client will be more likely to focus on expressing
feelings of discomfort rather than a positive body
image. (E, 10, M)
174.2. The client is asymptomatic but has had a change in
heart rhythm. More information is needed before calling
Lhephysician. Because the client is taking furosemide
(Lasix), a potassium-wasting diuretic, the next action
would be to check the client's potassium level. The nurse
would then call the physician with a more complete
database. The physician will need to be notified after the
nurse checks the latest potassium level. Calling the
nurse manager is not indicated at this time. Administering potassium requires a physician's order. (P, 10,M)
J75. 2: Depression is the most common affective disorder
during the postpartum period, affecting 10% to 15% of
all Women. It is characterized by mood swings, uncontrollable crying, anorexia, and feelings of sadness. It is
diagnosed when the transient "blues" persists beyond
2 weeks postpartum. Postpartum blues generally lasts
only a few days and then resolves. Postpartum psychosis exists when tr-~ client loses touch with reality
and requires hospitalization. Commonly, postpartum
adjustment is resolved within a few days after delivery.
(0, 6, 0)
.
176. 4. Just as with the child, it is best to answer relatives
honestly when they ask questions about their loved
one's condition. The nurse answers the questions honestly when explaining that infections are often a result
of leukemia rather than a cause of it. It is less satisfactory to tell the parents that everything possible has
been done for their child, that the child is no longer suffering from the illness, or that nothing could have
helped their child. (I, 10, Y)
177. 2. After a TURp, a client can be prone to bladder
spasms. Because of the spasms and the decreased urinary output, it is important for the nurse to evaluate
the client to determine whether the bladder spasms
have been caused by blood clots that are obstructing
the flow of urine from the catheter. The client will be
acutely uncomfortable until the situation is resolved.
The febrile client will need to be assessed for the possible source of the fever, but this assessment can be
delayed until the client with bladder sp?sms has
received care. The client with the ileal conduit needs to
have the pouch emptied of urine; this activity can be
delegated to the assistant. A small amount of hemoptysis after a bronchoscopy with biopsy is to be expected
and does not require immediate follow-up. (0, 1, M)
178. 1. Microdrip administration sets have a drop factor of
60 gtt/mL. Therefore, 60 gtt/mL X 500 mL / 600 minutes = 50 gtt/minute. (1,8, M)
179. 1. The client must wait 14 days between stopping
phenelzine (Nardil) and starting fluoxetine (Prozac)
because of the risk for serotonin syndrome, a potentially lethal condition manifested by hyperreflexia
hyperthermia, myoclonus, and other symptoms sug..
gesting neuroleptic malignant syndrome. The client
does not need to have blood levels drawn every week
while taking fluoxetine. Weekly blood draws are
needed especially when lithium or clozapine therapy
is initiated. Notifying the physician before. taking any
over-the-counter medication is not usually necessary
unless other conditions warrant it. Headache and nausea are common side effects of fluoxetine and do not
require immediate physician notification. However,
severe headaches or nausea should be reported. (I, 8,
X)
180. 3. Taking a deep abdominal breath and then "huff"
coughing is the most effective manner of coughing.
This technique helps facilitate removal of secretions
and conserves energy for the client. The client sh01 17
breathe slowly but not hold her breath. Short panting
breaths and then cCl1ghing fr0m the throat does not
promote expectoration of sputum from the lungs.
Coughing forcefully can cause alveoli to collapse;
"huff" cOl1ghingprevents this. (E, 9, M)
181. 3. The first objecti'le is for the nurse to get the client's
!
attention. This can be done by looking the client in
the eyes and speaking in a calm voice. Once the nurse
has her attention, the nurse can instruct the client in
breathing techniq'.1es. M~dified pace breathii'tg;"
used during the contractions. The nurse Inay
assist the client to breathe with each conh'action;
the client to calm ~own o~ to ~re~t~.ewi~heach~
tion is not helpful If the clIent Isn t listerung to the n- .
TIle nurse needs to get the client's attention fust,"AJ
gesia is not warranted at this phase of labor becaus'e'
neonate may experience respiratory depression if dca...
ery occurs within. 1 to 2 hours. (I, 5, 0)
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