66. Following spinal injury, the nurse should encourage the client to drink fluids to avoid: A. Urinary tract infection.B. Fluid and electrolyte imbalance.C. Dehydration.D. Skin breakdown.

67. The client is transferred from the operating room to recovery room after an open-heart surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the physician when the temperature of the client rises to 38.8 ºC or 102 ºF because elevated temperatures: A) May be a forerunner of hemorrhage.B) Are related to diaphoresis and possible chilling.C) May indicate cerebral edema.D) Increase the cardiac output.

68. After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder. Which of the following sign of bladder irritability is correct? A) HematuriaB) DysuriaC) PolyuriaD) Dribbling

69. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience? A) Visual hallucinations.B) Receptive aphasia.C) Hemiparesis.D) Personality changes.

70. A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that decreased blood pressure of the client with Addison’s disease involves a disturbance in the production of: A) AndrogensB) GlucocorticoidsC) MineralocorticoidsD) Estrogen

71. The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that: A) Inspired air will move from the lung into the pleural space.B) There is greater negative pressure within the chest cavity.C) The heart and great vessels shift to the affected side.D) The other lung will collapse if not treated immediately.

72. During an assessment, the nurse recognizes that the client has an increased risk for developing cancer of the tongue. Which of the following health history will be a concern? A) Heavy consumption of alcohol.B) Frequent gum chewing.C) Nail biting.D) Poor dental habits.

73. The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than cancellous bone. Which of the following is the correct response of the nurse? A) Compact bone is stronger than cancellous bone because of its greater size.B) Compact bone is stronger than cancellous bone because of its greater weight.C) Compact bone is stronger than cancellous bone because of its greater volume.D) Compact bone is stronger than cancellous bone because of its greater density.

74. The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count, the nurse understands that the higher the red blood cell count, the : A) Greater the blood viscosity.B) Higher the blood pH.C) Less it contributes to immunity.D) Lower the hematocrit.

75. The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane will be needed. The nurse explains to the client that cane is advised specifically to: A) Aid in controlling involuntary muscle movements.B) Relieve pressure on weight-bearing joints.C) Maintain balance and improve stability.D) Prevent further injury to weakened muscles.

76. The nurse is conducting a discharge teaching regarding the prevention of further problems to a client who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction will the nurse includes? 

A) Learn to type using your left hand only.B) Avoid typing in a long period of time.C) Avoid carrying heavy things using the right hand.D) Do manual stretching exercise during breaks.

77. A female client is admitted because of recurrent urinary tract infections. The client asks the nurse why she is prone to this disease. The nurse states that the client is most susceptible because of: A) Continuity of the mucous membrane.B) Inadequate fluid intake.C) The length of the urethra.D) Poor hygienic practices.

78. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for one of these presenting adaptations is: A) Catecholamines released at the site of the infarction causes intermittent localized pain.B) Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.C) Constriction of central and peripheral blood vessels causes a decrease in blood pressure.D) Inflammation in the myocardium causes a rise in the systemic body temperature. 

79. Following an amputation of a lower limb to a male client, the nurse provides an instruction on how to prevent a hip flexion contracture. The nurse should instruct the client to:. A) Perform quadriceps muscle setting exercises twice a day.B) Sit in a chair for 30 minutes three times a day.C) Lie on the abdomen 30 minutes every four hours.D) Turn from side to side every 2 hours.

80. The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone into the knee joint. The client asks the nurse why there is a need for this injection. The nurse explains that the most important reason for doing this is to: A) Lubricate the joint.B) Prevent ankylosis of the joint.C) Reduce inflammation.D) Provide physiotherapy.

81. The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour ago. The nurse should: A) Advise the client to refrain from vigorous brushing of teeth and hair.B) Instruct the client to avoid driving for 2 weeks.C) Encourage eye exercises to strengthen the ocular musculature.D) Teach the client coughing and deep-breathing techniques.

82. A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The client’s arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood gases are drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should; A) Have arterial blood gases performed again to check for accuracy.B) Increase the oxygen flow rate.C) Notify the physician.D) Decrease the tension of oxygen in the plasma.

83. An 18-year-old college student is brought to the emergency department due to serious motor vehicle accident. Right above-knee-amputation is done. Upon awakening from surgery the client tells the nurse, “What happened to me? I cannot remember anything?” Which of the following would be the appropriate initial nursing response? A) “You sound concerned; You’ll probably remember more as you wake up.”B) “Tell me what you think happened.”C) “You were in a car accident this morning.”D) “An amputation of your right leg was necessary because of an accident.”

84. A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is something wrong with the medication and nursing care. The nurse recognizes this behavior is probably a manifestation of the client’s: A) Reaction to hypertensive medications.B) Denial of illness.C) Response to cerebral anoxia.D) Fear of the health problem.

85. Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for discharge instruction about resuming activities. The nurse should plan to help the client understands that: A) After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation.B) Most sports activities, except for swimming, can be resumed based on the client’s overall physical condition.C) With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.D) Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.

86. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of the following statement would alert the nurse that further teaching to the client is necessary? A) “I will be limiting my intake to 600 to 800 calories a day once I start eating again.”B) “I’m going to have a figure like a model in about a year.”C) “I need to eat more high-protein foods.”D) “I will be going to be out of bed and sitting in a chair the first day after surgery.”.

87. The client who had transverse colostomy asks the nurse about the possible effect of the surgery on future sexual relationship. What would be the best nursing response? A) The surgery will temporarily decrease the client’s sexual impulses.B) Sexual relationships must be curtailed for several weeks.C) The partner should be told about the surgery before any sexual activity.D) The client will be able to resume normal sexual relationships.

88. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he had of getting also osteoporosis like his wife. Which of the following is the correct response of the nurse? A) “This is only a problem for women.”B) “You are not at risk because of your small frame.”C) “You might think about having a bone density test,”D) “Exercise is a good way to prevent this problem.”

89. An older adult client with acute pain is admitted in the hospital. The nurse understands that in managing acute pain of the client during the first 24 hours, the nurse should ensure that: A) Ordered PRN analgesics are administered on a scheduled basis.B) Patient controlled analgesia is avoided in this population.C) Pain medication is ordered via the intramuscular route.D) An order for meperidine (Demerol) is secured for pain relief. 

90. A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this client, the nurse should expect that hearing loss of the client that is caused by aging to have: A) Overgrowth of the epithelial auditory lining.B) Copious, moist cerumen.C) Difficulty hearing women’s voices.D) Tears in the tympanic membrane.

91. The nurse is reviewing the client’s chart about the ordered medication. The nurse must observe for signs of hyperkalemia when administering: A) Furosemide (Lasix)B) Hydrochlorothiazide (HydroDIURIL)C) Metolazone (Zaroxolyn)D) Spironolactone (Aldactone)

92. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the administration of the medication the nurse should monitor the client for: A) PalpitationB) Visual disturbanceC) Decreased pulse rateD) Lethargy

93. A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at reducing the side effects of this medication? A) Take the drug with an antacid.B) Lie down after meals.C) Avoid dairy products in diet.D) Change positions slowly.

94. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in: A) The triglyceridesB) The INRC) Chest painD) Blood pressure

95. A client is taking nitroglycerine tablets, the nurse should teach the client the importance of: A) Increasing the number of tablets if dizziness or hypertension occurs.B) Limiting the number of tablets to 4 per day.C) Making certain the medication is stored in a dark container.D) Discontinuing the medication if a headache develops.

96. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male client

with arthritis. The nurse provides information about toxicity of the hydroxychloroquine. The nurse can determine if the information is clearly understood if the client states: A) “I will contact the physician immediately if I develop blurred vision.”B) “I will contact the physician immediately if I develop urinary retention.”C) “I will contact the physician immediately if I develop swallowing difficulty.”D) “I will contact the physician immediately if I develop feelings of irritability.”

97. The client with an acute myocardial infarction is hospitalized for almost one week. The client experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms may indicate the: A) Adverse effects of spironolactone (Aldactone)B) Adverse effects of digoxin (Lanoxin)C) Therapeutic effects of propranolol (Indiral)D) Therapeutic effects of furosemide (Lasix)

98. A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding adverse effects of Coumadin. The nurse should tell the client to consult with the physician if: A) Swelling of the ankles increases.B) Blood appears in the urine.C) Increased transient Ischemic attacks occur.D) The ability to concentrate diminishes.

99. Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse should know that: A) Levodopa is inadequately absorbed if given with meals.B) Levodopa may cause the side effects of orthostatic hypotension.C) Levodopa must be monitored by weekly laboratory tests.D) Levodopa causes an initial euphoria followed by depression.

100. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in: A) Muscle strengthB) SymptomsC) Blood pressureD) Consciousness

81. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of trigeminal neuralgia by monitoring the client’s: A) Seizure activityB) Liver functionC) Cardiac outputD) Pain relief

82. Administration of potassium iodide solution is ordered to the client who will undergo a subtotal thyroidectomy. The nurse understands that this medication is given to: A) Ablate the cells of the thyroid gland that produce T4.B) Decrease the total basal metabolic rate.C) Decrease the size and vascularity of the thyroid.D) Maintain function of the parathyroid gland.

83. A client with Addison’s disease is scheduled for discharge. Before the discharge, the physician prescribes hydrocortisone and fludrocortisone. The nurse expects the hydrocortisone to: A) Increase amounts of angiotensin II to raise the client’s blood pressure.B) Control excessive loss of potassium salts.C) Prevent hypoglycemia and permit the client to respond to stress.D) Decrease cardiac dysrhythmias and dyspnea.

84. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug is effective, the nurse should monitor the client’s: A) Arterial blood pHB) Pulse rateC) Serum glucoseD) Intake and output

85. A client with recurrent urinary tract infections is to be discharged. The client will be taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to the client. Which of the following instructions will be correct? A) Strain urine for crystals and stonesB) Increase fluid intake.C) Stop the drug if the urinary output increasesD) Maintain the exact time schedule for drug taking.

86. A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the: A) Bone marrowB) LiverC) Lymph nodesD) Blood

87. The physician reduced the client’s Dexamethasone (Decadron) dosage gradually and to continue a lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to allow: A) Return of cortisone production by the adrenal glands.B) Production of antibodies by the immune systemC) Building of glycogen and protein stores in liver and muscleD) Time to observe for return of increases intracranial pressure

88. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The nurse is aware that fluid deficit can most accurately be assessed by: A) The presence of dry skinB) A change in body weightC) An altered general appearanceD) A decrease in blood pressure

89. Which of the following is the most important electrolyte of intracellular fluid? A) PotassiumB) SodiumC) ChlorideD) Calcium

90. Which of the following client has a high risk for developing hyperkalemia? A) Crohn’s diseaseB) End-Stage renal diseaseC) Cushing’s syndromeD) Chronic heart failure

91. The nurse is reviewing the laboratory result of the client. The client’s serum potassium level is 5.8 mEq/L. Which of the following is the initial nursing action? A) Call the cardiac arrest team to alert themB) Call the laboratory and repeat the testC) Take the client’s vital signs and notify the physicianD) Obtain an ECG strip and have lidocaine available

92. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic ketoacidosis. The primary reason for administering this drug is: A) Replacement of excessive lossesB) Treatment of hyperpneaC) Prevention of flaccid paralysisD) Treatment of cardiac dysrhythmias

93. A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On assessment, client is experiencing anorexia and weight is reduced. The physician’s diagnosis is colitis. Which of the following symptoms of fluid and electrolyte imbalance should the nurse report immediately? A) Skin rash, diarrhea, and diplopiaB) Development of tetaniy with muscles spasmsC) Extreme muscle weakness and tachycardiaD) Nausea, vomiting, and leg and stomach cramps.

94. The client is to receive an IV piggyback medication. When preparing the medication the nurse should be aware that it is very important to: A) Use strict sterile techniqueB) Use exactly 100mL of fluid to mix the medicationC) Change the needle just before adding the medicationD) Rotate the bag after adding the medication

95. The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the client’s pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are consistent with: A) Metabolic acidosisB) Metabolic alkalosisC) Respiratory acidosisD) Respiratory alkalosis

1. A. Clients in the early stage of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output.

2. D. The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac workload.

3. B. Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.

4. A. The occipital lobe is involve with visual interpretation.

5. C. Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes hypotension.

6. B. As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.

7. A. Heavy alcohol ingestion predisposes an individual to the development of oral cancer.

8. D. The greater the density of compact bone makes it stronger than the cancellous bone. Compact bone forms from cancellous bone by the addition of concentric rings of bones substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to haversian canals.

9. A. Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of red cells suspended in plasma.

10. C. Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability.

11. D. Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity.

12. C. The length of the urethra is shorter in females than in males; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in females also increases this incidence.

13. D. Temperature may increase within the first 24 hours and persist as long as a week.

14. C. The hips are in extension when the client is prone; this keeps the hips from flexing.

15. C. Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.

16. A. Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber.

17. C. This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.

18. C. This is truthful and provides basic information that may prompt recollection of what happened; it is a starting point.

19. D. Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear.

20. C. There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.

21. B. Clients need to be prepared emotionally for the body image changes that occur after bariatric surgery. Clients

generally experience excessive abdominal skin folds after weight stabilizes, which may require a panniculectomy. Body image disturbance often occurs in response to incorrectly estimating one’s size; it is not uncommon for the client to still feel fat no matter how much weight is lost.

22. D. Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.

23. C. Osteoporosis is not restricted to women; it is a potential major health problem of all older adults; estimates indicate that half of all women have at least one osteoporitic fracture and the risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses the mass of bone per unit volume or how tightly the bone is packed.

24. A. Around-the-clock administration of analgesics is recommended for acute pain in the older adult population; this help to maintain a therapeutic blood level of pain medication.

25. C. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds.

26. D. Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.

27. A. Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia and palpitation.

28. D. Changing positions slowly will help prevent the side effect of orthostatic hypotension.

29. A. Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and cholesterol.

30. C. Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight container.

31. A. Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.

32. B. Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.

33. B. Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it may indicate toxic levels of the drug.

34. B. Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.

35. A. Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.

36. D. Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia.

37. C. Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases the risk for hemorrhage.

38. C. Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it enables the body to adapt to stress.

39. D. DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of normal urine output and thirst.

40. B. To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug.

41. A. Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus suppressing the activity of the immune system. Antibiotics may be required to help counter infections that the body can no longer handle easily.

42. A. Any hormone normally produced by the body must be withdrawn slowly to allow the appropriate organ to adjust and resume production.

43. B. Dehydration is most readily and accurately measured by serial assessment of body weight; 1 L of fluid weighs 2.2 pounds.

44. A. The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a

critical factor in the cell’s ability to function.

45. B. The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate dialysis.

46. C. Vital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac dysrhythmias.

47. A. Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally supplied.

48. C. Potassium, the major intracellular cation, functions with sodium and calcium to regulate neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In hypokalemia these symptoms develop.

49. A. Because IV solutions enter the body’s internal environment, all solutions and medications utilizing this route must be sterile to prevent the introduction of microbes.

50. A. A low pH and bicarbonate level are consistent with metabolic acidosis.

Nursing practice IV part A

61. The nurse is administering I.V fluids to an infant. Infants receiving I.V therapy are particularly vulnerable to:a. hypotensionb. fluid overloadc. cardiac arrhythmiasd. pulmonary emboli.

62. a client is in the late stage of cirrhosis. When planning the client’s diet, the nurse should focus on providing increased amount of: a. fat

b. fiberc. proteind. carbohydrate

63. a 2 year old child is brought to the emergency department with a history of upper airway infecton that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor and:a. a barking coughb. a high feverc. sudden onsetd. dysphagia

64. a client with delusional thinking shows a lack of interest in eating at meal times. She states that she is unworthy of eating and that her children will die if she eats. Which nursing action would be most appropriate for this client?a. telling the client that she may become sick and die unless she eatsb. paying special attention to the client’s rituals and emotions associated with mealsc. restricting the client’s access to food except at specified meal and snack timesd. encouraging the client to express her feelings at meal times.

65. a client admitted with a cerebral contusion is confused, disoriented and restless. Which nursing diagnosis takes highest priority?a. sensory-perceptual alterations(visual) related to neurologic traumab. feeding self-care deficit related to neurologic traumac. impaired verbal communication related to confusiond. risk for injury related to neurologic deficit

66. a client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:a. weight gainb. fine motor tremorsc. respiratory acidosisd. bilateral hearing loss

67. a client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; PaO2 60 mmHg; PaCO2 30 mmHg; bicarbonate 25 mEq/L. what should the nurse do first?a. instruct the client to breath into a paper bag.b. administer O2 by nasal cannula as prescribed.c. auscultate breath sounds bilaterally every 4 hours.D. encourage the client to deep breath and cough every 2 hours

68. Which of the following is one of the advantages of the newer antipsychotic medication risperidone (Risperdal)?a. the absence of anticholinergic effectsb. a lower incidence of extrapyramidal effectsc. photosensitivity and sedationd. no incidence of neuroleptic malignant syndrome

69. after an extensive diagnostic workup, a client is diagnosed with systemic lupus erythematosus (SLE). Which statement about the incidence of SLE is true?A. SLE is most common in women between ages 45 and 60b. SLE affects more whites than blacksc. SLE tends to occur in familiesd. SLE is more common in underweight that overweight persons.

70. an infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note:a. symmetrical thigh and gluteal folds.b. Ortolani’s signc. increased hip abductiond. femoral lengthening

71. which medications have been found to help reduce or eliminate panic attacks?a. antidepressantsb. anticholinergicsc. antipsychoticsd. mood stabilizer

72. a client is brought to the facility in an agitated state and is admitted to the psychiatric unit for observation and treatment. While putting personal items away, the client talks rapidly and folds and unfolds garments several times. The client can’t seem to settle down. Which nursing diagnosis is most applicable at this time?a. self-care deficitb. anxietyc. impaired verbal communicationd. powerlessness

73. the nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the:a. stomachb. small intestinec. large intestined. rectum

74. for a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reaction?a. increase weight, hypertension and insomniab. vaginal bleeding, jaundice and inflammationc. stupor, breast lumps and paind. dyspnea, numbness and headache

75. a client with suspected renal dysfunction is scheduled for excretory urography. The nurse reviews the history for conditions that may warrant changes in client preparation. Normally, a client should be

mildly hypovolemic (fluid depleted) before excretory urography. Which history finding would call for the client to be well hydrated instead?a. cystic fibrosisb. multiple myelomac. goutd. myasthenia gravis

76. a client admitted to an acute care facility with heart failure is found to have a cystocele. When planning care for this client, the nurse is most likely to formulate which nursing diagnosis?a. total incontinenceb. functional incontinencec. reflex incontinenced. stress incontinence

77. the nurse understands that for the parathyroid hormone to exert its effect, what must be present?a. decreased phosphate levelb. adequate vitamin D levelc. functioning thyroid glandd. increased calcium level

78. the nurse records a client’s history and discovers several risk factors for coronary artery disease. Which cardiac risk factors are considered controllable?a. diabetes, hypercholesterolemia and heredityb. diabetes, age and genderc. age, gender and heredityd. diabetes, hypercholesterolemia and hypertension

79. which of the following agents cant’ be administered by way of intraosseous infusion?a. sodium bicarbonateb. dopamine (intropin)c. calcium chlorided. isoproterenol (Isuprel)

80. a client in the manic phase of bipolar disorder arrives at the outpatient psychiatric clinic. To help the client manage a manic episode, the nurse should suggest that she:a. a go shopping with a friendb. read a book in a quiet roomc. reorganize a kitchen cabinetd. play a game with a few friends