Part One You will have two hours and 30 minutes to complete Part One.
1. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)?
A.Monthly blood tests will be necessary.
B.Report a sore throat or fever to the physician immediately.
C.Blood pressure must be monitored for hypertension.
D.Stop the medication when symptoms subside.
A B C D
B
A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/μL, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician.
2. A client is brought to the hospital after vomiting bright red blood and is admitted through the emergency department with a diagnosis of bleeding duodenal ulcer. While the client is bleeding, it will be essential for the nurse to assess frequently for signs of early shock. Which one of the following is an important indicator of early shock?
A.Tachycardia.
B.Dry, flushed skin.
C.Increased urine output.
D.Loss of consciousness.
A B C D
A
In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation.
3. Which condition could a mother have and still be allowed to breast-feed her child?
A.Positive for human immunodeficiency virus (HIV).
B.Active tuberculosis (TB).
C.Cardiac disease.
D.Endometritis.
A B C D
D
Of the listed conditions, endometritis is the only one in which a mother can continue to breast-feed provided that the antibiotics she's taking aren't contraindicated. A mother who has HIV or active TB is strongly discouraged from breast-feeding because of concerns about transmitting the infection to the neonate. Clients with cardiac disease are also discouraged from breast-feeding because of the strain on the mother's defective heart.
4. For a client in addisonian crisis, it would be very risky for a nurse to administer
A.potassium chloride.
B.normal saline solution.
C.hydrocortisone.
D.fludrocortisone.
A B C D
A
Addisonian crisis results in hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.
5. The client has a newly positive Mantoux skin test although she does not have active tuberculosis. Which medical therapy would be appropriate for her?
A.Reevaluating the client's condition every 6 months.
B.Performing a repeat skin test every 6 months.
C.Administering isoniazid for about 9 months.
D.Administering isoniazid until the skin test reverts to negative.
A B C D
C
Clients with newly positive skin tests are aggressively treated with isoniazid for about 9 months.
6. Theophylline ethylenediamide is administered to a client with COPD. The nurse knows that the medication is for which of the following purpose?
A.To reduce bronchial secretions.
B.To relax bronchial smooth muscle.
C.To strengthen myocardial contractions.
D.To decrease alveolar elasticity.
A B C D
B
Theophylline ethylenediamide is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease. Theophylline ethylenediamide does increase strength of myocardial contractility, but this is not the action for which it is used.
7. The nurse is preparing the client with heart failure to go home. Which of the following should be most important to include in the discharge education?
A.Monitor urine output daily.
B.Monitor daily potassium intake.
C.Maintain bed rest for at least 1 week.
D.Weigh daily.
A B C D
D
People with heart failure are taught to maintain a target weight and to weigh themselves daily to monitor increasing fluid retention. Fluid retention can lead to decompensation and hospitalization.
8. During a private conversation, a client with borderline personality disorder asks the nurse to "keep my secret" and then displays multiple self-inflicted, superficial lacerations on the forearms. What is the nurse's best response?
A."This type of behavior requires you to be on suicide precautions. "
B."I'm going to tell your physician. Do you want to tell me why you did that?"
C."Tell me what type of instrument you used. I'm concerned about infection. "
D."Whenever something important occurs in treatment, the team needs to know about it. I'll have to tell the others, but let's talk about it first. "
A B C D
D
This response informs the client of the nurse's planned actions and allows time to discuss the client's actions. The first two responses put the client in a defensive position and may set up a power struggle. The third response ignores the psychological implications of the client's actions.
9. Which outcome would indicate successful treatment of diabetes insipidus?
A.Fluid intake of less than 2,500 mL in 24 hours.
B.Urine output of more than 200 mL/hour.
C.Blood pressure of 90/50 mmHg.
D.Pulse rate of 126 beats/minute.
A B C D
A
Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease urine output and oral fluid intake.
10. All of the following would be appropriate interventions for a client with acute epididymitis EXCEPT which of the following?
A.Maintaining bed rest.
B.Elevating the testes.
C.Applying ice packs intermittently.
D.Applying hot packs to the scrotum.
A B C D
D
Intermittent ice application will enhance comfort and reduce swelling.
11. A 15-year-old boy is admitted to the health care facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include which of the following?
A.Violence on television.
B.Passive parents.
C.An internal locus of control.
D.A single-parent family.
A B C D
A
Violence on television has been correlated with an increase in aggressive behavior. Passive parents contribute to acting-out behaviors but not specifically to violence. An internal locus of control leads to a positive sense of self-esteem and isn't related to violence or aggression. There is no direct correlation between single-parent families and violence.
12. Which of the following home regimens should the nurse suggest to relieve itching in children with chicken pox?
A.Generous amounts of fine baby powder.
B.Oatmeal preparation baths.
C.Terrycloth towels moistened with hydrogen peroxide.
D.Cool compresses moistened with a weak salt solution.
A B C D
B
Because of colloidal properties, oatmeal preparation baths often help relieve the itching associated with chicken pox. Calamine lotion can be used also.
13. Eight hours after catheterization, the postoperative client with abdominal hysterectomy has not voided. The client tells the nurse, "I don't think I can urinate. " What should the nurse do?
A.Call and inform the surgeon of the client's status.
B.Administer additional pain medication.
C.Increase the client's fluid intake.
D.Assess the client's bladder.
A B C D
D
The nurse should suspect that a client has urinary retention when she is unable to void in an 8-hour period. Before calling the physician for an order to catheterize the client, the nurse should assess the client's bladder for distention.
14. When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following?
A.Fetal hypoxia.
B.Maternal comfort.
C.The contraction pattern.
D.The status of a trapped cord.
A B C D
A
These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions won't improve the contraction pattern, free a trapped cord, or improve maternal comfort.
15. The plan of care for a client with hypertension taking propranolol hydrochloride would include which of the following?
A.Instructing the client to discontinue the drug if nausea occurs and to monitor blood pressure.
B.Instructing the client to notify the physician of irregular or slowed pulse rate.
C.Monitoring blood pressure every week and adjusting the medication dose accordingly.
D.Measuring partial thromboplastin time weekly to evaluate blood clotting status.
A B C D
B
Propranolol hydrochloride is a β-adrenergic blocking agent used to treat hypertension. In addition to lowering blood pressure by blocking sympathetic nervous system stimulation, the drug lowers the heart rate. Therefore, the client should be assessed for bradycardia and other dysrhythmias.
16. Which of the following pieces of equipment would do best job to help prevent external rotation of the client's right leg postoperatively?
A.Sandbags.
B.A high footboard.
C.A rubber air ring.
D.A metal bed cradle.
A B C D
A
It is best to support the client's leg in its proper anatomic position and to prevent external rotation by supporting the leg with sandbags. A trochanter roll can also be used. Sandbags should be placed along the length of the thigh and lower leg.
17. The client asks when he can stop taking the eye medication for his chronic open-angle glaucoma. Which would be the nurse's best response?
A."You can stop using the eye drops when your vision improves. "
B."You Need to use the eye drops only when you has symptoms. "
C."You can discontinue the eye drops after 2 months of normal eye examinations. "
D."You must use the eye medication for the rest of his life. "
A B C D
D
To control his increased intraocular pressure, the client will need to continue taking eye medications for the rest of his life.
18. Which of the following postoperative complications would the nurse particularly anticipate in a client undergoing a pelvic surgical procedure such as an ileal conduit?
A.Bleeding.
B.Infection.
C.Thrombophlebitis.
D.Atelectasis.
A B C D
C
Clients undergoing pelvic surgery are at increased risk for thrombophlebitis postoperatively. Extensive pelvic surgery, such as that involved in an ileal conduit, removes lymph nodes from the pelvis and results in circulatory congestion from edema and stasis.
19. A parent reports that his 2-year-old child often fails when running. The nurse interprets this as indicating which of the following as a normal aspect of a toddler's vision?
A.Near-sightedness.
B.Far-sightedness.
C.Binocular vision.
D.Strabismus.
A B C D
A
Until age 7 years, children are normally myopic and nearsighted. Additionally toddlers lack motor coordination and their depth perception is not well developed, placing them at risk for falling.
20. A school-aged child is admitted to the hospital with newly diagnosed, insulin-dependent diabetes mellitus. On admission his blood sugar is 180 mg/dL. His urine tests negative for ketones. He receives 10 units of regular humulin insulin subcutaneously half hour after admission. What should the nurse do next?
A.Carefully regulate an intravenous solution of normal saline and insulin at 2. 5 hours after admission.
B.Encourage the child to drink at least 500 mL of a sugar-free clear liquid 1.5 hours after admission.
C.Begin intravenous administration of 5% dextrose in water 1 hour after admission.
D.Assess the child 2. 5 hours after admission for shakiness, feelings of anxiety, or decreased level of consciousness.
A B C D
D
The onset of the action of insulin is 1/2 to 1 hour. The peak action occurs in 2 to 4 hours. The child needs to be checked for a hypoglycemic reaction (shaking, feelings of anxiety, and decreased level of consciousness) 2 hours after the insulin is given.
21. Which of the following nursing measures would be most important to decrease the risk of a surgical wound infection in a client with an internal fixation and hip pinning?
A.Inserting an indwelling urinary catheter to prevent possible soiling of the dressing.
B.Accurately measuring drainage from the surgical drainage tube.
C.Changing the surgical dressings using strict sterile technique.
D.Monitoring the incision for signs of redness, swelling, and warmth.
A B C D
C
Wound infection can best be prevented by using strict sterile technique during dressing changes.
22. The nurse should plan to include which of the following interventions in the plan of care for a child admitted to the hospital with a medical diagnosis of febrile seizure?
A.Keep the child supine.
B.Place the child in respiratory isolation and restrict visitors.
C.Keep the room temperature low and bedclothes to a minimum.
D.Place a padded tongue blade at the bedside.
A B C D
C
One nursing goal for clients with febrile seizures is to maintain temperature at a level low enough to prevent recurrence of seizures. Decreasing the environmental temperature and removing excess clothing and blankets will help decrease the client's temperature.
23. When preparing to give a child with insulin-dependent diabetes his dose of regular and NPH humulin insulin, which of the following actions would be most appropriate?
A.Taking the premixed insulin out of the refrigerator, then withdrawing the amount into in one syringe.
B.Using two syringes, one for each type of insulin, and giving two injections.
C.Withdrawing the NPH insulin first, then withdrawing the regular insulin into one syringe.
D.Withdrawing the regular insulin first, then withdrawing the NPH insulin into one syringe.
A B C D
D
Using only one syringe is recommended for the client taking regular insulin along with an intermediate-or long-acting insulin. Additionally, insulin types, such as protamine zinc, globin zinc, and NPH, contain an additional modifying protein that slows absorption. Therefore, a vial of insulin that does not contain the protein (ie, regular insulin) should never be contaminated with insulin that does have the added protein.
24. The client with diverticulitis is treated as an outpatient with drug therapy. Which drug therapy will most probably be employed?
A.Antidepressants.
B.Laxatives.
C.Steroids.
D.Broad-spectrum antibiotics.
A B C D
D
Clients with diverticulitis usually receive antibiotics. Anticholinergics may also be prescribed.
25. Prevention of preterm births is vital for which of the following reasons?
A.It's costly to care for these neonates.
B.These neonates are usually mentally retarded.
C.Preterm birth causes high incidence of the neonatal deaths.
D.These neonates usually wind up with long-term health care needs.
A B C D
C
Prematurity is the leading cause of neonatal deaths in the United States; other industrialized nations have fewer premature births and fewer neonatal deaths than the United States does. Although the other three answers are complications of prematurity, prevention is the outcome nurses must focus on while providing care to their clients.
26. Promethazine hydrochloride (Phenergan) 35 mg IM is ordered for a client who is experiencing nausea and vomiting after surgery. The ampule's label reads 25 mg/mL. How many mL should the nurse prepare to administer?
A.0.7 mL.
B.1.0 mL.
C.1.4 mL.
D.1.8 mL.
A B C D
C
35mg/x mL=25mg/mL, x=1.4mL.
27. When assessing a toddler diagnosed with spastic cerebral palsy, which of the following would the nurse expect to find?
A.Toe-walking.
B.Drooling.
C.Facial grimacing.
D.Wide-based gait.
A B C D
A
Spasticity can cause the toddler to stand or walk on his toes due to an upper motor neuron type of muscular weakness resulting in increased muscle tone.
28. A 35-year-old multigravida at 16 weeks gestation tells the nurse that she has had frequent mood swings during this pregnancy. What would be the nurse's best suggestion to the client?
A.Seek professional counseling.
B.Keep her feelings to herself.
C.Try to avoid fatigue and stress.
D.Decrease her narcissistic behaviors.
A B C D
C
Mood swings are thought to be related to the altered hormonal levels associated with pregnancy. The nurse should suggest that the patient try to avoid fatigue and stress because these factors can exacerbate mood swings. The patient doesn't need professional counseling unless symptoms of psychosis are present. Telling the patient to keep her feelings to herself or to decrease her narcissistic behaviors would be inappropriate.
29. A client diagnosed with gestational diabetes has been admitted for induction of labor at 38 weeks. The client asks the nurse, "My previous labors started on their own. How will this induction of labor be different from my last labor?" Upon which theory would the nurse base her response?
A.An induction causes the contractions to be more intense during the first stage of labor.
B.The risk of uterine rupture is less because the oxytocin (Pitocin) is controlled with an infusion pump.
C.The goal of induction is to produce a contractile pattern similar to that observed in spontaneous labor.
D.During an induction, fetal monitoring begins as soon as oxytocin is started, whereas in a spontaneous labor, monitoring begins when signs of distress occur.
A B C D
C
The goal during induction of labor is to produce a contractile pattern similar to that observed in spontaneous labor. The infusion of oxytocin is increased until a contractile pattern is achieved in which the contractions occur every 2 to 3 minutes with a duration of 40 to 60 seconds in a 10-minute period and the uterus relaxes between contractions. One of the complications of an induction is the risk of uterine rupture. The client scheduled to receive oxytocin is monitored for at least 20 minutes before initiation of the drug to establish a baseline fetal heart rate. Thereafter, the client is monitored in the same way as a client in spontaneous labor, which depends on the maternal and fetal responses to labor.
30. The nurse is changing the subclavian dressing over the catheter insertion site. Which one of the following actions would be appropriate for the nurse to incorporate into the dressing change?
A.Place the client in high-Fowler's position.
B.Check for tubing kinks and leakage.
C.Cleanse the area, starting 2 inches from the insertion site and moving inward.
D.Remove old ointment from the insertion site with soap and warm water.
A B C D
B
To maintain proper infusion rates and prevent line contamination, it is important to inspect the site carefully for fluid leakage or kinks in the tubing under the dressing.
Part Two You will have one hour and 50 minutes to complete Part Two.
1. A client with peptic ulcer has been prescribed propantheline (Pro-Banthine) as part of the treatment. Which of the following side effects is associated with this medication?
A.Nausea.
B.Hypotension.
C.Urinary frequency.
D.Fatigue.
A B C D
A
A common side effect of propantheline, an antichoiinergic, is nausea. Other common side effects include blurred vision, dry mouth, vomiting, and urinary retention.
2. The nurse formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands such as the following
A.drinking more than 1,500 mL of fluid daily.
B.eating a high-protein snack at bedtime.
C.eating more than three large meals per day.
D.being overweight.
A B C D
D
Conditions that increase oxygen demands include being overweight, smoking, exposure to temperature extremes, and stress. A client with chronic bronchitis should drink at least 2,000 mL of fluid daily to thin mucus secretions; restricting fluid intake may be harmful. The nurse should encourage the client to eat a high-protein snack at bedtime because protein digestion produces an amino acid with sedating effects that may ease the insomnia associated with chronic bronchitis. Eating more than three large meals per day may cause fullness, making breathing uncomfortable and difficult; however, it doesn't increase oxygen demands. To help maintain adequate nutritional intake, the client with chronic bronchitis should eat small, frequent meals (up to six per day).
3. Which of the following would the nurse expect to include in a community health program designed to control sexually transmitted diseases (STDs)?
A.Mass screening of all individuals.
B.Location of the possible sources of infection.
C.Treatment of those with the disease.
D.Isolation of those suspected of having STDs.
A B C D
B
Community health measures for controlling STDs most commonly focus on locating the sources of infection. Doing so allows the infected person to identify the person's sexual contacts and urge them to get treatment.
4. The mother of a 2-year-old child tells the nurse that her baby is using a potty seat but is still having problems toilet-training. Which of the following suggestions by the nurse would he most appropriate?
A.Offer the child more praise each time.
B.Use a potty chair instead of a potty seat.
C.Focus on the "accidents" that occur during training.
D.Defer training until the child is developmentally ready.
A B C D
D
The most common reason for failed toilet-training is that the child is simply not developmentally ready for training. Even with appropriate rewards and proper equipment, the child who is not ready for training will not be able to learn voluntary control.
5. Which nursing action is most effective in defusing a client's impending violent behavior?
A.Helping the client identify and express feelings of anxiety and anger.
B.Involving the client in a quiet activity to divert attention.
C.Leaving the client alone until he can talk about his feelings.
D.Placing the client in seclusion.
A B C D
A
In many instances, the nurse can defuse impending violence by helping the client identify and express feelings of anger and anxiety. Statements such as, "What happened to get you this angry?" may help the client discuss feelings rather than act on them.
6. A toddler with croup is given a vaponefrin updraft because of increasing respiratory distress. The nurse evaluates the treatment as being effective when see which of the following?
A.The child's color is normal.
B.The child's retractions are less severe.
C.The child's heart rate is 100 bpm.
D.The child's pulse oximeter reads 90.
A B C D
B
Vaponefrin is epinephrine in an inhalant form. It is given to decrease inflammation in the upper airway through vasoconstriction. It also has bronchodilator effects. In the case of croup, epinephrine is used to increase the opening of the narrowed airway. A decrease in the severity of retractions is the only answer indicating a change that reflects an increase in the airway opening.
7. The nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes of remissions and exacerbations. Which of the following resources can best help the client adapt to the disease?
A.The client's family.
B.Support group.
C.Pastoral care.
D.Hospice care.
A B C D
B
Support groups consist of clients with the same diagnoses who share experiences of the disease with each other. Sharing experiences helps the client understand disease- related problems and gives him a forum in which he can vent his feelings, which are usually similar to those of the group. The client's family and clergy, although supportive, can't share similar disease experiences. Hospice care is usually implemented late in the disease, at the end of life.
8. The nurse is performing a neurologic assessment on a client during a routine physical examination. To assess the Bakinski's reflex, indicate the point where the nurse would place the tongue blade to begin the stroke of the foot.
A.A
B.B
C.C
D.D
A B C D
D
To test for the Babinski reflex, use a tongue blade to slowly stroke the lateral side of the under side of the foot. Start at the heel and move towards the great toe. The normal response in an adult is planter flexion of the toes. Upward movement of the great toe and fanning of the little toes, called the Babinski reflex, is abnormal.
9. A young adult had a significant reaction to the Mantoux test. What conclusion would the nurse make from the findings?
A.The client has active tuberculosis.
B.The client had active tuberculosis.
C.The client has been exposed to tuberculosis.
D.The client is immunocompromised.
A B C D
C
A reaction to the Mantoux test for tuberculosis means that the client has been exposed to the tuberculin bacillus. Further testing needs to be done to determine whether the disease is active or dormant. A positive reaction doesn't mean the client is immunocompromised, but clients who are immunocompromised have a high risk of tuberculosis.
10. A client undergoes extracorporeal shock wave lithotripsy (ESWL) to break up and remove renal calculi. Which of the following nursing measures is appropriate for the postoperative care of this client?
A.Maintain client on strict bed rest for 48 hours after the procedure.
B.Instruct client to anticipate a decrease in urinary output.
C.Instruct client to anticipate hematuria for about 24 hours after the procedure.
D.Limit fluid intake to 1000 mL/day until all stone fragments have been passed.
A B C D
C
It is normal for hematuria to occur for up to 24 hours after ESWL. Hematuria that occurs for longer than 24 hours should be reported to the physician.
11. The nurse teaches the mother of an infant diagnosed with congenital hypothyroidism about daily oral levothyroxine sodium (Synthroid) therapy. Which of the following signs and symptoms would indicate an overdose?
A.Anorexia.
B.Constipation.
C.Sweating.
D.Sleepiness.
A B C D
C
Sweating, insomnia, rapid pulse, dyspnea, irritability, fever, and weight loss are all signs indicating levothyroxine (Synthroid) overdose.
12. The nurse notices that the client's pupils are fixed and dilated. What does this finding indicate?
A.The client is permanently paralyzed.
B.The client is going to be blind as a result of an injury.
C.The client probably has meningitis.
D.The client has received a significant brain injury.
A B C D
D
When the client has received an injury to the midbrain, the pupils become fixed and dilated, an ominous sign. Paralysis, blindness, and meningitis have clinical manifestations other than fixed and dilated pupils.
13. Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. Which nursing observation most suggests the client is bleeding?
A.Prolonged partial thromboplastin time (PTT).
B.Recent history of warfarin (Coumadin) usage.
C.Diminished breath sounds.
D.Orthostatic hypotension.
A B C D
D
Bleeding is a volume-loss problem, which causes a drop in blood pressure. As the bleeding persists and the body's ability to compensate declines, orthostatic hypotension becomes evident. A prolonged PTT and a history of warfarin usage are causes of bleeding but aren't evidence of bleeding. As bleeding persists and the client's level of consciousness declines, breathing will become more shallow and breath sounds will diminish; however, this is a late and unreliable manifestation of bleeding.
14. An 18-year-old primagravida tells the nurse that the physician told her that she needed to increase her intake of thiamine (vitamin Bi) in her diet. Which of the following foods should the nurse instruct the client to consume more?
A.Milk.
B.Rice.
C.Asparagus.
D.Beef.
A B C D
A
Good sources of thiamin include pork, liver, milk, potatoes, enriched cereals, and enriched breads. Rice, asparagus, and beef aren't good sources of thiamine.
15. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by cirrhosis?
A.Dyspnea and fatigue.
B.Ascites and orthopnea.
C.Purpura and petechiae.
D.Gynecomastia and testicular atrophy.
A B C D
C
A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
16. Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which of the following conditions?
A.Hyperpyrexia, slow pulse, and weight gain.
B.Tachycardia, weight loss, and mood swings.
C.Hypotension, weight gain, and listlessness.
D.Increased appetite, slowing of sensorium, and arrhythmias.
A B C D
B
Stimulants produce mood swings, weight loss, and tachyeardia. The other symptoms indicate CNS depression.
17. A client returns from a myelogram, for which an iodized oil (Pantopaque) was used. Which one of the following nursing measures would be included in his care?
A.Bed rest with bathroom privileges.
B.Restricted fluid intake.
C.Head of the bed elevated 45 degrees.
D.Assessment of lower extremity movement and sensation.
A B C D
D
Neurologic status in the lower extremities is assessed frequently, as is the client's ability to void. This is done to determine if there is any nerve impairment.
18. Which of the following would the nurse expect to assess as presumptive signs of pregnancy?
A.Amenorrhea and quickening.
B.A positive pregnancy test and a fetal outline.
C.Braxton Hicks contractions and Hegar's sign.
D.Uterine enlargement and Chadwick's sign.
A B C D
A
Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective but nonconclusive indicators--for example, uterine enlargement, Chadwick's sign, a positive pregnancy test, Braxton Hicks contractions, and Hegar's sign. Positive signs and objective indicators such as fetal outline on ultrasound confirm pregnancy.
19. Which of the following signs or symptoms would lead the nurse to suspect that a 10-year-old child is experiencing early salicylate toxicity?
A.Chest pain.
B.Pink-colored urine.
C.Slowed pulse rate.
D.Dizziness.
A B C D
D
Signs and symptoms of early salicylate toxicity include tinnitus, disturbances in hearing and vision, and dizziness. Salicylate toxicity may cause nausea, vomiting, diarrhea, and bleeding from mucous membranes from long-term use.
20. The nurse is caring for a client with an acute bleeding cerebral aneurysm. Which of the following activities is not appropriate in nursing care?
A.Position the client to prevent airway obstruction.
B.Keep the client in one position to decrease bleeding.
C.Administer IV fluid as ordered and monitor the client for signs of fluid volume excess.
D.Maintain the client in a quiet environment.
A B C D
B
The nurse shouldn't keep the client in one position but rather carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.
21. The physician has ordered the client to receive digoxin (Lanoxicaps) twice per day until a therapeutic level is attained. When the nurse takes the client's apical pulse on the 3rd day, the pulse is 58, and the client complains of nausea. What should the nurse do next?
A.Administer the medication and leave a note on the chart for the physician.
B.Order a serum digoxin level to be drawn.
C.Administer the medication and medicate the client for nausea.
D.Withhold the medication and notify the physician.
A B C D
D
Withholding the medication and notifying the physician is the first step in treating what very well may be digitalis toxicity. Continuing to administer digoxin may result in heart block, while obtaining a serum level doesn't treat the problem.
22. The client is taking triamcinolone acetonide (Azmacort) inhalant to treat her bronchial asthma. Which of the following conditions is the client at increased risk for developing while taking this medication?
A.Oral candidiasis.
B.Hyperglycemia.
C.Gastric ulcer.
D.Fluid retention.
A B C D
A
Azmacort inhalant is a corticosteroid. Use of a steroid inhalers can cause the client to develop oral candidiasis (thrush). It is important that the client rinse his or her mouth after use of the inhaler.
23. The overweight adolescent client tells the nurse that he would like to lose weight and asks the nurse's opinion on how to accomplish his goal. Which of the following suggestions would be most appropriate?
A.Exercising more often.
B.Severely limiting calorie intake.
C.Participating in an adolescent weight-reduction program.
D.Cutting clown on sweets and other snacks.
A B C D
C
Weight loss treatment modalities that include peer involvement have been proven to be the most successful approach with obese adolescents. This is because peer support is critical to adolescents, especially with an all-encompassing problem such as obesity.
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