Part One You will have two hours and 30 minutes to complete Part One.
1. The nurse teaches the client with peptic ulcer disease about how to effectively adjust his response to work-related stress. Which of the following statements by the client indicates that the education is effective?
A."My job is too stressful. I will have to find a different career. "
B."I don't have any control over my stressors at work. My coworkers are difficult to work with. "
C."Well, I guess this ulcer means I won't be able to work toward a promotion. "
D."I will have to improve my ability to cope with stress. "
A B C D
D
Although clients cannot eliminate stress, they can improve their ability to cope with it.
2. Which nursing diagnosis would be the most appropriate for a client with coronary artery disease (CAD) ?
A.Ineffective thermoregulation.
B.Impaired gas exchange.
C.Risk for injury.
D.Decreased cardiac output.
A B C D
D
CAD develops when fatty deposits line the walls of the coronary arteries, impeding blood flow and therefore decreasing cardiac output. Thermoregulatory disturbances aren't usually associated with CAD unless accompanied by heart failure. Impaired gas exchange may occur if the blood's oxygen-carrying capacity were altered, as in anemia, chronic obstructive pulmonary disease, or carbon monoxide poisoning. There would be a risk of injury if the client had sensory or motor deficits.
3. At what gestational age would a primigravida expect to feel "quickening"?
A.12 weeks.
B.16 to 18 weeks.
C.20 to 22 weeks.
D.By the end of the 26th week.
A B C D
C
It's important for the nurse to distinguish between a client who is having her first baby and one who has already had a baby. For the client who is pregnant for the first time, quickening occurs around 20 to 22 weeks. Women who have had children will feel quickening earlier, usually around 18 to 20 weeks, because they recognize the sensations.
4. Hormonal effects of the antipsychotic medications include which of the following?
A.Retrograde ejaculation and gynecomastia.
B.Dysmenorrhea and increased vaginal bleeding.
C.Polydipsia and dysmenorrhea.
D.Akinesia and dysphasia.
A B C D
A
Decreased libido, retrograde ejaculation, and gynecomastia are all hormonal effects that can occur with antipsychotic medications. Reassure the client that the effects can be reversed or that changing medication may be possible. Polydipsia, akinesia, and dysphasia aren't hormonal effects.
5. From an analysis of the data collected about the client who has had a gastric resection, the nurse formulates the nursing diagnosis Risk for ineffective airway clearance. Based on which of the following postoperative factors would the nurse make this diagnosis?
A.Incisional pain.
B.Nausea.
C.Progressive ambulation.
D.Maintenance of a semi-Fowler's position.
A B C D
A
Breathing and coughing cause pain in clients with high abdominal incisions. Chest excursion decreases, which decreases coughing and deep-breathing efforts. Shallow breathing leads to hypoventilation and atelectasis.
6. The nurse discusses with the 4-year-old child and parents the plan of care that will be implemented when the child returns from the throat surgery. Which of the following interventions should the nurse emphasize?
A.Need for frequent coughing.
B.Use of acetylsalicylic acid for pain, as needed.
C.Ability to have ice cream right after surgery.
D.Use of sips of clear liquids when awake and alert.
A B C D
D
Once the child is alert, he may have sips of clear liquids. Eating enhances the blood supply to the throat, which promotes rapid healing. However, the child should start with clear fluids.
7. Which of the following criteria would be a reliable indicator of improvement in a patient who has a diagnosis of anorexia nervosa?
A.Electrolyte balance.
B.Energy level.
C.Fluid intake.
D.Desire to eat.
A B C D
A
The most reliable indicator of improvement in the patient with anorexia nervosa is electrolyte balance. As the patient starved herself, the body entered a hypometabolic state. Decreased nutrients and the loss of electrolytes through vomiting and laxative use contribute to electrolyte imbalances. As the patient begins eating and ceases purging, electrolyte begin returning to normal.
8. The nurse identifies a client's responses to actual or potential health problems during which step of the nursing process?
A.Assessment.
B.Analysis.
C.Planning.
D.Evaluation.
A B C D
B
The nurse identifies human responses to actual or potential health problems during the analysis step of the nursing process, which encompasses the ability of the nurse to formulate a nursing diagnosis. During the assessment step the nurse systematically collects data about the client or family. During the planning step the nurse develops strategies to resolve or decrease the client's problem. During the evaluation step the nurse determines the effectiveness of the plan of care.
9. After 5 days of hospitalization, the client who is receiving morphine sulfate for pain control asks for more pain medication with increasing frequency and exhibits increased anxiety and restlessness. His physical condition is stable. What is the probable cause of his behavior?
A.His morphine dosage is too high.
B.His coping mechanisms are exhausted.
C.He is becoming addicted to the narcotic.
D.He has developed tolerance to his narcotic dosage.
A B C D
D
Tolerance to a regular narcotic dose can develop with frequent use. The client experiences increased discomfort, asks for medication more frequently, and exhibits anxious and restless behavior, which are often misinterpreted as indicative of developing dependence or addiction.
10. An assisted birth using forceps or a vacuum extractor may be performed for ineffective pushing, for large neonates, to shorten the second stage of labor, or for a malpresentation. When caring for the mother following an assisted birth, the nurse should keep which of the following in mind?
A.A vacuum extractor is safer than forceps because it causes less trauma to the neonate and the mother's perineum.
B.The neonate will develop a cephalohematoma as a result of the instrumentation.
C.The use of instruments during the birth process is a fairly rare occurrence.
D.Additional nursing interventions are needed to ensure an uncomplicated postpartum.
A B C D
A
When used properly, a vacuum extractor is a safer delivery with fewer complications for the mother and the neonate than a forceps delivery. Cephalohematomas occur more often in assisted births than in unassisted births. Instruments are used during delivery when individually necessary. No additional nursing interventions are needed during the postpartum period.
11. A 20-year-old woman has just been diagnosed with Crohn's disease. She has lost 10 lb (4.5kg) and has cramps and occasional diarrhea. The nurse should include which of the following when doing a nutritional assessment?
A.Let the client eat as desired during hospitalization.
B.Weigh the client daily.
C.Ask the client to list what she eats during a typical day.
D.Place the client on I＆O status and draw blood for electrolyte levels.
A B C D
C
When performing a nutritional assessment, one of the first things the nurse should do is to assess what the client typically eats. The client shouldn't be permitted to eat as desired. Weighing the client daily, placing her on I＆O status, and drawing blood to determine electrolyte levels aren't part of a nutritional assessment.
12. Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt?
In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure.
13. Nursing care for a client after electroeonvulsive therapy (ECT) should include which of the following?
A.Nothing by mouth for 24 hours after the treatment because of the anesthetic agent.
B.Bed rest for the first 8 hours after a treatment.
C.Assessment of short-term memory loss.
D.No special care.
A B C D
C
The nurse must assess the level of short-term memory loss. Short-term memory loss is the most common adverse effect of ECT. In most cases, memory returns within 3 months. The client might need to be reoriented. The client can get out of bed and eat as soon as he feels comfortable.
14. After receiving large doses of an ovulatory stimulant such as menotropins (Pergonal), a client comes in for her office visit. Assessment reveals the following: 6 lb (2.7 kg) weight gain, ascites, and pedal edema. These findings indicate which of the following?
A.They are normal signs of an ovulatory stimulant.
B.The client is demonstrating signs of hyperstimulation syndrome.
C.The client is having a reaction to the menotropins.
D.The client is probably pregnant.
A B C D
B
Characterized by abdominal swelling from ascites, weight gain, and peripheral edema, hyperstimulation syndrome from ovulatory stimulants is an unusual occurrence. This client must be admitted to the hospital for management of the disorder. Nursing care includes emotional support to reduce anxiety and management of symptoms. These signs aren't normal reactions to ovulatory stimulants and aren't signs of pregnancy.
15. A client, a gravida 3 para 2 at 35 weeks' gestation, comes in to the antepartum clinic for a check-up. She has been experiencing backaches after standing all day at her job as a grocery clerk. Which of the following exercise would the nurse suggest to relieve backache?
A.The pelvic tilt.
B.Squatting.
C.Stretching.
D.Walking.
A B C D
A
An exercise, such as the pelvic tilt, can help restore body alignment and alleviate backache. Squatting strengthens the pelvic muscles. Stretching and walking are good exercises but often don't relieve backache.
16. A 68-year-old woman is admitted to the general surgical unit for removal of a breast mass malignancy. In the presurgical assessment of the client, which of the following choices would be most appropriate for the nurse to ask when assessing her self-concept?
A."Let's talk about what you'd like to do that you haven't done. "
B."List for me your accomplishments and achievements in life. "
C."Tell me how this breast surgery will make you feel about yourself. "
D."What does your husband say when he compliments you?"
A B C D
C
Breast surgery can be psychologically traumatic to a woman, especially if she closely links her womanhood and sexuality to her breasts. With this in mind, the nurse must ask proactive questions regarding the client's feelings about her own breasts. Listing accomplishments or describing ambitions will give the nurse a general impression of the client's self-concept; however, at this point, the breast-related question is more valuable because of the nature of the illness and the proposed surgery. Eliciting information about the husband's comments doesn't focus on the nurse's assessment of the client's perception of herself.
17. A 58-year-old client complaining of difficulty driving at night states that the "lights bother my eyes" even though he wears corrective glasses. The nurse would suspect that the client is experiencing a deficiency in which of the following vitamins?
A.Vitamin Ａ.
B.Vitamin Ｂ complex.
C.Vitamin Ｅ.
D.Vitamin Ｃ.
A B C D
A
Vitamin A is important for the eye's ability to see color. The B complex vitamins play a role in many functions, including nerve conduction. Vitamins E and C have antioxidant properties and aid in wound healing.
18. The primary reason for withholding food and fluids from a client who will receive general anesthesia is to help prevent
A.constipation during the immediate postoperative period.
B.vomiting and possible aspiration of vomitus during surgery.
C.pressure on the diaphragm with poor lung expansion during surgery.
D.gas pains and distention during the immediate postoperative period.
A B C D
B
Oral food and fluids are withheld before surgery when a client receives general anesthesia primarily to help prevent vomiting and possible aspiration of stomach contents.
19. The nurse is caring for a client who has a history of alcohol abuse. Why would the client act as if he didn't have a problem?
A.The client has never taken the CAGE questionnaire.
B.Denial is a defense mechanism commonly used by alcoholics.
C.Thought processes are distorted.
D.Alcohol is expensive.
A B C D
B
Denial is a defense mechanism commonly used by alcoholics. The CAGE questionnaire is a direct method of discovering whether the client is a substance abuser, but the client is likely to deny the problem regardless of whether he's familiar with this assessment tool. Distorted thought processes and the cost of alcohol are less likely to influence the client's use of denial.
20. For a child receiving steroids in therapeutic doses over a long period, the nurse should pay more attention on which of the following?
A.Monitor the child's serum glucose level.
B.Decrease the child's ingestion of potassium-rich foods.
C.Give the drug on an empty stomach.
D.Monitor the child's temperature to assess for infection.
A B C D
A
Steroid use tends to elevate glucose levels. The child should be monitored for increases.
21. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to have which of the following findings?
A.Tension and irritability.
B.Slow pulse.
C.Hypotension.
D.Constipation.
A B C D
A
An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.
22. A client with newly diagnosed type 1 diabetes mellitus is learning about diabetic foot care. Which of the following statements by the client indicates further instruction is needed?
A."I should use lotions. "
B."I should use antiperspirants. "
C."I should use foot soaks. "
D."I should use nail files. "
A B C D
C
Foot soaks macerate the skin and increase the risk for breaks. Water-soluble lotions are recommended to moisturize the feet. Nail files are preferred over nail clippers or scissors. Antiperspirants may be used when foot perspiration exists.
23. What is the nurse's most important role in caring for a client with a mental health disorder?
A.To offer advice.
B.To know how to solve the client's problems.
C.To establish trust and rapport.
D.To set limits with the client.
A B C D
C
It's extremely important that the nurse establish trust and rapport. The nurse shouldn't offer advice. Instead, she should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also important but not as important as developing trust and rapport.
24. A client with testicular cancer is scheduled for a right orchiectomy. The day before surgery, the client asks the nurse whether losing a testicle will have influence on his manhood. Which of the following facts about orchiectomy should form the basis for the nurse's response?
A.Testosterone levels are decreased.
B.Sexual drive and libido are unchanged.
C.Sperm count increases in the remaining testicle.
D.Secondary sexual characteristics change.
A B C D
B
The remaining testicle undergoes hyperplasia and produces enough testosterone to maintain sexual drive, libido, and secondary sexual characteristics.
25. Which of the following would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia?
A.Change current diet habits.
B.Seek prompt antibiotic therapy for viral infections.
C.Receive prophylactic antibiotic therapy.
D.Obtain annual influenza and pneumococcal vaccines.
A B C D
D
Annual influenza and pneumococcal vaccines are effective in reducing the recurrence of pneumonia.
26. Which of the following laboratory tests is considered the most reliable indicator of renal function?
A.BUN.
B.Urinalysis.
C.Serum potassium.
D.Serum creatinine.
A B C D
D
Serum creatinine is the most reliable indicator of renal function.
27. When assessing a client as a candidate for crutch walking, the nurse should take into account that for some elderly people, crutch walking is an impractical goal primarily because which of the following reason?
A.Decreased reaction time.
B.Decreased visual acuity.
C.Decreased motor coordination.
D.Decreased level of comprehension.
A B C D
C
Some elderly people are not good candidates for crutch walking because they are not strong enough to use crutches or are not coordinated enough to walk safely with crutches.
28. To help promote independence in the area of feeding for a school-aged child in skeletal traction, the nurse would help the child choose which of the following meals?
A.Carrot sticks, celery with cream cheese, roast beef and gravy, peas, gelatin, and milk in a cup.
B.Chicken noodle soup with crackers, grilled cheese sandwich, cole slaw, and chocolate milk in a carton.
C.Chicken nuggets with sauce, carrot sticks, French-fried potatoes, ice cream sandwich, and milk in a carton.
D.Spaghetti and meat sauce, cherry cobbler, and apple juice in a can.
A B C D
C
To promote self-feeding, the nurse should provide the child with foods that can be eaten with the fingers or that do not spill easily.
29. Oxytocin (Pitocin) is administrated to a client during labor. Which of the following is the most serious adverse effect associated with oxytocin?
A.Water intoxication.
B.Tetanic contractions.
C.Elevated blood pressure.
D.Early decelerations of fetal heart rate.
A B C D
B
Tetanic contractions are the most serious adverse effect associated with administering oxytocin. When tetanic contractions occur, the fetus is at high risk for hypoxia and the mother is at risk for uterine rupture. The client may be at risk for pulmonary edema if large amounts of oxytocin have been administered, and this drug can also increase blood pressure. However, pulmonary edema and increased blood pressure aren't the most serious adverse effects. Early decelerations of fetal heart rate aren't associated with oxytocin administration.
30. The nurse notices that a client's abdominal wound has eviscerated. Which of the following would the nurse do first?
A.Notify the client's physician immediately.
B.Reinsert the protruding viscera into the abdominal cavity.
C.Place the client in reverse Trendelenburg's position.
D.Cover the wound with sterile saline-moistened dressings.
A B C D
D
In the event of wound evisceration, the first action would be to cover the wound with a sterile towel or dressing moistened with sterile normal saline solution to prevent possible infection and keep the protruding viscera moist.
Part Two You will have one hour and 50 minutes to complete Part Two.
1. When preparing a client for a scheduled colonoscopy, which of the following nursing interventions would the nurse include?
A.Inserting a nasogastric tube 12 hours before the procedure.
B.Cleansing the bowel with laxatives or enemas.
C.Administering an antibiotic to decrease the risk of infection.
D.Spraying a local anesthetic into the client's throat to calm the gag reflex.
A B C D
B
A colonoscopy is the visual examination of the large bowel using a fiberoptic endoscope inserted into the client's rectum. Typically the client will be placed on a liquid diet 24 hours before the procedure and kept NPO after midnight the night before the procedure. The bowel is cleansed through the use of laxatives and enemas.
2. The nurse is caring for a client with an exacerbation of ulcerative colitis. Which of the following nursing measures should be included in the plan of care?
A.Encourage regular use of antidiarrheal medications.
B.Incorporate frequent rest periods into the client's schedule.
C.Have the client maintain a high-fiber diet.
D.Wear a gown when providing direct client care.
A B C D
B
It is important for the client to have frequent rest periods. Repeated episodes of diarrhea interrupt sleep patterns, and poor nutrition may also cause the client to feel weak. If the client is experiencing a severe exacerbation of ulcerative colitis, bed rest may be ordered.
3. Which of the following is appropriate to include in a teaching plan for a 9-year-old who has had diabetes for several years?
A.Beginning recognition of symptoms of hypoglycemia.
B.Measurement of insulin accurately in the syringe.
C.Beginning ability to give own injections with adult supervision.
D.Assumption of responsibility for self-care.
A B C D
C
Children who are from eight to ten years old are developmentally ready to begin to give their own injections with adult supervision. Their fine motor skills are developed enough to accomplish this skill.
4. The nurse is caring for a client who is experiencing auditory hallucinations. What would be most critical for the nurse to assess?
A.Possible hearing impairment.
B.Family history of psychosis.
C.Content of the hallucinations.
D.Possible sella turcica tumors.
A B C D
C
To prevent the client from harming himself or others, the nurse should encourage the client to reveal the content of auditory hallucinations.
5. The nurse is caring for a client with mild active bleeding from placenta previa. Which of the following observations indicates that an emergency cesarean section may be necessary?
A.Increased maternal blood pressure of 150/90 mmHg.
B.Decreased amount of vaginal bleeding.
C.Fetal heart rate of 80 beats per minute.
D.Maternal heart rate of 65 beats per minute.
A B C D
C
A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean delivery to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate the delivery of the neonate.
6. A new mother is concerned because her breast-feeding neonate wants to "nurse all the time. " Which of the following responses best indicates the normal neonate's breast-feeding behavior?
A."Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings. "
B."Let me call the lactation consultant to make sure that your baby is feeding properly. "
C."Don't worry; your baby is an aggressive feeder and needs a lot of sucking satisfaction. "
D."It seems as if your baby is hungry. Why don't you provide your baby with some formula after the feeding to make sure he's getting enough nourishment?"
A B C D
A
Breast milk is the ideal food for a neonate. As a result, the neonate will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk. Although a lactation consultant may be helpful, the nurse should be able to provide the mother with adequate information. Telling the client not to worry ignores her concern. Suggesting supplementation with formula indicates that the mother's breast-feeding attempts are unsatisfactory. Nurses shouldn't suggest giving formula to a breast-feeding infant.
7. An 8-year-old child with asthma is being switched from parenteral steroid therapy to a daily dose of oral prednisone. Which of the following instructions would the nurse give to the parents?
A.Have the child take the dose with meals to prevent gastric irritation.
B.Make sure the pill is given intact to maintain the enteric coating.
C.Administer the dose before bedtime to minimize side effects.
D.Give the medication according to the child's response.
A B C D
A
Prednisone causes severe gastric upset. Therefore, it should be given with food.
8. A client undergoes a total laryngectomy and tracheostomy formation. On discharge, which instruction should the nurse give to the client and family?
A."Clean the tracheostomy tube with alcohol and water. "
B."Family members should continue to talk to the client. "
C."Oral intake of fluids should be limited for 1 week only. "
D."Limit the amount of protein in the diet. "
A B C D
B
Commonly, family members are reluctant to talk to a client who has had a total laryngectomy and no longer can speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client and family to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.
9. Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?
A.Having the client take rapid, shallow breaths to decrease pain.
B.Having the client lay on the left side while coughing and deep breathing.
C.Teaching the client to use a folded blanket or pillow to splint the incision.
D.Withholding pain medication so the client can be alert enough to follow the nurse's instructions.
A B C D
C
A folded bath blanket or pillow placed over the incision will be most effective in helping the client cough and deep breathe after a cholecystectomy.
10. Which of the following would the nurse interpret as indicating that a child is receiving too much intravenous fluid too rapidly?
A.Marked increase in abdominal girth.
B.Evidence of protein in the urine.
C.Dark amber colored urine.
D.Moist crackles in the lung fields.
A B C D
D
Moist crackles in the lung fields are an indication that fluid is accumulating in the lungs due to overhydration or too-rapid delivery of fluids.
11. Which of the following observations indicates that the mother of a child receiving home intravenous ampicillin therapy requires further teaching?
A.The mother allows the antibiotic to run into the child's vein over a period of 30 minutes.
B.The mother flushes the venous access site with heparin 20 minutes after giving the antibiotic.
C.The mother stops the infusion when the area around the insertion site becomes hard and reddened.
D.The mother calls the home care nurse because the antibiotic solution will not infuse.
A B C D
B
When administering intravenous antibiotics, heparin or saline should be used to flush the intravenous line as soon as the infusion is completed so that the line remains patent. Waiting for 20 minutes is too long.
12. A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. What should the nurse do first?
A.Auscultate for bowel sounds.
B.Palpate the abdomen.
C.Change the client's position.
D.Insert a rectal tube.
A B C D
A
If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation, and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.
13. A client is diagnosed with hyperthyroidism. The clinical manifestations of hyperthyroidism are similar to which of the following?
A.Hypovolemic shock.
B.Adrenergic stimulation.
C.Benzodiazepine overdose.
D.Addison's disease.
A B C D
B
Hyperthyroidism is a hypermetabolic state characterized by signs, such as tachycardia, systolic hypertension, and anxiety--all seen in adrenergic (sympathetic) stimulation. Manifestations of hypovolemic shock, benzodiazepine overdose, and Addison's disease are more similar to a hypometabolic state.
14. When developing a plan of home care for the client with multiple sclerosis, the nurse should teach the client about which of the following complications most likely to occur?
A.Ascites.
B.Contractures.
C.Fluid volume overload.
D.Myocardial infarction.
A B C D
B
Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications.
15. During a panic attack, a client runs to the nurse and reports breathing difficulty, chest pains, and palpitations. The client also is pale and has a wide open mouth and raised eyebrows. What should the nurse do first?
A.Assist with deep breathing into a paper bag.
B.Orient the client to person, place, and time.
C.Set limits for acting out delusional behaviors.
D.Administer an anxiolytic agent IM.
A B C D
A
Physiologic needs, particularly breathing, are the first priority during a panic attack. Restoring normal breathing patterns should relieve the other symptoms. Orientation usually is unnecessary because most clients respond to external control and reduced stimulation. During a panic attack, the client isn't likely to act out but may strike out if feeling threatened. An anxiolytic agent may be effective but isn't the first priority.
16. Signs and symptoms of retinal detachment include which of the following?
A.Painless decrease in vision, a veil over the visual field, and flashing lights.
B.A veil over the visual field, increased intraocular pressure, and yellow-green halos around visual images.
C.Photophobia, yellow-green halos around visual images, and blurred vision.
D.Unilateral eye inflammation, a cloudy cornea, and a moderately dilated pupil.
A B C D
A
A client with retinal detachment has a painless decrease in vision and vision that is cloudy or smoky with flashing lights. The client may also indicate that a curtain or veil is over the visual field. Intraocular pressure is normal or low. Photophobia, yellow-green halos around visual images, and blurred vision may occur with digoxin toxicity. Unilateral eye inflammation, cloudy cornea, and a moderately dilated pupil that isn't reactive to light may occur with glaucoma.
17. The nurse palpates a multipara's fundus immediately after delivery of the placenta and assesses that it's boggy. The nurse massages the client's uterus until it's firm. Which medication would the nurse anticipate to administer if the uterus becomes boggy again?
A.Rho(D) immune globulin (RhoGAM).
B.Magnesium sulfate.
C.Oxytocin (Pitocin).
D.Ibuprofen.
A B C D
C
Oxytocin would be given to cause the uterus to maintain a firm contraction. When the uterus remains boggy, the myometrium isn't contracted, and bleeding occurs at the placental attachment site. Ibuprofen has anti-inflammatory properties but doesn't prevent a boggy uterus. RhoGAM is given to prevent Rh isoimmunization. Magnesium sulfate is given to stop preterm labor contractions because it causes the uterine smooth muscle to relax.
18. A client with a serum glucose level of 618mg/dL is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs, temperature of 100. 6°F (38.1℃), heart rate of 116 beats/minute, and blood pressure of 108/70mmHg. Based on these assessment findings, which nursing diagnosis takes highest priority?
A.Deficient fluid volume related to osmotic diuresis.
B.Decreased cardiac output related to elevated heart rate.
C.Imbalanced nutrition. Less than body requirements related to insulin deficiency.
D.Ineffective thermoregulation related to dehydration.
A B C D
A
A serum glucose level of 618 mg/dL indicates hyperglycemia, which causes polyuria and deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid volume than from decreased cardiac output because his blood pressure is normal. Although the client's serum glucose is elevated, food isn't a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced nutrition. Less than body requirements isn't appropriate. A temperature of 100. 6°F isn't life-threatening, eliminating ineffective thermoregulation as the top priority.
19. Which of the following home care activities would be appropriate for a client with a laryngectomy?
A.Keep the stoma opening covered at all times.
B.Participate in activities such as walking and golfing.
C.Stay inside in an air-conditioned environment in the summer.
D.Avoid showering; take tub baths instead.
A B C D
B
The client should be encouraged to participate in activities such as walking, golfing, and other moderate recreational sports.
20. When developing a teaching plan for the family of a child with seizures, which of the following would the nurse include when discussing pharmacologic treatment?
A.Medication is adjusted independently when side effects occur.
B.Abrupt cessation of the medication must be avoided.
C.Dosages will be decreased as the child grows older.
D.Medication therapy is necessary for the rest of the child's life.
A B C D
B
Abrupt cessation of the medication must be avoided because sudden drug withdrawal most commonly leads to status epilepticus, a life-threatening emergency situation.
21. A 40-year-old client is admitted to the psychiatric emergency department because of sleeping difficulty, poor judgment, and incoherent at times. The client's speech is rapid and loose. She reports being a special messenger from the Messiah. She has a history of depressed mood for which she has been taking an antidepressant. Which diagnosis would the nurse suspect?
A.Schizophrenia.
B.Paranoid personality.
C.Bipolar illness.
D.Obsessive-compulsive disorder (OCD).
A B C D
C
Bipolar illness is characterized by mood swings from profound depression to elation and euphoria. Delusions of grandeur along with pressured speech are common symptoms of mania. Schizophrenia doesn't exhibit mood swings from depression to euphoria. Paranoia is characterized by unrealistic suspiciousness and is commonly accompanied by grandiosity. OCD is a preoccupation with rituals and rules.
22. For a client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to
A.prevent respiratory alkalosis.
B.lower arterial pH.
C.promote carbon dioxide elimination.
D.maintain partial pressure of arterial oxygen (PaO2) above 80 mmHg.
A B C D
C
The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mmHg; 60 mmHg will adequately oxygenate most clients.
23. Which of the following activities should the nurse discourage the client with a peptic ulcer?
A.Chewing gum.
B.Smoking cigarettes.
C.Eating chocolate.
D.Taking acetaminophen (Tylenol).
A B C D
B
Cigarette smoking should be avoided because of its stimulatory effect on gastric secretions. Nicotine also increases the release of epinephrine, which leads to vasoconstriction.
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