Part One You will have two hours and 30 minutes to complete Part One.
1. The nurse assesses the client to determine the cause of autonomic dysreflexia. Which of the following is the most common stimulus for an autonomic dysreflexia episode?
A.Rising intracranial pressure.
B.Bowel distention.
C.Bladder distention.
D.Anxiety.
A B C D
C
The dysreflexia occurs from a sympathetic response to autonomic nervous system stimulation. A distended bladder is the most common cause. After placing the client in Fowler's position, the nurse should check the urinary catheter for patency.
2. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
A.Make inhalation longer than exhalation.
B.Exhale through an open mouth.
C.Use diaphragmatic breathing.
D.Use chest breathing.
A B C D
C
In chronic bronchitis, the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing--not chest breathing-- increases lung expansion.
3. A 6-week-old female infant exhibits dry scaly skin and a protruding tongue after having trouble breast-feeding. A diagnosis of congenital hypothyroidism is made. The mother asks the nurse why the child was not diagnosed with this condition at birth. Which of the following would be the nurse's best response?
A."We had the results of the newborn screen, but you did not bring the baby in for the 2-week checkup. "
B."We could not reach you at home to give you the results of tests taken at birth. "
C."Your baby had little need for thyroid hormone until she was 1 month old. "
D."Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks. "
A B C D
D
With congenital hypothyroidism, failure of normal development occurs during the embryonic period or when an inborn error of metabolism prevents the normal synthesis of thyroxine. Although the condition is present at birth, maternal thyroxine can pass through the placenta to the fetus, supplying the fetus and neonate sufficiently. Thus, in most neonates, the signs of hypothyroidism are commonly masked at birth.
4. Which of following would lead the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?
A.An increased sense of rectal pressure.
B.An increase in fetal heart rate variability.
C.A decrease in intensity of contractions.
D.Episodes of nausea and vomiting.
A B C D
A
An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur.
5. The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?
A.Set up a strict eating plan for the client.
B.Encourage the client to exercise, which will reduce her anxiety.
C.Restrict visits with the family until the client begins to eat.
D.Provide privacy during meals.
A B C D
A
Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals--not given privacy. Exercise must be limited and supervised.
6. Which of the following would be best to help prepare a preschool-aged child for an injection?
A.Having an older child explain that shots do not hurt.
B.Helping the child to imagine she is in a different place.
C.Giving the child a play syringe and a bandage to give a doll injections.
D.Giving the child a pounding board to encourage expressions of anger.
A B C D
C
Allowing the preschool-aged child to give play injections can help to prepare the child to receive an injection. Preschoolers have a limited vocabulary. They express their feelings through play. They also use play to help cope with stress.
7. The nurse assesses the client's urinary stoma regularly for edema. Which of the following signs and symptoms might indicate excessive stomal edema?
A.Elevated temperature.
B.Urine output below 30 mL/hour.
C.Urine dribbling from the stoma.
D.Complaints of discomfort around the stoma.
A B C D
B
Urine output below 30 mL/hour could indicate stomal edema which obstructs urine output.
8. Which of the following nursing diagnoses would be most appropriate for a client newly diagnosed with non-insulin-dependent diabetes mellitus?
A.Risk for infection related to newly diagnosed diabetes.
B.Altered nutrition, more than body requirements related to overproduction of insulin.
C.Altered health maintenance related to lack of knowledge of proper foot care.
D.Pain related to elevated blood glucose levels.
A B C D
C
Knowledge of foot care is essential for the client with diabetes mellitus, especially a newly diagnosed diabetic, because of the risk for complications secondary to the effects of diabetes on the vascular and neurologic systems. Improper care may lead to serious debilitating complications.
9. When completing an assessment of a healthy adolescent client, which of the following would be most appropriate?
A.Obtain a detailed account of the adolescent's prenatal and early developmental history.
B.Discuss sexual preferences and behaviors with the parents present for legal reasons.
C.Discuss the client's smoking with parents present in the room.
D.Assess the adolescent in private; gather additional information from the parents.
A B C D
D
When assessing an adolescent, it is appropriate to first obtain information from the adolescent in private then interview the parents for additional information. Doing so helps to promote independence and responsibility for self-care.
10. Which of the following case meets the criteria for involuntary commitment?
A.A single parent who leaves her minor children unattended and stays out all night drinking.
B.A person who lives alone and isn't able to care for himself and has schizophrenia with delusions of persecution.
C.A man who threatens to kill his wife.
D.A person with depression who says he's tired of living but doesn't have a suicide plan.
A B C D
C
One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others. A parent might have a child removed from the home because of neglect, but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself.
11. A client diagnosed with a peptic ulcer undergoes an upper gastrointestinal endoscopy to help the physician visualize the ulcer's location and severity. Immediately after the endoscopy, what would be a priority for the nurse to assess?
A.Return of the gag reflex.
B.Bowel sounds.
C.Peripheral pulses.
D.Intake and output.
A B C D
A
Prior to an upper gastrointestinal endoscopy, a local anesthetic is applied to the posterior pharynx. This results in temporary loss of the gag reflex which facilitates passage of the endoscope. The client is at risk for aspiration until the gag reflex returns. Therefore, monitoring the client for return of the gag reflex is a priority nursing assessment.
12. The nurse is caring for a client with bipolar disorder in a manic state. Which of the following nursing interventions should be included in the plan of care?
A.Allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.
B.Listening attentively with a neutral attitude and avoiding power struggles.
C.Offering high-calorie meals and strongly encouraging the client to finish all food.
D.Insisting that the client remain active through the day so that he'll sleep at night.
A B C D
B
The nurse should listen to the client's requests, express willingness to seriously consider the requests, and respond later. High-calorie finger foods should be offered to supplement the client's diet, if he can't remain seated long enough to eat a complete meal. The client shouldn't be forced to stay seated at the table to finish a meal. The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldn't try to restrain the client when he feels the need to move around as long as his activity isn't harmful. The nurse should set limits in a calm, clear, and self-confident tone of voice.
13. Which of the following would the nurse expect to find in a client diagnosed with hyperparathyroidism?
A.Hypocalcemia.
B.Hypercalcemia.
C.Hyperphosphatemia.
D.Hypophosphaturia.
A B C D
B
Hypercalcemia is the hallmark of excess parathyroid hormone levels. Serum phosphate will be low (hypophosphatemia), and there will be increased urinary phosphate (hyperphosphaturia) because phosphate excretion is increased.
14. The nurse would teach the client to implement which of the following nasal care measures after the nasal packing is removed?
A.Irrigate the nares with normal saline solution daily.
B.Remove old blood from inside the nares with cotton-tipped applicators.
C.Avoid cleaning the nares for at least 2 days.
D.For comfort lubricate the membranes with a water-soluble lubricant.
A B C D
D
A water-soluble lubricant offsets dryness and enhances comfort during healing. The lubricant also prevents secretions from drying and crusting in the nose.
15. A client with type 1 (insulin-dependent) diabetes mellitus who is a multigravida visits the clinic at 28 weeks' gestation. Which of the following instruction by the nurse is appropriate for the client?
A.Nonstress testing is performed weekly until 32 weeks' gestation.
B.Weekly fetal movement counts are made by the mother.
C.Contraction stress testing is performed weekly.
D.Induction of labor is begun at 34 weeks' gestation.
A B C D
A
For most clients with insulin-dependent diabetes mellitus, nonstress testing is done weekly until 32 weeks' gestation to assess fetal well-being. A nonreactive test may be followed by a contraction stress test (CST), but CST's aren't performed weekly because of the risks involved. The mother should make daily fetal movement counts beginning at 28 weeks' gestation. Labor may be induced for clients with large fetuses at 37 to 38 weeks' gestation.
16. Labor is divided into how many stages?
A.Two.
B.Three.
C.Four.
D.Five.
A B C D
C
Labor is divided into four stages: first stage, onset of labor to full dilation. second stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, 1-hour postpartum. The first stage is divided into three phases: early, active, and transition.
17. A respectable lawyer is admitted to an acute care facility with epigastric pain. Since admission, the client has called the nurse every 15 minutes with one request or another. Which of the following could explain this client's behavior?
A.Repression.
B.Somatization.
C.Regression.
D.Conversion.
A B C D
C
The client is exhibiting the defense mechanism of regression--a return to behavior characteristic of an earlier developmental level. Dependent, attention-getting behavior is an attempt to relieve anxiety. Repression would manifest as ignoring the symptoms. Somatization is the channeling of anxiety into a preoccupation with physical complaints. Conversion involves transfer of a mental conflict into a physical symptom to relieve anxiety.
18. A client with multiple sclerosis has been prescribed baclofen. The nurse teaches the client about the action of the drug. Which of the following is an accurate instruction regarding this drug's action?
A."Baclofen will decrease your fatigue and help increase your energy levels. "
B."Baclofen will help relieve the muscle spasms that you have been experiencing. "
C."It is an antibiotic that will help treat your urinary tract infection. "
D."Taking this drug will help decrease the visual problems you have been having. "
A B C D
B
Baclofen is a central-acting skeletal muscle relaxant that is used to decrease the spasticity experienced by individuals with multiple sclerosis.
19. For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which of the following acid-base imbalances?
A.Respiratory alkalosis.
B.Respiratory acidosis.
C.Metabolic alkalosis.
D.Metabolic acidosis.
A B C D
C
Metabolic alkalosis occurs because of the excessive loss of potassium, hydrogen, and chloride in the vomitus. Chloride loss leads to a compensatory increase in the number of bicarbonate ions. The bicarbonate side of the carbonic acid-base bicarbonate is increased, and the pH becomes more alkaline.
20. The nurse is administering magnesium sulfate to a client with preeclampsia. The nurse explains to the client that this drug is given for which of the following reason?
A.To prevent seizures.
B.To reduce blood pressure.
C.To slow the process of labor.
D.To increase diuresis.
A B C D
A
The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium.
21. Which of the following methods would the nurse use to feed an infant after surgical repair of cleft lip?
A.Gastric gavage.
B.Intravenous fluids.
C.Rubber-tipped medicine dropper.
D.Bottle with a lamb's nipple.
A B C D
C
Feeding methods should produce the least tension possible on the sutures to promote effective healing of the cleft lip repair. Therefore, a rubber-tipped medicine dropper has been found to be a satisfactory method for feeding an infant who has had surgical repair of a cleft lip.
22. The nurse is teaching a client and his family about dietary practices related to Parkinson's disease. A priority for the nurse to address is risk of
A.fluid overload and drooling.
B.aspiration and anorexia.
C.choking and diarrhea.
D.dysphagia and constipation.
A B C D
D
The eating problems associated with Parkinson's disease include dysphagia, aspiration, constipation, and risk of choking. Fluid overload, anorexia, and diarrhea aren't problems specifically related to Parkinson's disease. Drooling occurs with Parkinson's disease but doesn't take priority.
23. Which assessment finding would lead the nurse to suspect dehydration in a preterm neonate?
A.Bulging fontanels.
B.Excessive weight gain.
C.Urine specific gravity below 1.012.
D.Urine output below 1 mL/hour.
A B C D
D
A urine output below 1mL/hour is a sign of dehydration. Other signs of dehydration include depressed fontanels, excessive weight loss, decreased skin turgor, dry mucous membranes, and urine specific gravity above 1.012.
24. Which of the following would lead the nurse to suspect that a neonate with an infection is developing septic shock?
A.Axillary temperature is 99.8°F?(37.7℃).
B.Blood pressure is 45/25 mmHg.
C.Heart rate during sleep is 205 beats per minute.
D.Respiratory rate while awake is 32 breaths per minute.
A B C D
C
A sleeping heart rate of 205 bpm is above the normal 200 bpm for this age. Increased heart rate is an early indication of ensuing septic shock.
25. A client is being admitted to the labor unit. Because she's well advanced in labor, the nurse must prioritize the admission questions. Which information is most important to obtain when birth is imminent?
A.Duration of previous labor.
B.Frequency of contractions.
C.Presence of bloody show.
D.Expected due date.
A B C D
D
Because birth is imminent, the most important information is the expected due date because it will help the health care team prepare to meet the special needs of a preterm or postterm infant. The duration of previous labor, frequency of contractions, and presence of bloody show aren't significant because birth is imminent and these factors don't affect the provision of safe care during childbirth.
26. The most effective health-promotion measure related to glaucoma that the nurse could teach clients is which of the following?
A.Appropriate blood pressure control.
B.Prompt treatment of all eye infections.
C.Avoidance of extended-wear contact lenses by older people.
D.Annual intraocular pressure measurements for people older than 40 years.
A B C D
D
The most effective health-promotion measure associated with glaucoma is annual intraocular pressure measurements after 40 years of age. People who are at risk for developing glaucoma, such as those with diabetes or hypertension, African Americans, and people with a family history of glaucoma, should have their intraocular pressure checked annually after 35 years of age. Glaucoma is insidious, basically asymptomatic, and must be diagnosed before the client becomes aware of any vision changes.
27. Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which of the following?
A.Poor ability to concentrate urine.
B.Little skin pigment to prevent sunburn.
C.Poorly functioning temperature control center.
D.Abnormally high salt loss through perspiration.
A B C D
D
One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Salt supplements are almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual.
28. A 2-year-old child is brought to the emergency room with a broken arm. Which of the following findings would lead the nurse to suspect child abuse?
A.The child has bruises on the forearms.
B.The child's clothes are dirty, torn, and obviously "hand-me-downs. "
C.The child's father alters the story of the injury each time he tells it.
D.The child's mother did not come to the hospital with the child.
A B C D
C
The nurse should suspect child abuse when the child's earegiver changes the story of the injury each time it is told.
29. During the first 3 months, which hormone is responsible for maintaining pregnancy?
A.Human chorionic gonadotropin (HCG).
B.Progesterone.
C.Estrogen.
D.Relaxin.
A B C D
A
HCG is the hormone responsible for maintaining the pregnancy until the placenta is in place and functioning. Serial HCG levels are used to determine the status of the pregnancy in clients with complications. Progesterone and estrogen are important hormones responsible for many of the body's changes during pregnancy. Relaxin is an ovarian hormone that causes the mother to feel tired, thus promoting her to seek rest.
30. Which of the following concepts would the nurse incorporate into the plan of care for a 4-year-old child to psychologically prepare the child for cardiac catheterization?
A.Anxiety decreases when a preschooler is protected from learning about unpleasant events.
B.Preschoolers are unable to understand the procedure.
C.Little psychological preparation can be given to preschoolers.
D.Preparation is a joint responsibility of the physician, parents, and nurse.
A B C D
D
For a preschooler, psychological preparation for events is the joint responsibility of the physician, parents, and nurse, each playing a major role in caring for the child and meeting specific needs.
Part Two You will have one hour and 50 minutes to complete Part Two.
1. A client is fully dilated. Which of the following actions would be inappropriate during the second stage of labor?
A.Positioning the mother for effective pushing.
B.Preparing for delivery of the baby.
C.Assessing for rupture of membranes.
D.Assessing vital signs every 15 minutes.
A B C D
C
In most cases, the membranes have ruptured (spontaneously or artificially) by this stage of labor. Positioning for effective pushing, preparing for delivery, and assessing vital signs every 15 minutes are appropriate actions at this time.
2. To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals which of the following?
A.Elevational rubor.
B.No rubor for 10 seconds after the maneuver.
C.Dependent pallor.
D.A 30-second filling time for the veins.
A B C D
C
If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.
3. A client who has been using crutches at home for t week reports that he is having trouble using the crutches because his armpits hurt and his fingers tingle. What would be the nurse's most appropriate response?
A."You need to do more arm exercises. It sounds like your muscles need strengthening. "
B."That's normal. As you adjust to the crutches, the discomfort will diminish. "
C."Be sure to take your pain medication before ambulating. That will help your discomfort. "
D."Let me watch you ambulate. Your crutches or technique may need some adjustment. "
A B C D
D
The nurse should reevaluate the client's use of his crutches because pressure on the axillae from the crutches can lead to "crutch paralysis" secondary to pressure on the brachial plexus nerves. This pressure can result from crutches that are used inappropriately or sized incorrectly.
4. A client diagnosed as having panic disorder with agoraphobia is admitted to the inpatient psychiatric unit. Until her admission, she had been a virtual prisoner in her home for 5 weeks, afraid to go outside even to buy food. Which of the following should be the nurse's overall goal of care?
A.To help the client perform self-care activities.
B.To help the client function effectively in her environment.
C.To help control the client's symptoms.
D.To help the client participate in group therapy.
A B C D
B
A client with panic disorder typically confines movements to increasingly smaller areas to avoid confronting fears, which may dominate her life and limit everyday activities. The overall goal of care is to help the client function within her environment as effectively as possible. Panic disorder with agoraphobia doesn't impair ability to perform self-care activities. Controlling symptoms isn't the overall goal; furthermore, helping the client function effectively will help control symptoms. Although participation in group therapy may help the client control symptoms, encouraging such participation isn't the overall goal of nursing care.
5. The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, which of the following interventions is appropriate?
A.Administer oxygen.
B.Have the client take deep breaths and cough.
C.Place the client in high Fowler's position.
D.Perform chest physiotherapy.
A B C D
C
The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase content in the blood. Deep breathing and coughing will improve oxygenation postoperatively, but may not immediately retieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.
6. A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). The nurse explains the procedure to the client. Which of the following statements by the nurse is most appropriate?
A."PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter. "
B."PTCA involves cutting away blockages with a special catheter. "
C."PTCA involves passing a catheter through the coronary arteries to find blocked arteries. "
D."PTCA involves inserting grafts to divert blood from blocked coronary arteries. "
A B C D
A
PTCA is best described as insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery.
7. Most antipsychotic medications exert which of the following effects on the central nervous system (CNS) ?
A.Stimulate the CNS by blocking postsynaptic dopamine, norepinephrine, and serotonin receptors.
B.Sedate the CNS by stimulating serotonin at the synaptic cleft.
C.Depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine.
D.Depress the CNS by stimulating the release of acetylcholine.
A B C D
C
The exact mechanism of antipsychotic medication action is unknown, but it appears to depress the CNS by blocking the transmission of three neurotransmitters: dopamine, serotonin, and norepinephrine. They don't sedate the CNS by stimulating serotonin, and they don't stimulate neurotransmitter action or acetylcholine release.
8. The nurse assesses the client's burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. What should be the nurse's priority response?
A.Document findings and recheck in 1 hour.
B.Elevate extremity on one pillow.
C.Implement passive range-of-motion exercises.
D.Notify the physician immediately.
A B C D
D
The absence of a pulse, decreased sensation in the extremity, and increasing edema are all indicative of compromised neurovascular status due to compartment syndrome. Loss of pulse or sensation must be reported immediately to the physician. An escharotomy or fasciotomy may need to be performed to release pressure in the extremity. Other assessments to note include the temperature, capillary refill time, and movement or increasing pain of the affected extremity.
9. Which of the following would the nurse teach the mother of a child with leukemia who has an absolute neutrophil count of 900/mm3?
A.The child should wear gloves when in contact with others.
B.The child should stay away from crowds of people.
C.The child should eat raw fruits and vegetables.
D.Anyone in direct contact with the child must wear a gown and mask.
A B C D
B
The normal neutrophil count range is 3,000 to 5,000 cells/mm3. An absolute neutrophil count of 900/mm3 is low, placing the child at high risk for infection. Therefore, the nurse should instruct the mother to have the child avoid crowds because of the risk of exposure to infection. Additionally, siblings and others who have an active infection should stay away from the child.
10. A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is
A.an example of presenting reality.
B.reinforcing the client's delusions.
C.focusing on emotional content.
D.a nontherapeutic technique called mind reading.
A B C D
C
The nurse should help the client focus on the emotional content rather than delusional material. Presenting reality isn't helpful because it can lead to confrontation and disengagement. Agreeing with the client and supporting his beliefs are reinforcing delusions. Mind reading isn't therapeutic.
11. The client was admitted with severe head injury resulting from a motor vehicle accident. The client is presently unconscious. To facilitate rehabilitation when the client's condition allows, the nurse should
A.maintain limbs in the position of function.
B.apply restraints to arms and legs to control spasms.
C.exercise just the arms as the legs maintain their tone longer.
D.notify physical therapy as soon as the physician orders passive range of motion.
A B C D
A
Maintaining the client's limbs in the position of function decreases the likelihood of contractures. There's no evidence that the client is experiencing spasms, and the nurse would exercise the arms and legs as long as injuries permit. The longer rehabilitation is delayed, the more difficult it is.
12. The nurse is preparing the client with a cerebrovascular accident for discharge to home. The nurse should recognize which of the following factors would most likely influence the client's continuing progress in rehabilitation at home?
A.The family's ability to provide support to the client.
B.The client's ability to ambulate.
C.The availability of a home health aide to care for the client.
D.The frequency of follow-up visits with the physician.
A B C D
A
The strong support of family members is frequently identified as an important factor that influences a stroke client's continuing progress in rehabilitation after discharge. Discharge planning should prepare the client and family for the many changes necessary when the client returns home.
13. A 23-year-old client in the manic phase of bipolar disorder is admitted to the facility. Which of the following agents would be appropriate for this client?
A.Bupropion (Wellbutrin) and lithium (Lithobid).
B.Lithium (Lithobid) and valproic acid (Depakene).
C.Haloperidol (Haldol) and fluphenazine (Prolixin).
D.Risperidone (Risperdal) and clozapine (Clozaril).
A B C D
B
Lithium and valproic acid are the drugs of choice for manic depression. Wellbutrin is an antidepressant, not an antimanic. Haloperidol, fluphenazine, clozapine, and risperidone are antipsychotic agents.
14. A client is placed in full leather restraints. How often must the nurse check the client's circulation?
A.Once per hour.
B.Once per shift.
C.Every 10 to 15 minutes.
D.Every 2 hours.
A B C D
C
Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isn't often enough and could result in permanent damage to the client's extremities.
15. Which of the following would the nurse expect to include in the plan of care for a client with diabetes who is in labor?
A.Measuring urine output every 4 hours.
B.Monitoring blood glucose levels every hour.
C.Administering insulin subcutaneously every 4 hours.
D.Checking deep tendon reflexes every 2 hours.
A B C D
B
Because metabolic changes occur during labor and delivery, close monitoring of the diabetic client's blood glucose level, every hour during the labor, is necessary.
16. Which of the following is the most appropriate activity for the nurse to assess motor strength for a neurologically injured client?
A.Compare equality of hand grasps.
B.Observe spontaneous movements.
C.Observe the client feed himself.
D.Ask the client to signal if he feels pressure applied to his feet.
A B C D
A
Comparing equality of hand grasps is a technique used to assess motor strength.
17. A client with an incomplete small bowel obstruction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the client's care once the Cantor tube has passed into the duodenum?
A.Maintain bed rest with bathroom privileges.
B.Advance the tube 2 to 4 inches at specified times.
C.Provide frequent mouth care.
D.Provide ice chips for the client to suck.
A B C D
B
Once the intestinal tube has passed into the duodenum, it is usually advanced as ordered 2 to 4 inches every 30 to 60 minutes. This, along with gravity and peristalsis, enables passage of the tube forward.
Directions: The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number. The nurse is teaching an adolescent with inflammatory bowel disease about treatment with corticosteroids. Which adverse effects are concerns for this client?
18. Acne.
对 错
A
19. Hirsutism.
对 错
A
20. Mood swings.
对 错
A
21. Growth spurts.
对 错
B
22. Osteoporosis.
对 错
A
23. Adrenal suppression.
对 错
A
Adverse effects of corticosteroids include acne, hirsutism, mood swings, osteoporosis, and adrenal suppression. Steroid use in children and adolescents may cause delayed growth, not growth spurts.
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