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8/9/2019 Critical Nursing Care Exam

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Critical Thinking Nursing CareCompiled by Zudota

Identify the letter of the choice that best completes the statement or answersthe question.

____ 1. Which action by the nurse demonstrates understanding of a bestpractice intervention for client education?a. Breaking comple skills into small partsb. !sing only visual and oral educational aidsc. "roviding standardi#ed educational informationd. !sing client goals developed by the nursing sta$

1. ANS: ABest practices for adult learning include the following% breaking comple skills

and information into small parts& assessing willingness to learn' includingfamily(signi)cant others in the education as appropriate& assessing factorsthat may in*uence learning' such as educational level& using psychomotorskills in addition to visual aids to enhance learning& and providing the clientwith a contact for follow+up questions.

____ ,. -ow have recent changes in health care delivery a$ected practicesettings for medical+surgical nurses?a. hird+party payment systems have restricted the delivery of medical+surgical nursing services to acute care hospitals.b. /anaged care organi#ations prefer less epensive care delivered byunlicensed personnel.c. /edical+surgical nursing is practiced in community centers and long+termcare facilities.d. he delivery of medical+surgical nursing practice is now limited to adultsonly.

2. ANS: C/edical+surgical nursing is practiced in a wide variety of settings. 0lthoughhospitals remain the largest employer of nurses' community+based integratedhealth care centers and long+term care facilities also require nurses withmedical+surgical nursing eperience.

____ . Which of the following nursing home facilities o$ers the residents arange of services from independent living to skilled nursing care?a. 2killed nursing facilitiesb. 3hronic care facilitiesc. 4esidential facilitiesd. 5ursing facilities

3. ANS: C


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4esidential facilities' which include rest homes and assisted living orcontinuing care facilities' can provide a continuum of services ranging fromindependent living to skilled care. 5ursing facilities provide custodial care&skilled nursing facilities and chronic care facilities provide services requiringlicensed health care professionals.

____ 6. Which client is likely to require transitional subacute care before beingdischarged home?a. he client with stable human immunode)ciency virus infectionb. he client with a progressive neurologic diseasec. he client requiring deep wound managementd. he client who is ventilator dependent

. Ans. C 0lthough clients requiring subacute care can encompass all theseconditions' transitional care is considered an alternative to prolonged hospitalstay before discharge home or a long term care facility. ransitional subacutecare is provided to continued management before discharge' he stableclient with -I7 infection would receive medical(surgical subacute care

whereas the client who is ventilator dependent or who has a progressiveneurologic disorder would require chronic subacute are.

____ 8. 0 nurse is caring for an older client who has 9ust been admitted to thehospital. !pon admission the client becomes increasingly confused' agitated'and combative. What action should the nurse take to minimi#e relocationstress syndrome in this client?a. 4eorient the client frequently to his or her location.b. :btain a certi)ed sitter to remain with the client.c. 2peak to the client as little as possible to avoid overstimulation.d. "rovide adequate sedation for all procedures to avoid fear+provokingsituations.

!. ANS: A here are many nursing interventions that can be helpful to older adults whoeperience relocation stress syndrome. If the client becomes confused'agitated' or combative' the nurse should reorient the client to his or hersurroundings. he nurse also can encourage family members to visit often'keep familiar ob9ects at the client;s bedside' and work to establish a trustingrelationship with the client.

____


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:lder adults can eperience a number of losses that a$ect their sense of control over their lives' including a decrease in physical mobility. he nurseshould support the client;s self+esteem and increase feelings of competencyby encouraging activities that assist in maintaining some degree of control'such as participation in decision making and performing tasks they canmanage.

____ . Which behavior ehibited by an older adult client should alert thenurse to the possibility that the client is eperiencing delirium?a. he client becomes confused within ,6 hours after hospital admission.b. he client displays a cheerful attitude despite a poor prognosis.c. he client becomes depressed and sleeps most of the day.d. he client begins to use slurred speech.

$. ANS: A@elirium is characteri#ed by acute confusion that is usually short term.@elirium can result from placement in unfamiliar surroundings' such as beinghospitali#ed.

____ A. Which statement regarding chronic pain is true?a. "hysiologic adaptation occurs so that manifestations of tachycardia andelevated blood pressure are not present.b. he person with chronic pain eperiences local nerve adaptation so thatthe intensity of chronic pain diminishes over time.c. 3hronic pain allows for better psychosocial adaptation over time' and theclient has a reduction in the perception of pain.d. /orphine and morphine agonists are not e$ective for chronic pain becausethe cells involved in neuromodulation are no longer responsive.

%. ANS: A

he pain manifestations of tachycardia and increased blood pressure occurwith acute pain as a result of activation of the stress response. he stressresponse uses much energy and is a relatively short+term response' withphysiologic adaptation occurring over time. he absence of tachycardia orblood pressure changes in a client with chronic pain do not correlate to adecreased perception of intensity of pain.

____ . he client with cholecystitis also has pain in the right shoulder bladearea. he client epresses concern that a new problem is occurring. What isthe nurse;s best response to this client situation?a. 4eposition the client on the left side and then check the muscle strength'capillary re)ll' and touch sensation in the right hand and arm.b. =plain to the client that problems in the gallbladder area often aretransmitted by nerves in the area with many branches and can be felt as painin the shoulder area.c. Withhold the net dose of analgesic until the source of the pain isidenti)ed.d. 5otify the physician of the new complaint.

&. ANS: #


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/any types of visceral pain can be felt. felt in body areas other than theoriginating site& this is known as referred pain. "ain originating in thegallbladder can be referred to the right posterior shoulder. he client shouldbe reassured that this is normal and medicated appropriately.

____ 1C. 0n unconscious client who has 9ust been involved in a motor vehicle

accident is brought to the emergency department. Which presenting clinicalmanifestation makes the nurse suspicious of an opioid overdose rather thanincreased intracranial pressure as a cause of the unconsciousness?a. "inpoint pupilsb. 4espiratory depressionc. -ypore*eive deep tendon re*eesd. =vidence that the client has vomited

1'. ANS: A/orphine and other opioids bind tightly to the mu DEF opioid receptor' whichcauses pupillary constriction. -ead in9uries resulting in increased intracranialpressure cause pupillary dilation. 0 symptom of withdrawal from opioids is

pupillary dilation.

____ 11. Which intervention is compatible with the goals for end+of+life care?a. 0dministering a *u shotb. "reventing the client with 3:"@ from smokingc. "erforming passive range+of+motion eercises to prevent contracturesd. "ermitting the client with diabetes mellitus to have a serving of ice cream

11. ANS: ( he goals of end+of+life care are to control distressing symptoms' promotemeaningful interactions between the client and signi)cant others' andfacilitate a peaceful death. /easures that prolong life are discontinued whenthey interfere with the clientGs comfort or pleasure.

____ 1,. Which statement regarding disability and chronic illness is true?a. @isabilities and chronic illnesses occur most often in young adults.b. 0ccidents are responsible for more chronic and disabling conditions thanchronic disease.c. In the !nited 2tates' one in seven persons eperiences activity limitationsbecause of chronic health problems.d. /en eperience more disability than women' but women eperience ahigher incidence of chronic illness than men.

12. ANS: CIn the !nited 2tates' approimately 8CH of the population has one or morechronic health problems' and about 8 million people Done in sevenFeperience some activity limitations because of their chronic healthproblems.

____ 1. he client who has been found to have a mutation in the B4301 geneallele and an increased risk for breast and ovarian cancer has asked you to be


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present when she discloses this information to her grown daughter. What isyour role in this situation?a. "rimary health care providerb. enetic counselorc. 3lient advocated. 3lient support

13. ANS: ( Jou are supporting the client emotionally while she tells her daughter theinformation she has learned about the test results. Jou are not interpretingthe results nor are you counseling the client or her daughter about whatsteps to take net.

____ 16. What is the primary survey?a. 0irway' breathing' circulation' head to toe assessmentb. 0irway' breathing' circulation' neurologic assessmentc. 0irway and cervical spine control' breathing' circulation' disability'eposure

d. 0irway and cervical spine control' breathing' circulation' head to toeassessment1. ANS: C

he primary survey for a trauma client organi#es the approach to the clientso that life+threatening in9uries are rapidly identi)ed and managed. heprimary survey is based on the standard mnemonic 0B3' with an added @and =. 0' airway and cervical spine control' B' breathing' 3' circulation' @'disability' =' eposure.

____ 18. What statement best describes the basic concept of mass causalitythe basic concept of mass causality triage?a. Khe greatest good for the greatest amount of peopleLb. K>irst come' )rst servedLc. KWomen and children )rstLd. K>irst priority to the most criticalL1!. ANS: A

riage for a mass causality incident di$ers from KcivilianL triage in that itsmain goal is to provide the most e$ective care for the greatest number of people. 3lients are classi)ed into one of four categories% emergent' urgent'nonurgent' or epected to die. 3lients who are classi)ed as epected to diewould not be assigned )rst priority in a mass causality situation.

____ 1


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____ 1. he primary )rst aid intervention in the prehospital setting for ablack widow spider bite is the application of ice. Which statement providesthe best rationale for this intervention?a. Ice inhibits the action of neurotoin.b. Ice reduces swelling in the a$ected etremity.

c. Ice decreases venous return from the a$ected etremity.d. Ice decreases the pain associated with spider bites.1$. ANS: AIce inhibits the action of neurotoin and should be the )rst interventionprovided to a client bitten by a black widow spider.

____ 1A. What e$ect would an infusion of ,CC mM of albumin have on ahealthy clientGs plasma osmotic and hydrostatic pressures?a. Increased osmotic pressure' increased hydrostatic pressureb. Increased osmotic pressure' decreased hydrostatic pressurec. @ecreased osmotic pressure' increased hydrostatic pressure

d. @ecreased osmotic pressure' increased hydrostatic pressure1%. ANS: A

he addition of albumin to the plasma would add a colloidal substance thatdoes not move into the interstitial space. hus' the osmotic pressure wouldimmediately increase. 5ot only does the additional ,CC mM add to the plasmahydrostatic pressure' but the increased osmotic pressure would draw waterfrom the interstitial space' increasing the plasma volume and ultimatelyleading to increased hydrostatic pressure in the plasma volume.

____ 1. Which speci)c condition triggers the NthirstN center in thehypothalamus?a. -yperosmolar etracellular *uidb. -ypo+osmolar etracellular *uidc. =levated serum potassium leveld. @ecreased serum potassium level1&. ANS: A

he thirst mechanism is triggered when the osmoreceptors of thehypothalamus detect that the etracellular *uid is hyperosmolar' especiallywhen the serum sodium level is elevated. :ther conditions that trigger thethirst centers include hypotension and hypoemia.

____ ,C. Why is sterile pure water not usually ordered as an intravenous *uid?a. It would suppress the clientGs natural thirst re*e.b. It would cause red blood cells to swell and break.c. It would cause red blood cells to shrink and crenate.d. It would cause overstimulated 0@- secretion.2'. ANS: #"ure water is hypotonic compared to normal body *uids. hus if water wereadministered intravenously' the plasma would become hypotonic compared


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with red blood cells. he red blood cells would take up the hypotonic *uid'swell' and lyse open.

____ ,1. Which intervention is most important for the nurse to teach the clientwho has lymphedema in her right arm from a mastectomy 1 year ago?a. K=ercise your arm and use it during tasks that occur at the level of your

chest or higher.Lb. KBe sure to use sunscreen or protective clothing to reduce the risk ofin9uring this arm.Lc. K4educe your salt intake to prevent ecess water retention.Ld. K@o not epose the right arm to temperature etremes.L 21. ANS: A2keletal muscle contractions facilitate *ow in lymph channels. Oeeping thearm at chest level or higher prevents stasis of lymph *uid from gravitationalforces.

____ ,,. Which is the most important question the nurse should ask the client

who has been diagnosed with isotonic dehydration to identify a possiblecause of the *uid imbalance?a. K@o you take diuretics or Gwater pillsG?Lb. KWhat and how much do you normally eat over a dayGs time?Lc. K-ow many bowel movements do you usually have each day?Ld. K-ave you or any member of your family been diagnosed with diabetesmellitus?L22. ANS: A/isuse or overuse of diuretics is a common cause of isotonic dehydration.

____ ,. Which intervention for the client with overhydration+inducedconfusion is most likely to relieve the confusion?a. /easuring intake and outputb. 2lowing the I7 *ow rate to 8C mM(hourc. 0dministering diuretic agents as prescribedd. "lacing the client in modi)ed rendelenburg position Dfeet and legselevated& head and chest *atF23. ANS: C:verhydration most frequently leads to poor neuronal function' causingconfusion as a result of electrolyte imbalances Dusually sodium dilutionF.=liminating the *uid ecess is the best way to reduce confusion.

____ ,6. Which nursing intervention would be most e$ective in preventingin9ury in a hospitali#ed client with hypocalcemia of long duration?a. eaching the client to wear shoes when ambulatingb. 0pplying antiembolic stockings on the clientGs legsc. "lacing an egg+crate mattress on the client;s bedd. !sing a lift sheet when moving the client in bed2. ANS: ("rolonged hypocalcemia results in loss of bone calcium' making the bonesbrittle and fragile. !sing a lift sheet when moving the client rather thangrasping or pulling the client helps prevent fractures.


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d. Because hydrogen ions and potassium ions eist in the blood in abalanced' reciprocal relationship' an increase or decrease in the blood p-requires a corresponding decrease or increase in potassium ions.2%. ANS: C

he blood p- is a measure of the concentration of the blood hydrogen ionconcentration. -ydrogen ions are cations epressing a positive charge. In

order for body *uids to remain electrically neutral' an increase in hydrogenion concentration requires fewer other positive ions and more negative ionsfor balance. he reverse is true for decreased hydrogen ion concentration.

____ ,. he hand grasps of the client with acidosis have diminished since theprevious assessment 1 hour ago. What is the nurse;s best )rst action?a. 0ssess the clientGs rate' rhythm' and depth of respiration.b. /easure the clientGs pulse and blood pressure.c. @ocument the )ndings as the only action.d. 5otify the physician.2&. ANS: A"rogressive skeletal muscle weakness is associated with increasing severity

of the acidosis. /uscle weakness can lead to severe respiratory insuPciency.Oetamine hydrochloride induces dissociative reactions such as hallucinations'distorted images' and irrational behavior during emergence from theanesthesia.

____ C. Which client is at greatest risk for the development of metabolicacidosis?a. 8


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surgery' this medication should not increase the risk of intraoperative orpostoperative aspiration.

____ ,. he client who has received ketamine hydrochloride during a surgicalprocedure has all of the following manifestations and behaviors. Which onealerts the nurse to a dissociative reaction?

a. -ypoventilation and decreased oygen saturationb. "resence of hives on the skin around the I7 sitec. 3rying because the pain at the surgical site has increasedd. "ulling out the I7 because he sees bugs in the solution bag32. ANS: ( Oetamine hydrochloride induces dissociative reactions such ahallucinations' distorted images and irrational behavior during emergencefrom the anesthesia.

____ . he client returning to the clinic for a follow+up visit weeks afterabdominal surgery is concerned because she can feel small' uneven lumps

under the suture line of the incision. What is the nurse;s best response?a. K0void touching those areas because you may dislodge the blood clots thatkeep your incision from bleeding.Lb. KWhat you are feeling is growth of new tissue proceeding at di$erent ratesin the incision.Lc. Khose are the deep stitches the surgeon placed' and they will eventuallybe absorbed and disappear.Ld. KOeep the incision covered for as long as those lumps can be felt.L33. ANS: #

issue healing and growth of new cells proceed at di$erent rates along theincision. 2mall' )rm lumps are usually new blood vessels or new collagenbases. hey eventually smooth out without intervention when the scar ismature.

____ 6. -ow do immune system cells di$erentiate between normal' healthybody cells and non+self cells within the body?a. 0ll normal' healthy body cells are considered part of the immune system.b. Immune system cells recogni#e normal healthy body cells by the presenceof the nucleus' a structure that is lacking in non+self cells.c. 5on+self cells epress surface proteins that are di$erent from normal'healthy body cells and recogni#ed as KforeignL by immune system cells.d. 5on+self cells are easily identi)ed by the immune system cells' becausenon+self cells are much larger than normal' healthy body cells.3. ANS: C5ormal' healthy body cells all epress surface proteins that are unique to theperson' coded by the ma9or histocompatibility genes. 5on+self cells epressdi$erent cell surface proteins. Immune system cells can distinguish betweentheir own surface proteins and all others.

____ 8. he ,A+year+old client has a deep puncture wound on his foot fromstepping on a nail. When the nurse prepares to give him a tetanus tooid


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vaccination' he says he does not need another tetanus shot because he had atetanus shot 9ust 1 year ago. What is the nurse;s best response?a. KJou need this vaccination because the strain of tetanus changes everyyear.Lb. KI will check with the doctor. Jou probably do not need another vaccinationnow.L

c. KBecause antibody production slows down as you age' it is better to takethis vaccination as a booster to the one you had a year ago.Ld. Ketanus is a more serious disease among younger people because it canbe spread to others by seual transmission' so it is best to take thisvaccination now.L3!. ANS: #When people have been KboostingL their tetanus antibodies on a regularlyscheduled basis' they should have suPcient circulating antibodies to mount adefense against eposure to tetanus. If this client;s medical recordssubstantiate that he did indeed receive a tetanus tooid booster 1 year ago'he does not need another one now.

____


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problem. >or other clients' the etra retained *uid may lead to hypertension'heart failure' and pulmonary edema. he client;s cardiovascular status shouldbe assessed before any decision is made to keep or discontinue the currenttherapy.

____ A. What is the most important precaution or action the nurse should

teach a client newly diagnosed with systemic lupus erythematosus D2M=F?a. /onitoring urine outputb. Being immuni#ed yearly against in*uen#ac. 0ssessing skin daily for open areas or rashesd. 0voiding the use of hair dyes and having permanents3%. ANS: A2M= is a connective tissue disorder that most profoundly a$ects tissues andorgans that are highly vascular. he leading cause of death in clients with 2M=is kidney disease.

____ . he client who has 0I@2 is admitted with cryptosporidiosis. Whichclinical manifestation should the nurse epect the client to have?a. "ersistent watery diarrhea and abdominal crampingb. "roductive cough with dyspnea and low+grade feverc. 4ed' pruritic rash that bleeds easily with light pressured. hick' white coating on the tongue and oral mucous membranes3&. ANS: A3ryptosporidiosis is a proto#oal infection causing gastroenteritis. 3lientseperience mild to voluminous diarrhea.

____ 6C. Which is the most important precaution for the nurse to take whenadministering pentamidine D"entamF intravenously to a client withpneumocystis pneumonia?a. /onitoring intake and outputb3hecking the I7 site hourly for phlebitisc. 0ssessing the client hourly for manifestations of hypoglycemiad. 0ssessing deep tendon re*ees and handgrip strength bilaterally'. ANS: C

his drug can induce a rapid and severe state of hypoglycemia that can befatal. 3lients receiving I7 pentamidine should be monitored no less thanevery hour for sub9ective symptoms of hypoglycemia and blood glucose level.

____ 61. 0 health care professional has been occupationally eposed to -I7through a needle stick in9ury from a client who is -I7+positive and has a lowviral load. What drug regimen should the nurse be prepared to initiate?a. 5o regimen is necessaryb. Qidovudine D4etrovirF 1CC mg every 6 hours for ,6 hoursc. Qidovudine D4etrovirF and lamivudine D=pivirF for 6 weeksd. Qidovudine D4etrovirF and lamivudine D=pivirF for 1 year1. ANS: C


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his combination of antiretroviral medications is recommended by the 3@3for prophylais against occupational eposure to -I7 when the source clientis -I7+positive and has a low viral burden. he regimen is recommended for aduration of at least 6 weeks.

____ 6,. he client who has 9ust been diagnosed as -I7+positive asks if heposes a health ha#ard to his co+workers in the secretarial pool. What is thenurse;s best response?a. Khe only time you could make someone else sick is when you have"neumocystis pneumonia.Lb. K0s long as you are taking your antiviral medications' you cannot transmitthe virus to your co+workers.Lc. K!nless your blood or other body *uids comes into contact with your co+workers' you are not a health risk to them.Ld. KJou should inform your co+workers of your -I7 status so that they cantake proper precautions to reduce their risk.L2. ANS: C

-I7 transmission requires signi)cant contact with contaminated body *uids. If his co+workers are immunocompetent' even the client;s opportunisticinfection will have no physical impact on these people.

____ 6. With which client should the nurse be alert to the possibility of latehypersensitivity?a. A+year+old man allergic to shell)shb. ,A+year+old woman with spina bi)dac.


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____ 68. Which characteristic of a tumor indicates that it is benign rather thanmalignant?a. It does not cause pain.b. It is less than , cm in si#e.c. It is surrounded by a capsule.

d. It causes the sensation of itching.!. ANS: CBenign tumors are made up of normal cells growing in the wrong place orgrowing at a time when they are not needed. hey grow by epansion ratherthan invasion and often are encapsulated. he si#e and the fact that it ispainless does not mean that the tumor is benign. 0dditionally' the presenceof any sensation Dsuch as itchingF does not rule out malignancy.

____ 6 for , days' I should take twice asmuch medicine.L


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c. KWhen my incision stops draining' I will no longer need to take theantibiotics.Ld. K=ven if I feel completely well' I should take the medication until it isgone.L%. ANS: (0ntibiotic therapy is most e$ective when the client takes the prescribed

medication for the entire course and not 9ust when symptoms are present. 0ma9or nursing responsibility is to reinforce to clients the necessity of completing the antibiotic regimen to ensure that the organism is eradicated.

____ 6. 0 client has all of the following family and personal factors. Whichone greatly increases the risk for the client to develop respiratory problems?a. he client has long+standing hypertension.b. he client;s father died of lung cancer at age A,.c. he client;s sister has a child with cystic )brosis.d. he client has a de)ciency of alpha1+antitrypsin.&. ANS: (0lpha1+antitrypsin is an en#yme in the lungs that limits the activity of other

protein+ destroying en#ymes in the lungs. Without this limitation' thoseprotein+destroying en#ymes break down the collagen and elastin in the lungs'dramatically increasing the risk for developing emphysema at an early age.:ther types of severe pulmonary problems are also more common amongindividuals who are de)cient in alpha1+antitrypsin.

____ 8C. he client with long+standing pulmonary problems is classi)ed ashaving class III dyspnea. Based on this classi)cation' what type of assistancewill you need to provide for 0@Ms?a. @yspnea is minimal and no assistance is required.b. he client may complete activities of daily living without assistance butrequires rest periods during performance.c. he client is severely dyspneic with activity and requires assistance forsome but not all tasks.d. he client is severely dyspneic at rest and cannot participate in any self+care. !'. ANS: #3lass III dyspnea occurs during usual activities' such as showering' but theclient does not require assistance from others. @yspnea is not present at rest.

____ 81. Which technique should you teach the caregiver and client with atracheostomy to reduce the risk for aspiration during feeding(eating?a. =ncourage the client to swallow as fast as possible to limit the time theclient is at risk for aspiration.b. ell the client and family to keep the phone nearby during feedings toshorten the time it takes to dial 11.c. each the client(caregiver to thicken liquids and avoid foods that generatethin liquids during chewing.d. Instruct the client(caregiver to in*ate the cu$ maimally during and for 1hour after the feeding.!1. ANS: C


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hin liquids are hard to control and can slip past the epiglottis and into thetrachea. hicker liquids remain as a bolus that the client can control duringbreathing so that he or she does not attempt to swallow during an inhalation.

____ 8,. What is the priority teaching focus for the client being dischargedhome after a )ed centric occlusion for a mandibular fracture?

a. Oeeping wire cutters close at handb. =ating at least < soft or liquid meals each dayc. !sing an irrigating device for oral care 6 times a dayd. 2leeping in a semisitting position for the )rst week after surgery!2. ANS: A0spiration is possible if the client vomits with the wires in place. he vomitusmay not be able to move out of the mouth fast enough through the closedteeth and could obstruct the upper airway' as well as move into the trachea.

____ 8. Which conditions or factors in a


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!!. ANS: (5eck veins are normally distended D9ugular venous distentionF only when aperson is supine. !sually' the neck veins *atten when a person sits at a C+degree angle or higher. Sugular venous distention in a full sitting position isassociated with right+sided heart failure' a characteristic of cor pulmonale.

____ 8


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hot' sudsy water. he mouth has more protective mechanisms to preventviral infection than do either the nose or the con9unctiva of the eye. /asksworn by others have not been proven e$ective in preventing the spread ofcolds and may give family members a false sense of security. -umidifying theair promotes comfort but does not inhibit viral spread.

____ 8. Which person is a greatest risk for developing nosocomialpneumonia?a. he


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d. 7itamin O "2. ANS: #"rotamine sulfate is an antidote for heparin.

____


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"". ANS: AWhen a client eperiences hypotension' baroreceptors in the aortic archsense a pressure decrease in the vessels. he parasympathetic systemresponds by lessening the inhibitory e$ect on the 20 node' and this results inan increase in heart rate.

____


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0 heart rate of 6C beats(min or below' with widened U42 complees' shouldalert the nurse to the possibility that the 07 block is infranodal and aventricular escape focus is pacing the ventricles. his could havehemodynamic consequences and the client is at risk of inadequate cerebralperfusion. he nurse should assess for lightheadedness' confusion' syncope'and sei#ure activity.

____ 1. he health care provider is planning to treat a client who hassymptomatic' infranodal' third+degree heart block following cardiac surgerywith temporary pacing. Which type of pacing would be most appropriate forthis client?a. lobal pacingb. !niversal pacingc. 2ynchronous pacingd. 0synchronous pacing$1. ANS: (0synchronous pacing is most often used for clients who are profoundly

bradycardic because it is found in clients with infranodal blocks or in thosewho are asystolic. his type of pacing )res at a )ed rate' regardless of theclient;s intrinsic rhythm.

____ ,. 0 client has been admitted to the acute care unit for an eacerbationof heart failure. Which of the following nursing actions should be performed)rst?a. 0ssessment of respiratory and oygenation statusb. /onitoring of serum electrolyte levelsc. 0dministration of intravenous *uidsd. Insertion of a >oley catheter$2. ANS: A

0ssessment of respiratory and oygenation status is the priority nursingintervention for the prevention of complications.

____ . he client with hypercholesterolemia and atherosclerosis reports skin*ushing and itching while taking nicotinic acid. What is the nurse;s bestresponse?a. Kake this product with meals.Lb. Kake this product at bedtime.Lc. K0void taking aspirin with this product.Ld. K0void smoking cigarettes while taking this product.L$3. ANS: A5icotinic acid causes an increased release of prostaglandins' resulting invasodilation. aking the drug with meals minimi#es this side e$ect.

____ 6. What instructions should be given to a client who is about to begintreatment with an -/+3o0 reductase inhibitor such as simvastatin?a. Khis drug can cause constipation.Lb. Kake this drug on an empty stomach.L


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c. K4eport any muscle tenderness to your health care provider.Ld. KJou may eperience *ushing of the skin with this medication.L$. ANS: C

his class of drugs can cause myopathy. /uscle tenderness should bereported to the client;s health care provider.

____ 8. 0 client in the hyperdynamic phase of septic shock has beenadmitted to the intensive care unit. What complication should the nurse bealert for as shock progresses from the hyperdynamic to the hypodynamicphase?a. 0cute respiratory distress syndromeb. 0cute bowel obstructionc. 7entricular tachycardiad. 2ei#ure activity$!. ANS: A0s septic shock progresses to the hypodynamic phase' acute respiratorydistress syndrome D04@2F' a potentially fatal complication' can develop.

____


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he normal range for hemoglobin in adult males of this age is 16 to 1A g(dM. his clientGs hemoglobin level is elevated' which could indicate possiblechronic hypoia or polycythemia vera.

____ . Which clinical manifestation is common to all types of anemia

regardless of cause or pathologic mechanism?a. Saundiced sclera and roof of the mouthb. -ypertension and peripheral edemac. achycardia at basal activity levelsd. Increased "a3:,$&. ANS: C

he client with anemia has some degree of tissue hypoia. 0 compensatorymechanism to increase tissue oygenation is to increase cardiac output byincreasing heart rate.

____ AC. he client has anemia and all the following clinical manifestations.Which manifestation indicates to the nurse that the anemia is a long+standing

problem?a. -eadacheb. 3lubbed )ngersc. 3ircumoral pallord. :rthostatic hypotension%'. ANS: #3lubbing of the )ngers requires prolonged hypoia Dmany months to yearsF todevelop.

____ A1. Which problem or condition is most likely to stimulate a crisis in aperson who has sickle cell trait?a. Becoming pregnantb. 2hoveling snow when the temperature is at C degreesc. -aving surgery under general anesthesia for colon cancerd. -aving a cast placed on the wrist after sustaining a simple fracture%1. ANS: C

he person who has sickle cell trait usually has less than 6CH of his or hertotal hemoglobin as -gb 2. 0lthough these cells could still become sickled'hypoic conditions would have to be severe for this to occur to the level of sickle cell crisis. 2uch individuals are most vulnerable to crisis duringprolonged surgery under anesthesia.

____ A,. Which clinical manifestation or assessment )nding indicatese$ectiveness of the therapy for the client with polycythemia vera?a. -ematocrit of


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____ A. Which precaution should the nurse teach the client who is prescribedto take thalidomide DhalomidF as part of her treatment plan for multiplemyeloma?a. K0void high+)ber foods to prevent diarrhea.Lb. K!se multiple forms of birth control to prevent birth defects.Lc. K@rink plenty of *uids to prevent the development of diabetes mellitus.L

d. K0void crowds and sick people to prevent contraction of contagiousinfections.L%3. ANS: #

halidomide is a potent teratogen and has been known to cause severe birthdefects after even one eposure of the drug. Both women and men who aretaking this drug are urged to use multiple forms of contraception to preventeposing a fetus to this drug

____ A6. he client being discharged home after a bone marrowtransplantation for leukemia asks why protection from in9ury is so important.What is the nurse;s best response?

a. Khe transplanted bone marrow cells are very fragile and trauma couldresult in re9ection of the transplant.Lb. Krauma is likely to result in loss of skin integrity' increasing the risk forinfection when you are already immunosuppressed.Lc. K"latelet recovery is slower than white blood cell recovery and you remainat risk longer for bleeding than you do for infection.Ld. Khe medication regimen after transplantation includes drugs that slowdown cell division' making healing after any in9ury more diPcult.L%. ANS: C"latelets recover more slowly than other blood cells after bone marrowtransplantation. hus' the client is still thrombocytopenic at home andremains at risk for ecessive bleeding after any trauma of in9ury.

____ A8. 0 nurse is assessing a client for pain sensation using a sharp or dullinstrument. What technique should be used to obtain valid results?a. est the client )rst with eyes open' then with eyes closed.b. est the client for dull sensation )rst' followed by sharp.c. est the client for sharp sensation )rst' followed by dull.d. est the client for sharp and dull sensation randomly.%!. ANS: (

he proper assessment technique for assessing pain sensation is to test theclient for sharp and dull sensation randomly to prevent the client fromanticipating the type of stimulus that will follow.

____ A


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%". ANS: A he client is demonstrating decorticate posturing that is seen withinterruption in the corticospinal pathway. his )nding is abnormal' and a signthat the client;s condition has deteriorated. he physician' charge nurse' andother team members should be noti)ed immediately of this change in status.

____ A. What nursing action addresses the age+related changes of sensoryperception for an older adult client admitted to a general medical *oor?a. !sing a call button that requires only minimal pressure to activateb. "roviding a clock and calendar to minimi#e dementia onsetc. =nsuring that paths are free from equipmentd. 0dmitting the client to the room closest to the nursing station%$. ANS: C@ementia and confusion are not common phenomena among older adults.-owever' physical impairment related to illness can be epected& providingopportunity for ha#ard+free ambulation will maintain strength and mobility.

____ AA. 0 nurse is preparing a teaching plan for a client with migraine

headaches who is receiving a beta blocker to help manage this disorder. Whatinstructions would be appropriate to relay to this client?a. Kake this drug only when you have prodromal symptoms indicating theonset of a migraine headache.Lb. Kake this drug as ordered' even when feeling well' to prevent vascularchanges associated with migraine headaches.Lc. Khis drug will relieve the pain during the aura phase soon after aheadache has started.Ld. Khis medication will have no e$ect on your heart rate or blood pressurebecause you are taking it for migraines.L %%. ANS: #Beta blockers are prescribed as a prophylactic treatment to prevent thevascular changes that initiate migraine headaches. -eart rate and bloodpressure will also be a$ected and the client should monitor these side e$ects.

____ A. What statement made by a client with newly diagnosed epilepsyindicates that further teaching concerning the drug regimen is necessary?a. KI will avoid alcohol.Lb. KI will wear a medical alert bracelet.Lc. KI will let my doctor know about this drug when I receive a new prescriptionother conditions.Ld. KI can miss up to two pills if I run out of them or they make me ill.L%&. ANS: (

he nurse needs to emphasi#e that antiepileptic drugs must be taken even if sei#ure activity has stopped. @iscontinuing the medication can predispose theclient to sei#ure activity and status epilepticus.

____ C. Which of the following is the correct rationale for monitoringperipheral oygenation saturation in the client with encephalitis?a. It will prevent increased intracranial pressure.b. It will prevent permanent neurologic disabilities.


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c. It will alert the clinician to hypoia and possible secondary brain damage.d. It will prevent inadequate amounts of oygen in the circulating blood fromcausing brain hypoia.&'.ANS C. =arly of inadequate circulating oygen can allow the clinician tointervene before hypoic brain damage occurs.

____ 1. Which statement indicates that the family has a good understandingof the changes in motor movement associated with "arkinson;s disease?a. KI can never tell what he;s thinkingVhe hides behind a fro#en face.Lb. K2he drools all the time 9ust so I can;t take her out anywhere.Lc. KI think this disease makes him nervousVhe perspires all the time.Ld. KI can o$er smaller meals with bite+si#e portions and a liquid supplement.L&1. ANS: (0 masklike face' drooling' and ecess perspiration are common to clients with"arkinson;s disease. 3hanges in facial epression or a masklike facies in a"arkinson;s disease client can be misinterpreted. Because chewing andswallowing can be problematic' small' frequent meals and a supplement arebetter for meeting the client;s nutritional needs.

____ ,. Which nursing intervention will assist in preventing respiratorycomplications in the client with "arkinson;s disease?a. Oeeping an oral airway at the bedside.b. =nsuring a *uid intake of at least M(day.c. eaching the client pursed+lip breathing techniques.d. /aintaining the backrest elevation at greater than C degrees.C. 052% 3=arly detection of inadequate circulating oygen can allow the clinician tointervene before hypoic brain damage occurs.&2. ANS: (

=levation of the backrest will help prevent aspiration.

____ . 0 nurse is caring for a client eperiencing spinal shock after a spinalcord in9ury. What clinical manifestation would indicate the resolution of spinalshock?a. he return of re*e activityb. 5ormali#ation of the pupillary re*ec. 4eturn of bowel and bladder continenced. ingling in the etremities below the lesion&3. ANS: A

he resolution of spinal shock is signaled by the return of re*e activity. 5otethat spinal shock and neurogenic shock are not interchangeable terms anddescribe di$erent pathologic phenomena.

____ 6. 0 nurse is to assess proprioceptive function in the lower etremitiesin a client with a suspected spinal cord in9ury. What assessment techniqueshould the nurse use?a. 0sk the client to *e and etend the feet and knees.b. With the client;s eyes closed' move the client;s toe up or down.


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c. 0pply resistance while the client plantar *ees the legs and feet.d. 0pply pinprick to the lower etremities and compare bilaterally. &. ANS: #

he proper technique for testing proprioception is to ask the client to closehis or her eyes. /ove the client;s toe up or down and ask the client to identifythe position of the digit.

____ 8. Within 6 hours after a cervical spinal in9ury' the client candiscriminate light touch and position of the arms but cannot perform anymotor function. What is the nurse;s interpretation of this )nding?a. he client is likely to have a full recovery from this in9ury.b. he spinal cord has eperienced a complete in9ury.c. he spinal cord in9ury is posterior.d. he spinal cord in9ury is anterior.&!. ANS: (With a spinal cord in9ury to the anterior portion of the cervical spine' theclient may retain some sensory function Dtouch' vibration' and position are in

the posterior portionF but may not have motor function and pain andtemperature sensation. Whether the in9ury is permanent or temporary cannotbe ascertained at this time.

____


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drugs have produced their peak e$ect enables the client to chew and swallowmore easily.

____ A. Which of the following statements made by a client with peripheralpolyneuropathy indicates correct understanding of in9ury prevention?a. KI will change positions slowly.L

b. KI will avoid wearing cotton or wool socks.Lc. KBecause I now bleed more easily' I will use an electric ra#or.Ld. KBecause my feet are always cold' I will use a hot water bottle on them atnight.L&%. ANS: A

he autonomic dysfunction associated with peripheral polyneuropathy causesorthostatic hypotension.

____ . What statement by the client indicates her understanding of treatment for pain related to uillain+Barr syndrome?a. KI can use the button on the pump as often as I want to get more pain

medication.Lb. K0spirin will help me when I have pain from this disease.Lc. K0 combination of morphine and distraction seems to help bring me relief right now.Ld. KI should not have any pain as a result of impaired motor movement whileacutely ill.L&&. ANS: C

ypical pain from B2 is often not relieved by medication other than opiatesand distraction' repositioning' massage' heat' cold' and guided imagery mayenhance the opiate e$ects.

____ 1CC. Which statement or behavior by a client after a stroke indicates tothe nurse that the client is ad9usting to the residual limitations from thestroke?a. he client uses the una$ected side to perform passive range+of+motioneercises on the a$ected side.b. he client states the goal of regaining all sensory and motor functionwithin < months.c. he client says that she is well and nothing has happened.d. he client smiles continually while awake.1''. ANS: A0d9ustment to the limitations imposed by a health problem such as a strokeinvolves acceptance of the event and active participation in rehabilitativeactivities.

____ 1C1. Which assessment )nding alerts the nurse to the possibility that theclient has a paralysis of the medial rectus muscle for the right eye? he clientis unable toa. urn the right eye in toward the nose.b. Mift the right upper eyelid.c. /ove the right eye downward.d. /ove the right eye upward.


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1'1. ANS: A3ontraction of the medial rectus muscle turns the eye toward the nose.

____ 1C,. Which client is at greatest risk for developing vision problems?a. ,A+year+old woman in the postpartum phase of pregnancyb. ,A+year+old man who has diabetes mellitus

c. 8A+year+old man who takes aspirin daily for anticoagulationd. 8A+year+old woman using topical ointments daily for dry skin

1'2. ANS: # he hyperglycemia that characteri#es diabetes mellitus causes numerousvascular problems in the eye and damages the nerves. @iabetes mellitus is ama9or cause of blindness in 3anada and the !nited 2tates. 0lthough goodcontrol of blood glucose levels delays visual problems' it does not eliminate itin the diabetic population.

____ 1C. he client is using an ophthalmic beta+blocking agent for thetreatment of glaucoma. Which of the following actions should the nurse teach

the client to prevent orthostatic hypotension?a. K3hange positions slowly.Lb. Kake your pulse rate at least four times daily.Lc. K0pply pressure to the inside corner of your eye when putting the dropsinto the eye.Ld. KBe sure to lie down for at least 1C minutes after putting the drops intoyour eyes.L1'3. ANS: C5asal punctal occlusion during eye drop instillation keeps the drug in contactwith the eye structures longer and decreases systemic absorption and sidee$ects.

____ 1C6. he client has 9ust returned from having surgery for a scleralbuckling procedure to repair a large retinal detachment in the right eye.2ulfahea*uoride gas was used intraocularly. What postoperative positionshould the nurse use for this client?a. 3ompletely supine with sandbags to prevent the head from turning toeither sideb. :n the nonoperative side in the rendelenburg positionc. :n the operative side in the rendelenburg positiond. :n the abdomen with the a$ected eye up1'. ANS: (2ulfahea*uoride gas has a lower speci)c gravity than the vitreous humor. Itwill *oat to the highest position. he client should be positioned so that thegas will *oat up and against the newly reattached retina.

____ 1C8. >or which type of foreign ob9ect in the ear canal is irrigationcontraindicated?a. @ried beansb. Mive insectc. "encil eraser


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d. 3erumen1'!. ANS: AIrrigating the ear canal containing dried beans or any other vegetable matteris contraindicated because the irrigating *uid can cause the matter to swelland become more impacted.

____ 1C


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b. KJou may have stools that are darker in appearance for a few days.Lc. KJou may not eat or drink anything for < hours after the test.Ld. K@rink plenty of *uids.L1'&. ANS: (

he client is encouraged to drink plenty of *uids after a barium swallow tohelp eliminate the barium from the colon.

____ 11C. Which statement regarding oral candidiasis is true?a. It is an in*ammatory mucocutaneous disease.b. It is an acute bacterial infection of the gingiva.c. It is a complication of long+term antibiotic therapy.d. It is a risk factor for the development of oral cancer.11'. ANS: C0ntibiotic therapy can destroy the normal *ora that usually prevents fungalinfections. Mong+term treatment with antibiotics predisposes clients tocandidiasis.

____ 111. Which statement made by the client concerning the risk of oral

cancer indicates a need for further teaching?a. KI will brush my teeth and *oss regularly.Lb. KI will begin a smoking cessation program.Lc. KI will limit my intake of alcoholic beverages.Ld. KI can still use chewing tobacco since I stopped smoking.L111. ANS: (

obacco in any form increases the risk of oral cancer. he client should beeducated to eliminate all tobacco products

____ 11,. he most accurate method of diagnosing gastroesophageal re*udisease D=4@F is which of the following?a. =ndoscopyb. 2chilling;s testc. ,6+hour ambulatory p- monitoringd. 2tool testing for occult blood112. ANS: C

he most accurate method of diagnosing gastroesophageal re*u disease is,6+hour ambulatory p- monitoring.

____ 11. In caring for a client with a rolling hernia' the nurse should be alertfor which potential complication?a. 4e*ub. 7omitingc. "neumoniad. :bstruction113. ANS: (0 rolling hernia causes the fundus and portions of the stomach;s greatercurvature to roll into the thora net to the esophagus' predisposing theclient to volvulus' obstruction' and strangulation.


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____ 116. he nurse is caring for a client who has undergone esophagealdilation for achalasia. wo hours later' the client develops chest and shoulderpain. What would be the nurse;s best action?a. 0dminister an analgesic.b. @ocument the )nding as the only action.c. 4eposition the client.

d. 5otify the physician.11. ANS: (

he client may be eperiencing complications of the procedure' such asbleeding and perforation. hese complications require immediateintervention.

____ 118. :n assessment' the nurse notes the presence of bloody nasogastrictube drainage from a client who underwent an esophagogastrostomy , daysago. What conclusion should the nurse draw from this assessment?a. he client;s nasogastric tube requires irrigation.b. he drainage is as epected for this time period.c. he client;s nasogastric tube requires repositioning.

d. he client has developed bleeding at the suture line. 11!. ANS: (

he initial nasogastric drainage appears bloody' but should turn a yellow+green color by the end of the )rst postoperative day. If the bloody colorcontinues' it may indicate bleeding at the suture line.

____ 11


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____ 11A. What teaching regarding postoperative care should the nurseprovide for the client undergoing herniorrhaphy?a. KJou should avoid solid foods for the )rst 6A hours after surgery.Lb. K0fter surgery' you should take deep breaths' but avoid coughing.Lc. KJou will not be able to ambulate for , days after the surgery.Ld. K"lace 2teri+2trips over the incision if you note any separation.L

11%. ANS: # he client should change positions and take deep breaths to facilitate lungepansion' but should avoid coughing' which can place stress on the incisionline.

____ 11. 0 client prescribed polyethylene glycol solution DoMJ=MJF inpreparation for colorectal surgery asks why drinking this solution isnecessary. What is the nurse;s best response?a. Khis solution provides electrolytes directly to the bowel.Lb. Khis solution is given to rela the bowel and facilitate removal of thetumor.Lc. Khis solution will clear the bowel of feces and reduce the chance of

infection.Ld. Khis solution is optional' but drinking it will make the surgery easier totolerate.L11&. ANS: C"olyethylene glycol solution is an isosmotic solution that overwhelms theabsorptive capacity of the small bowel' clearing the bowel of feces anddecreasing the amount of bacteria present' and thereby reducing the risk of infection.

____ 1,C. 0 client with a mechanical bowel obstruction reports that theabdominal pain that was previously intermittent and colicky is now moreconstant. What would be the nurse;s priority action?a. /easure the abdominal girth.b. 5otify the health care provider.c. "lace the client in a knee+chest position.d. /edicate the client with an opioid analgesic.12'. ANS: #0 change in the nature and timing of abdominal pain in a client with a bowelobstruction can signal peritonitis or perforation. he health care providershould be noti)ed immediately.

____ 1,1. he laboratory data reveal a decreased fecal urobilinogenconcentration. What clinical manifestation would accompany this laboratory)nding?a. 3lay+colored stoolsb. "etechiaec. 0steriisd. /elena121. ANS: AWhen fecal urobilinogen levels are decreased as a result of biliary cirrhosis'the stools become light+ or clay+colored.


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____ 1,,. 0 client with an esophagogastric tube suddenly eperiences acuterespiratory distress. What should be the nurse;s immediate action?a. 3all the physician.b. 3ut the balloon ports and remove the tube.c. "lace the client in an upright position and apply oygen.

d. 4educe the balloon pressure slightly using the sphygmomanometer.

122. ANS: #In case of respiratory compromise in a client with an esophagogastric tube'the nurse should immediately cut both ports with a pair of scissors that iskept at the bedside and remove the tube.

____ 1,. he physician has ordered vasopressin for a client with bleedingesophageal varices. What is the action of vasopressin in the control of bleeding?a. 3onstriction of preportal splanchnic arteriolesb. Inducing the release of clotting factors II' 7II' IX' and X

c. Increasing portal pressure' thus decreasing portal blood *owd. @ecreasing contraction of smooth muscle in the vascular bed

123. ANS: A7asopressin acts to cause contraction of smooth muscle in the vascular bed'constricting preportal splanchnic arterioles and decreasing blood *ow to theabdominal organs' which in turn reduces portal pressure and portal blood*ow.

____ 1,6. Which of the following menus would be most appropriate for a clientwith cholelithiasis?a. wo eggs' two slices of toast with margarine' and a glass of whole milkb. rilled cheese sandwich' steamed vegetables with butter' and co$eec. 4oast chicken' baked potato' and skim milkd. Baked )sh' steamed broccoli' and tea

12. ANS: C3lients with cholelithiasis should avoid foods high in cholesterol' such aswhole milk and butter' fried foods' and gas+forming vegetables.

____ 1,8. What body mass inde DB/IF should older adults have?a. Mess than ,1b. Between ,C and ,6c. Between ,6 and ,d. reater than C

1,8. 052. 3 :lder adults should have a B/I between ,6 and ,.

____ 1,


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b. Muteini#ing hormonec. hyroid+stimulating hormoned. >ollicle+stimulating hormone

12". ANS: C0 de)ciency of thyroid+stimulating hormone D2-F is the most life+threatening

de)ciency of the hormones listed in this question. 2- is needed to ensureproper synthesis and secretion of the thyroid hormones' whose functions areessential for life.

____ 1,. he client scheduled for a partial thyroidectomy for hyperthyroidismasks the nurse why she is being given an iodine preparation before surgery.What is the nurse;s best response?a. Ko make the surgery as sterile as possible.Lb. Ko stimulate storage of thyroid hormones for use after surgery.Lc. Ko replace the thyroid hormones that will be eliminated as a result of thesurgery.Ld. Ko decrease the blood vessels in the thyroid and prevent ecessive

bleeding during surgery.L

12$. ANS: (Iodine preparations decrease the si#e and vascularity of the thyroid gland'reducing the risk for hemorrhage and the potential for thyroid storm duringsurgery.

____ 1,A. Which clinical manifestation indicates to the nurse that treatmentfor the client with hypothyroidism is e$ective?a. he client is thirsty.b. he client;s weight has been the same for weeks.c. he client;s total white blood cell count is


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3lients who have chronic renal failure do not completely activate vitamin @and poorly absorb calcium from the I tract. hey are chronicallyhypocalcemic' which triggers overstimulation of the parathyroid glands.

____ 1C. Which assessment )nding in the client with diabetes mellitusindicates that the disease is damaging the kidneys?

a. he presence of ketone bodies in the urine during acidosisb. he presence of glucose in the urine during hyperglycemiac. he presence of protein in the urine during a random urinalysisd. he presence of white blood cells in the urine during a random urinalysis

13'. ANS: C!rine should not contain protein' and the presence of proteinuria in a diabeticmarks the beginning of renal problems known as diabetic nephropathy' whichprogresses eventually to end+stage renal disease. 3hronically elevated bloodglucose levels cause renal hypertension and ecess kidney perfusion withleakage from the renal vasculature. he ecess leakiness allows largersubstances' such as proteins' to be )ltered into the urine.

____ 11. he client with type , diabetes is prescribed to take the antidiabeticagent nateglinide D2tarliF. Which statements made by the client indicatescorrect understanding of this therapy?a. KIGll take this medicine with my meals.Lb. KIGll take this medicine 18 minutes before I eat.Lc. KIGll take this medicine 9ust before I go to bed.Ld. KIGll take this medicine as soon as I wake up in the morning.L

131. ANS: #5ateglinide is a @+phenylalanine derivative that causes the beta cells of thepancreas to undergo depolari#ation and release a small amount of preformedinsulin. he peak action occurs about ,C minutes after ingestion. o have thebest action and prevent hypoglycemia' clients are instructed to take the drugabout 18 minutes before eating.

____ 1,. Which clinical manifestation in a client with uncontrolled diabetesmellitus should the nurse epect as a result of the presence of ketoacid in theblood?a. Increased rate and depth of respirationb. =tremity tremors followed by sei#ure activityc. :ral temperature of 1C,R > DA.R 3Fd. 2evere orthostatic hypotension

132. ANS: AOetoacidosis decreases the p- of the blood' stimulating the respiratorycontrol areas of the brain to bu$er the e$ects of increasing acidosis. he rateand depth of respiration are increased DOussmaul respirationsF in an attemptto ecrete more acids by ehalation.


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1. Which of the following assessments made by the nurse indicates thatclients has a typical sign of a hip fracture? he client right leg is%a. rotated internallyb. held in a *eed positionc. adductedd. shorter than the leg on the una$ected side

133. ANS. ( 0fter hip fracture' the leg on a$ected side is characteristicallyshorter than the una$ected le' ypically it is also abducted and rotatedeternally. "ain is usually present.

____ 16. What is the priority nursing diagnosis for the older adult client whohas very thin skin on the backs of the hands and arms?a. 4isk for In9uryb. 4isk for Infectionc. 4isk for @isuse 2yndromed. 4isk for Imbalanced Body emperature% hyperthermia

13. ANS: A he thinning skin' with a decreased attachment between the dermis and theepidermis' is at an increased risk for in9ury in response to even minimaltrauma or shearing events.

____ 18. What question should the nurse ask to determine a possible triggerfor the worsening of a clientGs psoriatic lesions?Na. K-ave you eaten a large amount of chocolate lately?Lb. K-ave you been under a lot of stress lately?Lc. K-ave you used a public shower recently?Ld. K-ave you been out of the country recently?L

13!. ANS: #2ystemic factors' hormonal changes' psychological stress' medications' andgeneral health factors can aggravate psoriasis.

____ 1


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5ow' the incision site is elevated' dark' and protrudes beyond her breast skin.What is the nurse;s interpretation of these )ndings?a. he client has formed a keloid' consisting of collagen and groundsubstance' as a result of surgical in9ury to the skin.b. here is a high probability that skin cancer has developed as a result of surgical in9ury to the skin DOoebner phenomenonF.

c. he benign breast disease has undergone malignant transformation tobreast cancer and become locally invasive.d. he change in the breast biopsy scar represents chronic in*ammatorychanges that accompany deep and persistent infection.

13$. ANS: A0 keloid is a benign' noninfectious' overgrowth of a scar from an ecessiveaccumulation of collagen and ground substance after skin trauma. 0lthoughanyone can form a keloid' the propensity is more common among people withdark skin.

____ 1A. Which clinical manifestation indicates that the burned client is

moving into the *uid remobili#ation phase of recovery?a. Increased urine output' decreased urine speci)c gravityb. Increased peripheral edema' decreased blood pressurec. @ecreased peripheral pulses' slow capillary re)lld. @ecreased serum sodium level' increased hematocrit

13%. ANS: A he K*uid remobili#ationL phase improves renal blood *ow' increasingdiuresis and restoring *uid and electrolyte levels. he increased watercontent of the urine reduces its speci)c gravity.

____ 1. he burned client relates the following history of previous healthproblems. Which one should alert the nurse to the need for alteration of the*uid resuscitation plan?a. 2easonal asthmab. -epatitis B 1C years agoc. /yocardial infarction 1 year agod. Oidney stones within the last < month

13&. ANS: CIt is likely the client has a diminished cardiac output as a result of the old /Iand would be at greater risk for the development of congestive heart failureand pulmonary edema during *uid resuscitation.

____ 16C. @uring the acute phase' the nurse applied gentamicin sulfateDtopical antibioticF to the burn before dressing the wound. he client has allthe following manifestations. Which manifestation indicates that the client ishaving an adverse reaction to this topical agent?a. Increased wound pain C to 6C minutes after drug applicationb. "resence of small' pale pink bumps in the wound bedsc. @ecreased white blood cell countd. Increased serum creatinine level


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____ 166. Which measure would be appropriate for the nurse to take in caringfor a client with chronic renal failure receiving dialysis via a right arm )stula?a. ake the client;s blood pressure in both arms.b. ake the client;s blood pressure in the left arm only.c. "lace the right arm in a sling to protect it from in9ury.

d. -ave the client perform active 4:/ arm eercises to aid blood *ow to the)stula.

1. ANS: # he blood pressure should be taken in the left arm only to prevent occlusionof the dialysis )stula.

____ 168. What instruction should the nurse provide to the client who isscheduled to have an abdominal ultrasound for evaluation of uterine si#e andshape?a. K@o not eat or drink after midnight.L

b. K3ompletely evacuate your bowels before this procedure.Lc. K@o not urinate within an hour of having the test' because a full bladder isneeded for best test results.Ld. K-ave someone drive you to and from the test because you will be sleepyfrom the anesthesia.L

1!. ANS: C he scan is noninvasive and painless. he abdominal and pelvic organs arebetter visuali#ed with the bladder full during the scan.

____ 16


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he term invasive when applied to in)ltrating ductal carcinoma means thatthe cancer cells are no longer con)ned to ductal tissue but have spread intosurrounding breast tissue. his term alone' however' does not indicate thatthe disease has spread beyond the breast itself

____ 16A. Which pathologic description of a breast cancer would the nurseinterpret as being indicative of a better prognosis for long+term survival?a. "oorly di$erentiated& ,CH of cells in 2 phase& estrogen receptor negativeb. /oderately di$erentiated& 8CH of cells in 2 phase& estrogen receptornegativec. !ndi$erentiated& 8CH of cells in 2 phase& estrogen receptor positived. -ighly di$erentiated& 1CH of cells in 2 phase& estrogen receptor positive

1%. ANS: (Mower grade malignancies are less aggressive and have a better chance forlong+term survival. Mower grade malignancies are slower growing Dhave asmaller percentage of cells in the 2 phaseF and more closely resemble the

di$erentiated breast tissue from which they arose. =strogen receptorTpositivetumors respond better to ad9uvant therapy' and the client usually has alonger survival rate. In addition' estrogen receptorTpositive tumors can betreated with hormonal manipulation techniques.

____ 16. he client asks how soon after a mastectomy she can engage inseual activity. What is the nurse;s best response?a. KJou may engage in seual activity as soon as you are comfortable.Lb. KJou should wait until months have passed before resuming seualactivity.Lc. KJou may safely engage in seual activity as soon as the incision hashealed completely.Ld. KJou should undergo counseling or therapy before you consider having seagain.L

1&. ANS: A2eual intercourse can be resumed whenever the client is comfortable. !ntilthe incision is healed' clients should be taught how to protect the incision andavoid contact with the surgical site during intercourse.

____ 18C. Which complication of therapy should the nurse teach to the clientprescribed to receive radiation for vaginal cancer?a. "erineal hypopigmentationb. @elay of spontaneous menopausec. @evelopment of vaginal adhesions or stenosisd. 4elaation of pelvic *oor muscles' causing urinary incontinence

1!'. ANS: C4adiation treatment causes local in*ammation' leading to the development of )brotic tissue changes that cause adhesions and(or stenosis. Withoutintervention' these changes can decrease the si#e and elasticity of vaginaltissues' limiting or inhibiting vaginal intercourse.


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