1. One morning the nurse overhears Elma, who is admitted with BPD, having an argument with her mother, When suppertime, Elma is very angry with the nurse and complains nurse must say something bad to her mother about her performance in ward. What the defense mechanism Elma is using?
A.Dissociation
B.Denial
C.Projection
D.Splitting
A B C D
C
2. 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.
3. The multidisciplinary team decides to employ a behavior modification approach to a young female's problem with anorexia nervosa. A planned nursing intervention that would follow this approach would he to
A.Have client role play interactions with her parents
B.Provide client with a high-calorie, high-protein diet
C.Restrict the client to her room until she gains 2 pounds
D.Force the client to talk about her favorite foods for 1 hour a day
A B C D
C
4. A client with hypotonic labor dysfunction is receiving oxytoein augmentation. Her contractions become more frequent and intense. Dilation progresses to 8 cm, but the fetal head remains at station +1. The nurse notes a soft bulge just above the symphysis. Which of the following actions is best?
A.Re-evaluate the fetal presentation.
B.Change the client's position.
C.Offer a narcotic analgesic.
D.Help the client urinate.
A B C D
D
Assessment data indicate a full bladder that may impede fetal descent. The other options are inappropriate because they don't address the assessment findings.
5. A 2-month-old neonate with diarrhea and vomiting has been receiving IV fluids for the past 24 hours. The specific gravity of the neonate's urine is 1.012. What should the nurse do next?
A.Check the neonate's blood pressure.
B.Check the specific gravity again as soon as possible.
C.Notify the physician.
D.Continue the ordered IV flow rate.
A B C D
D
The neonate's urine specific gravity is within normal limits, indicating that he's being adequately hydrated. The other options aren't necessary.
6. A client who survived an airplane crash has a diagnosis of posttraumatic stress disorder (PTSD). He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief for his symptoms?
A.The opportunity to verbalize memories of trauma to a sympathetic listener.
B.Family support.
C.Prescribed medications taken as ordered.
D.Alcoholics Anonymous (AA) meetings.
A B C D
A
Although talking about their experiences can be difficult, clients with PTSD can obtain the most lasting relief if they verbalize memories of the trauma to a sympathetic listener. Family members are commonly frightened by the information and can't be consistently supportive. Antidepressants may help but these drugs can mask feelings and can't provide lasting relief. Treatment for alcohol abuse, including AA meetings, must be considered when planning care but alone doesn't provide lasting relief.
7. The nurse is assessing a client with possible osteoarthritis. The most significant risk factor for osteoarthritis is
A.congenital deformity.
B.age.
C.trauma.
D.obesity.
A B C D
B
Age is the most significant risk factor for developing osteoarthritis. Development of primary osteoarthritis is influenced by genetic, metabolic, mechanical, and chemical factors. Secondary osteoarthritis usually has identifiable precipitating events such as trauma.
8. An elderly client's family tells the nurse that the client has suffered some memory loss in the last few years. They say that the client is sensitive about not being able to remember and tries to cover up this loss to avoid embarrassment. When attempting to increase the client's self-esteem, the nurse should try to avoid discussing events that require memory of the client's
A.Married
B.Work years
C.Recent days
D.Young adulthood
A B C D
C
9. The nurse is performing wound care. Which of the following practices violates surgical asepsis?
A.Holding sterile objects above the waist.
B.Considering a 1" (2.5 cm) edge around the sterile field as being contaminated.
C.Pouring solution onto a sterile field cloth.
D.Opening the outermost flap of a sterile package away from the body.
A B C D
C
Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.
10. A 20-year-old mother of a premature newborn smoked cigarettes during her pregnancy. Her son is a client in a neonatal intensive care unit and has a diagnosis of acute respiratory distress syndrome. Because the mother is Roman Catholic, which nursing intervention would be most appropriate for the nurse to discuss with her?
A.Baptism of the infant.
B.Circumcision of the infant.
C.Last rites for the infant.
D.Sacraments of the sick for the mother.
A B C D
A
The Roman Catholic practice is to baptize infants soon after birth, especially if they are ill and hospitalized. Circumcision may be performed on the infant of a Roman Catholic, but it isn't considered a Roman Catholic practice. Last rites or sacraments of the sick wouldn't be appropriate for the mother of the child.
11. The nurse is caring for a client with late-stage Alzheimer's disease. The client's wife tells the nurse that the client has become very dependent. The client's wife feels guilty if she takes any time for herself because the client cries out for her. The nurse should develop which outcome to assist the client's wife?
A.The caregiver learns to explain to the client why she needs time for herself.
B.The caregiver distinguishes obligations she must fulfill from those that can be controlled or limited.
C.The caregiver leaves the client at home alone for short periods of time to encourage independence.
D.The caregiver avoids asking other family members to help for fear of imposing on them.
A B C D
B
The caregiver must learn to distinguish obligations that she must fulfill and limit those that aren't necessary. The caregiver can tell the client when she leaves but she shouldn't expect that the client will remember or won't become angry with her for leaving. The caregiver shouldn't leave the client home alone for any length of time because it may compromise the client's safety. The nurse can provide support to the primary caregiver if she needs to ask other family members for assistance.
12. A mother whose daughter is killed in a school bus accident tells the nurse that her daughter was just getting over the chickenpox and did not want to go to school, but she insisted that she go. The mother cries bitterly and says her child's death is her fault. The nurse should realize that perceiving a death as preventable would most often influence the grieving process in that:
A.The loss may be easier to understand and to accept
B.Bereavement may be of greater intensity and duration
C.The grieving process may progress to a psychiatric illness
D.It causes the mourner to experience a pathologic grief reaction
A B C D
B
13. Which one is not right about personality disorder?
A.Multiple personality disorder is distinct and separate personalities within the same person
B.People with personality disorder often experience child abuse or traumatic
C.Only the symptoms of personality disorder represent the person's stable characteristics and social functioning, he can be diagnosed personality disorder
D.Paranoid and antisocial personality disorders are more commonly diagnosed in women than men
A B C D
D
14. Which of the following activities should a 2-year-old child to be able to do?
A.Build a tower of eight cubes.
B.Point out a picture.
C.Wash and dry his hands.
D.Remove a garment.
A B C D
D
According to the Denver Ⅱ Developmental Screening test, most 2-year-olds are able to remove one garment. A -year-old can build a tower of eight cubes and point out a picture. A 3-year-old can wash and dry his hands.
15. When planning care for a 7-year-old boy with Down syndrome, the nurse should
A.plan interventions at the developmental level of a 7-year-old child because that is the child's age.
B.plan interventions at the developmental level of a 5-year-old because the child will have developmental delays.
C.assess the child's current developmental level and plan care accordingly.
D.direct all teaching to the parents because the child can't understand.
A B C D
C
Nursing care should be planned at the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. A child with Down syndrome is capable of learning, especially one with mild limitations. Gear teaching toward the appropriate developmental age.
16. A primigravida in labor for 13 hours clenches her fists, tightens her muscles, and screams during every contraction. Her reaction to labor seems exaggerated compared to the contraction pattern recording from the electronic fetal monitor (EFM). What's the nurse's best response?
A.Explain to the client that the EFM shows mild contractions, so she should just relax and let the contractions work.
B.Take over as her coach because her husband isn't helping her properly.
C.Ignore her reactions, realizing that this is her first time in labor and her reactions will soon match the intensity of contractions shown on the EFM.
D.Palpate her abdomen to determine the intensity of labor contractions as they're taking place.
A B C D
D
Internal and external fetal monitors are helpful in assessing the duration and frequency of contractions, but the external monitor doesn't accurately portray the intensity of the contraction. The labor room nurse must evaluate this by palpation. Taking over as her coach, ignoring her reactions, and telling her to relax fail to recognize the need for palpation.
17. 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.
18. The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying.
A."Now isn't a good time to begin dieting because you are eating for two. "
B."Let's explore your feelings further. "
C." Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems. "
D."The prenatal vitamins should ensure the baby gets all the necessary nutrients. "
A B C D
C
Depriving the developing fetus of nutrients can cause serious problems, and the nurse should discuss this with the client. The client isn't eating for two; this is a misconception. Exploring feelings helps the client understand her concerns, but she needs to be aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or neonate needs; they work in congruence with a balanced diet.
19. The client with a head injury receives mannitol (Osmitrol) during surgery to help decrease intracranial pressure. Which of the following nursing observations would most likely indicate that the drug is having the desired effect?
A.Urine output increases.
B.Pulse rate decreases.
C.Blood pressure decreases.
D.Muscular relaxation increases.
A B C D
A
Mannitol is an osmotic diuretic that helps decrease intracranial pressure through its dehydrating effects. The drug is acting in the desired manner when urine output increases.
20. A client is prescribed 1000 mL of an antibiotic solution to be given over 6 hours. What would be the flow rate? The infusion set administers 15 gtts/mL.
A.28 gtts/min.
B.35 gtts/min.
C.42 gtts/min.
D.45 gtts/min.
A B C D
C
The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. Flow Rate = (Volume×Calibration) /Time (minutes). In this case, the Rate=15gtts/mL×1000mL/360min=42gtts/min.
21. Drugs to treat acute anxiety are prescribed to a client hospitalized for an acute myocardial infarction. The client is reluctant to take anti-anxiety drugs. The nurse suspects that the client is holding the drugs under his tongue and disposing of them after she has left the room. What should the nurse do first?
A.Report her suspicions to the client's physician.
B.Talk to the client about his attitude toward the medications.
C.Search the client's room for evidence of the medications.
D.Tell the client that his behavior must stop for his own well-being.
A B C D
B
Before reporting these concerns to the physician, the nurse should discuss the perceived problem about the medications with the client. The nurse will then have more information about the client's attitude toward anti-anxiety medications when she informs the physician of her suspicions. Searching the client's room for the medications is a violation of the client's right to privacy. The nurse and the physician can talk to the client about the benefits of taking the medication prescribed; however, the client has the right to refuse the medication.
22. A 10-year-old girl visits the clinic for a checkup before entering school. The child's mother questions the nurse about what to expect of her daughter's growth and development at this stage. Which response is most appropriate?
A."Her physical development will be rapid at this stage, and rapid development will continue from now on. "
B."She'll become more independent and won't require parental supervision. "
C."Don't anticipate any changes at this stage in her growth and development. "
D."Friends will be very important to her, and she'll develop an interest in the opposite sex. "
A B C D
D
Friends become very important at this age. Children usually begin having an interest in the opposite sex around this age, although they aren't always willing to admit it. Her physical development towards maturity continues, but it isn't as rapid at this stage as in previous years. Although independence increases at this stage, children continue to need parental supervision. Growth and development slow down, but gradual changes continue to occur.
23. A client with thyroid cancer undergoes a thyroidectomy. After surgery, the client develops peripheral numbness and tingling and muscle twitching and spasms. The nurse should expect to administer
A.thyroid supplements.
B.antispasmodics.
C.barbiturates.
D.IV calcium.
A B C D
D
Removal of the thyroid gland can cause hyposecretion of parathormone leading to calcium deficiency. Manifestations of calcium deficiency include numbness, tingling, and muscle spasms. Treatment includes immediate administration of calcium. Thyroid supplements will be necessary following thyroidectomy but aren't specifically related to the identified problem. Antispasmodics don't treat the problem's cause. Barbiturates aren't indicated.
24. 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.
25. The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
A.Heparin sodium (Hep-Lock).
B.Dexamethasone (Deeadron).
C.Methyldopa (Aldomet).
D.Phenytoin (Dilantin).
A B C D
A
Administration of heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. For a client with hemorrhagic shock, dexamethasone may be used to decrease cerebral edema and pressure; methyldopa, to decrease blood pressure; and phenytoin, to prevent seizures.
26. Which client has the highest risk of ovarian cancer?
D.36-year-old woman who had her first child at age 22.
A B C D
B
The incidence of ovarian cancer increases in women who have never been pregnant, are infertile, or have menstrual irregularities and after menopause. Other risk factors include a personal or family history of ovarian, breast, bowel, or endometrial cancer. The risk of ovarian cancer is reduced in women who have taken oral contraceptives, have had multiple births, or have had a first child at a young age.
27. A pregnant client with premature rupture of the membranes has had contractions every 10 minutes. After 48 hours, the contractions stop and the client is to be discharged with home monitoring. The nurse discusses with the client about preterm labor symptoms. Which of the following statements made by the client indicates that she needs further instruction?
A."I should report contractions that occur every 10 minutes in 1 hour. "
B."I should lie in bed on my left side if contractions begin. "
C."I should call the doctor if my contractions occur every hour for 6 hours. "
D."If I start having contractions, I should empty my bladder. "
A B C D
C
It is not necessary for the client to call the health care provider if she experiences contractions every hour for 6 hours, but she should continue to monitor the contraction pattern to determine if the contractions are increasing in frequency.
28. After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic would most suggest this diagnosis?
A.Supportive child-parent interaction (speaking, listening, touching, and eye-to-eye contact).
B.Parents' active participation in child's physical or emotional care.
C.Parents' failure to use available support systems or agencies to assist in coping.
D.Evidence of adaptation to parental role changes.
A B C D
C
A failure to use available support systems or agencies is one of the defining characteristics of this diagnosis. Supportive child-parent interaction, parents' active participation in the child's care, and evidence of adaptation to parental role changes don't suggest this diagnosis.
Part Two
1. 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.
2. A client who was found huddled in her apartment by the police is admitted to the clinic. The client stares toward one corner of the room and seems to be responding to something not visible to others. She appears hyperalert and scared. Which of the following conclusion by the nurse is most appropriate according to the situation?
A.Nothing is wrong because the client isn't a threat to society.
B.The client is malingering.
C.The client may be hallucinating.
D.The client is suicidal.
A B C D
C
The scenario is typical of a client who is hallucinating. Not enough information is available to suggest that she's a threat to herself or to society. Malingering refers to a medically unproven symptom that is consciously motivated.
3. 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.
4. A client who is breast-feeding has a temperature of 102°F (38.9℃) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which of the following actions would be inappropriate in managing the client's breast engorgement?
A.Applying frozen cabbage leaves to the breasts.
B.Encouraging the client to shower with her back to the water.
C.Encouraging the client to nurse her baby frequently.
D.Applying a breast binder to support the breasts.
A B C D
D
Engorgement in a breast-feeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Binding the breasts isn't appropriate because the constriction will diminish the milk supply. Frozen cabbage leaves work well to reduce the pain and swelling and should be applied every 4 hours. Facing the shower head can stimulate the breasts and intensify the problem. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant.
5. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?
A.Arm and leg weakness.
B.Absence of the gag reflex.
C.Difficulty swallowing.
D.Inability to speak clearly.
A B C D
D
Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
6. A client is admitted to the hospital with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of care?
A.Assessing the client's temperature every 8 hours.
B.Placing the client in respiratory isolation.
C.Monitoring the client's fluid intake and output.
D.Wearing gloves during all client contact.
A B C D
B
Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Assessing the temperature every 8 hours isn't frequent enough for a client with a fever. Monitoring fluid intake and output may be required, but the client should be placed in isolation first. The nurse should only wear gloves for contact with mucous membranes, broken skin, blood, and body fluids and substances.
7. An 20-month-old with acquired immunodeficiency syndrome (AIDS) is seen in the clinic for health maintenance. Which of the following vaccines would the nurse anticipate administering to this toddler?
A.Diphtheria-tetanus-acellular pertussis.
B.Varicella.
C.Measles, mumps, and rubella.
D.Hemophilus influenza.
A B C D
A
Diphtheria, acellular pertussis, and tetanus are killed vaccines and may be given to this toddler. Live virus vaccines are not routinely administered to anyone with an altered immune system because multiplication of the virus may be enhanced, causing a severe vaccine-induced illness.
8. An 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is most likely to help the child cope with fear and separation?
A.Ask the parents not to visit the child until he has adjusted to the new environment.
B.Ask the physician to explain to the child why he needs to stay in the health care facility.
C.Explain to the child that he must act like an adult while he's in the facility.
D.Have the parents stay with the child and participate in his care.
A B C D
D
Allowing the parents to stay and participate in the child's care can provide support to the parents and the child. The other interventions won't address the client's diagnosis and may exacerbate the problem.
9. The client complains a continuous bladder irrigation after a transurethral resection. Which of the following is the major goal of nursing interventions related to the irrigation?
A.Recognize signs of prostate cancer.
B.Perform activities of daily living.
C.Maintain catheter patency.
D.Reduce incisional bleeding.
A B C D
C
Maintaining catheter patency during the immediate postoperative period after a transurethral resection is a priority because postoperative bleeding can occlude the catheter. Catheter occlusion can lead to urinary retention, pain, bladder spasm, and the need to replace the catheter.
10. Conditions necessary for the development of a positive sense of self-esteem include
A.consistent limits.
B.critical environment.
C.inconsistent boundaries.
D.physical discipline.
A B C D
A
A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem.
11. During a routine follow-up examination, the nurse updates the client's medication history. The client currently receives prednisone therapy. Concomitant use of an agent from which of the following classes could increase the risk of peptic ulcer disease?
A.Antidiabetic agents, administered orally.
B.Nonsteroidal anti-inflammatory drugs (NSAIDs).
C.Beta-adrenergic blockers.
D.Contraceptive agents, administered orally.
A B C D
B
Concomitant use of NSAIDs may increase the risk of a peptic ulcer; therefore, they should be administered 2 hours before or 2 hours after prednisone. Oral antidiabetic agents, beta-adrenergic blockers, and oral contraceptive agents don't increase the risk of peptic ulcer disease when administered with prednisone.
12. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
A.Platelet count, prothrombin time (PT), and partial thromboplastin time (PTT).
B.Platelet count, blood glucose levels, and white blood cell (WBC) count.
C.Thrombin time, calcium levels, and potassium levels.
D.Fibrinogen level, WBC count, and platelet count.
A B C D
A
The diagnosis of DIC is based on the results of laboratory studies of PT, platelet count, thrombin time, PTT, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC.
13. Which toy would be most appropriate for a 3-year-old?
A.A bicycle.
B.A puzzle with large pieces.
C.A pull toy.
D.A computer game.
A B C D
B
At age 3, children like to color, draw, and put together puzzles. A bicycle is appropriate for a 5- or 6-year-old child; a pull toy, for a toddler; and a computer game, for a school-age child.
14. The nurse is teaching a new mental health aide. For which of the following clients is setting limits most important?
A.A depressed client.
B.A manic client.
C.A suicidal client.
D.An anxious client.
A B C D
B
Setting limits for unacceptable behavior is most important in a manic client. Typically, depressed, suicidal, or anxious clients don't physically or mentally test the limits of the caregiver.
15. A multigravida at 36 weeks' gestation visits the emergency department because her boyfriend has beaten her severely. What should the nurse do first?
A.Contact the authorities.
B.Ensure the client's safety.
C.Identify a support person.
D.Photograph the client's injuries.
A B C D
B
The first nursing intervention is to ensure the client's safety because these clients are terrified that the abuser will arrive and continue the cycle of violence. After this has been done, the nurse can contact the authorities, identify a support person, and ensure confidentiality. Photographing the client's injuries requires the client's consent.
16. The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
A.Avoiding the use of recreational drugs and alcohol.
B.Refraining from telling anyone about the diagnosis.
C.Following safer-sex practices.
D.Telling potential sex partners about the diagnosis, as required by law.
A B C D
C
It's essential that AIDS clients follow safer-sex practices to prevent transmission of the human immunodeficiency virus. Although it's helpful if AIDS clients avoid using recreational drugs and alcohol, for purposes of avoiding transmission it's more important that IV drug users use clean needles and dispose of used needles. Whether the AIDS client chooses to tell anyone about an AIDS diagnosis is the client's decision; there's no legal obligation to do so.
17. The nurse is caring for a client who is on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy?
A.Hypoglycemia.
B.Crackles.
C.Bradycardia.
D.Hyperkalemia.
A B C D
B
Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia.
18. Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should
A.keep the client warm.
B.maintain room temperature at 78°F (25.6℃).
C.keep the client uncovered.
D.match the room temperature with the client's body temperature.
A B C D
A
The nurse should keep the client covered and expose only the portion of the client's body that is being assessed. The nurse should also keep the client warm by maintaining his room temperature between 68° and 74°F (20° and 23.3℃). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient and exposing them to vast changes in temperature could influence the client's response. A room temperature of 78°F may be too warm for some clients and too cool for others. Keeping the client uncovered would lead to chilling. Matching the room temperature with the client's body temperature is inappropriate.
19. If none of the following bed positions is contraindicated, which position would be preferred for the client with hypovolemic shock?
A.Supine.
B.Semi-Fowler's.
C.Trendelenburg's.
D.Supine with the legs elevated 15 degrees.
A B C D
D
A client in hypovolemic shock is best positioned supine in bed with the feet elevated 15 degrees to bring peripheral blood into the central circulation.
20. A hospitalized client taking 30 mg of tranylcypromine (Parnate) twice per day complains of a stiff neck and headache. Which action would be best for the nurse to take?
A.Note the complaints as usual adverse effects.
B.Withhold the next dose of medication.
C.Administer an analgesic, as needed and as prescribed.
D.Help the client relax.
A B C D
B
A stiff neck and headache may be prodromal symptoms of hypertensive crisis. Rather than dismiss the symptoms, the nurse should continue to assess them and consult the physician. Administering an analgesic and helping the client relax would be appropriate measures for a tension headache.
-year-old can build a tower of eight cubes and point out a picture. A 3-year-old can wash and dry his hands.
深色：已答题 浅色：未答题