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NEW QUESTION 248
The nurse practitioner determines that a client is approximately 9 weeks' gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:
- A. Quickening
- B. Abdominal enlargement
- C. A 6-8 lb weight gain
- D. Nausea and vomiting
Answer: D
Explanation:
(A) Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. (B) Quickening is the mother's perception of fetal movement and generally does not occur until 18-20 weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. (C) During the first trimester there should be only a modest weight gain of 2-4 lb. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. (D) Physical changes are not apparent until the second trimester, when the uterus rises out of the pelvis.
NEW QUESTION 249
The nurse needs to be aware that the most common early complication of a myocardial infarction is:
- A. Anaphylactic shock
- B. Diabetes mellitus
- C. Cardiac hypertrophy
- D. Cardiac dysrhythmia
Answer: D
Explanation:
Explanation
(A) Diabetes mellitus is not a common complication of myocardial infarction. (B) Anaphylactic shock is an allergic reaction. (C) Cardiac hypertrophy is a late potential complication. It is a common complication of congestive heart failure. (D) Myocardial infarction causes tissue damage, which may interrupt electrical impulses. Myocardial irritability results from lack of oxygenated tissue.
NEW QUESTION 250
A 68-year-old man was recently diagnosed with endstage renal disease. He has not yet begun dialysis but is experiencing severe anemia with associated symptoms of dyspnea on exertion and chest pain. Which statement best describes the management of anemia in renal failure?
- A. Transfusion is often begun as early as possible to prevent complications of anemia such as dyspnea and angina.
- B. Hematocrit levels usually remain slightly below normalin clients with renal failure.
- C. Anemia in renal failure is frequently caused by low serum iron and ferritin and corrected by oral iron and ferritin replacement therapy.
- D. The renal secretion of erythropoiesis is decreased. The bone marrow requires erythropoietin to mature red blood cells.
Answer: D
Explanation:
(A) Clients in renal failure typically have very low hematocrits, often in the range of 16-22%. (B) Transfusion is avoided unless the client exhibits acute symptoms such as dyspnea, chest pain, tachycardia, and extreme fatigue. When the client is given a transfusion, the bone marrow adjusts by producing less red blood cells. (C) Anemia in renal failure is caused primarily by decreased erythropoietin. Low serum iron and ferritin may aggravate the anemia and require treatment. (D) Decreased secretion of erythropoietin by the kidney is the primary cause of anemia. The bone marrow requires this hormone to mature red blood cells. Treatment is with replacement therapy.
NEW QUESTION 251
A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?
- A. "Tell me about your dislike for your parents."
- B. "Why do you feel this way?"
- C. "Perhaps you and I can discover what produces your anxiety."
- D. "Don't worry, everything will be all right on your visit with your parents."
Answer: C
Explanation:
Explanation
(A) Asking the client to provide an explanation for her feelings is often intimidating. (B) This response is probing and may make the client feel used and valued only for the information she can provide. (C) This underrates the client's feelings and belittles her concerns. It may cause the client to stop sharing feelings for fear that they will be ridiculed. (D) The emphasis is on working with the client. It shows that there is hope for change through collaboration.
NEW QUESTION 252
Following a vaginal delivery, the postpartum nurse should observe for:
- A. Dystocia, kraurosis
- B. Chadwick's sign
- C. Fatigue, hemorrhoids
- D. Hemorrhage and infection
Answer: D
Explanation:
Section: Questions Set C
Explanation:
(A) Dystocia is difficult labor. The delivery has occurred. Kraurosis is atrophy and dryness of skin and any mucous membrane (vulva). (B) Chadwick's sign is a bluish color of vaginal mucosa suggestive of pregnancy.
(C) Fatigue is a common symptom in the postpartal period. Hemorrhoids may occur with pregnancy. (D) Hemorrhage and infection are potential complications of vaginal delivery. Hemorrhage may result from retained placental fragments or soft uterus. Infection may occur from the introduction of organisms into the uterus during the delivery.
NEW QUESTION 253
The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?
- A. "I will wash my hands before instilling eye medications."
- B. "I will wear an eye patch for the first 3 postoperative days."
- C. "I will maintain the sterility of the eye medications."
- D. "I will wear sunglasses when going outside."
Answer: B
Explanation:
Explanation
(A) Hand washing would be an important action designed to prevent transmission of pathogens from the hands to the eye. (B) Wearing sunglasses when going outside will prevent airborne pathogens from entering the eye.
(C) Eye patches are most frequently ordered to be worn while the client sleeps or naps, not constantly for this length of time. (D) Eye medications are sterile; clients need to be taught how to maintain this sterility.
NEW QUESTION 254
A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
- A. "We will not allow you to starve yourself. You may choose to eat voluntarily or be fed."
- B. "It's not appropriate for you to try to manipulate the staff into granting your wishes."
- C. "Okay, missing one meal won't hurt."
- D. "You'll have to eat lunch, or we'll force-feed you."
Answer: A
Explanation:
Explanation
(A) This response reinforces the client's maladaptive behavior, thereby contributing to the client's risk. (B) Ultimatums are not therapeutic. (C) This comment invites an argument because it puts the client on the defensive and stabs at her self-esteem, which is already compromised. (D) Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client an increased sense of control over her life and avoid an argument or power struggle.
NEW QUESTION 255
A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over
40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn?
- A. Fluid volume deficit related to increased capillary permeability
- B. Pain related to tissue damage from burns
- C. Potential for infection related to contamination of wounds
- D. Potential for impaired gas exchange related to edema of respiratory tract
Answer: D
Explanation:
Section: Questions Set G
Explanation:
(A, B, C) These answers are all correct; however, maintenance of airway is the top priority. (D) Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest.
NEW QUESTION 256
After a liver biopsy, the best position for the client is:
- A. Right lateral
- B. Prone
- C. Supine
- D. High Fowler
Answer: A
Explanation:
Explanation
(A) This position does not help to prevent bleeding. (B) This position does not help to prevent bleeding. (C) This position does not help to prevent bleeding. (D) The right lateral position would allow pressure on the liver to prevent bleeding.
NEW QUESTION 257
A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?
- A. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.
- B. Validate that he is not allergic to iodine or shellfish.
- C. Instruct him to start active range of motion of his left leg immediately following the procedure.
- D. Inform him that vital signs will be taken every hour for 4 hours after the procedure.
Answer: B
Explanation:
(A) Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. (B) The client is kept on complete bed rest for 6-12 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. (C) The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. (D) The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding.
NEW QUESTION 258
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
- A. Fluid volume excess
- B. Severe hypotension
- C. Decreased cardiac output
- D. Fluid volume deficit
Answer: A
Explanation:
(A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D) Hypertension is the result of hypervolemia.
NEW QUESTION 259
A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:
- A. Decreased breath sounds on the left and chest pain with movement
- B. Rhonchi and frothy sputum
- C. Crackles and paradoxical chest wall movement
- D. Wheezing and dry cough
Answer: A
Explanation:
(A) Crackles are caused by air moving through moisture in the small airways and occur with pulmonary edema. Paradoxical chest wall movement occurs with flail chest when a segment of the thorax moves outward on inspiration and inward on expiration. (B) Decreased breath sounds occur when a lung is collapsed or partially collapsed. Chest pain with movement occurs with rib fractures. (C) Rhonchi are caused by air moving through large fluid-filled airways. Frothy sputum may occur with pulmonary edema. (D) Wheezing is caused by fluid in large airways already narrowed by mucus or bronchospasm. Dry cough could indicate a cardiac problem.
NEW QUESTION 260
A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
- A. 5 mg
- B. 0.05 mg
- C. 20 mg
- D. 0.5 mg
Answer: A
Explanation:
Section: Questions Set C
Explanation:
(A) 1 mg = 0.1 mL, then 0.5 mL x = 55 mg. (B) Thisanswer is a miscalculation. (C) This answer is a miscalculation. (D) This answer is a miscalculation.
NEW QUESTION 261
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:
- A. Hypertonicity of the uterus
- B. A soft relaxed abdomen
- C. A rigid, boardlike abdomen
- D. Uterine atony
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. (B) A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. (C) The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. (D) In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.
NEW QUESTION 262
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?
- A. Olfactory
- B. Gustatory
- C. Visceral
- D. Auditory
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation.
NEW QUESTION 263
After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted ≥15 seconds and occurred 3 times during the 20- minute test. The RN knows that these test results will be interpreted as:
- A. An unsatisfactory test
- B. A negative test
- C. A reactive test
- D. A nonreactive test
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) A nonstress test that shows at least two accelerations of the fetal heart rate of 15 bpm with fetal activity, lasting ≥15 seconds over a 20-minute period. (B) Reactive criteria are not met. The accelerations of the fetal heart rate are not at least 15 bpm and do not last 15 seconds. This could mean fetal well-being is compromised. Usually a contraction stress test is ordered if the nonstress test results are negative. (C) An unsatisfactory test means the data cannot be interpreted, or there was inadequate fetal activity. If this happens, usually the test is ordered to be done at a later date. (D) A negative test is a term used to describe the results of a contraction stress test.
NEW QUESTION 264
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, "It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?" The client's actions and response best demonstrate:
- A. Anger
- B. Denial
- C. Bargaining
- D. Depression
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Depression may be an underlying feature, but it is not evident from limited data presented here. (B) Anger is not exhibited in his response. (C) Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. (D) There is no evidence of bargaining in the client's actions or verbal response.
NEW QUESTION 265
A 33-year-old client was brought into the emergency room unconscious, and it is determined that surgery is needed. Informed consent must be obtained from his next of kin.
The sequence in which the next of kin would be asked for the consent would be:
- A. Spouse, adult child, parent, sibling
- B. Parent, spouse, adult child, sibling
- C. Spouse, parent, sibling, adult child
- D. Parent, spouse, sibling, adult child
Answer: A
Explanation:
(A) Spouse and adult child would be asked before a parent. (B) The order of kin relationship for an adult, as determined from legal intestate succession, is usually spouse, adult child, parent, sibling. (C) Parent and sibling would be asked after adult child. (D) Spouse and adult child would be asked before parent. Sibling would be asked last.
NEW QUESTION 266
A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to:
- A. Relieve the client's concern regarding possible infection
- B. Reduce the risk of intraoperative fever
- C. Reduce the risk of wound infection from anaerobic bacteria
- D. Provide cathartic action within the colon
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Cathartic drugs promote evacuation of intestinal contents. (B) The client undergoing intestinal surgery is at increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines.
Administering antibiotics prophylactically can reduce the client's risk for infection. (C) Antibiotics are indicated in the treatment of infections and have no effect on emotions. (D) Antipyretics are useful in the treatment of elevated temperatures. Antibiotics would have an effect on infection, which causes temperature elevation, but would not directly affect such an elevation.
NEW QUESTION 267
A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.
What tests should the nurse anticipate?
- A. Aspartate transaminase, alanine transaminase
- B. Reticulocyte count, creatinine phosphokinase (CPK)
- C. Sedimentation rate, WBC count
- D. Lactic dehydrogenase, CPK
Answer: D
Explanation:
Explanation
(A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue.
Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury.
(C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
NEW QUESTION 268
The physician prescribes amitriptyline (Elavil) for a client. What does the patient need to know about this medication?
- A. When the medication is effective, he will experience no anxiety.
- B. The medication should relieve his symptoms of depression.
- C. Blood must be drawn weekly to test for toxicity.
- D. Prolonged use of this medication will result in extrapyramidal side effects.
Answer: B
Explanation:
(A) Phenothiazines cause extrapyramidal symptoms. (B) No amount of medication can relieve all anxiety in all cases. (C) The purpose of amitriptyline is to relieve the symptoms of depression because it is an antidepressant. It increases the action of norepinephrine and serotonin on nerve cells. (D) Periodic blood tests are done when lithium is prescribed.
NEW QUESTION 269
When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:
- A. Congestive heart failure
- B. Angina
- C. Pericarditis
- D. Anxiety
Answer: A
Explanation:
Explanation
(A) Pericarditis can cause dyspnea but primarily causes chest pain. (B) Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. (C) The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. (D) Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position.
NEW QUESTION 270
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