CliffsTestPrep NCLEX-RN

CliffsTestPrep

®

®

NCLEX-PN

An American BookWorks Corporation Project

Contributing Authors/Consultants Amy Anderson, RN, MSN

Cynthia O’Neal, PhD, RN

Texas Tech University Health Sciences Center, School of Nursing, TX

Texas Tech University Health Sciences Center School of Nursing, TX

Wanda Bradshaw, RNC, MSN

Deborah Persell, MSW, RN, CPNP

Duke University, NC

Arkansas State University, AR

Valerie Eschiti, RN, MSN, CHTP, HNC

Vicki A. Schnetter, MSN, RN

Midwestern State University, TX

Texas Tech University Health Sciences Center School of Nursing, TX

Sara Freuchting, RN, MNSc, CCRN, APRN, BC University of Arkansas at Little Rock, AR

Sharon Krumm, RN, MN, CCRN Arkansas State University, AR

Mary Alice Momeyer, MSN, CNP Ohio State University

Brenda Leigh Yolles Smith, EdD RN, MN, CNM, ICCE Arkansas State University, AR

Carolyn Mathis White, RN, MSN, FNP, PNP, JD University of South Alabama, AL

Joan Williams, MS, RN, CS, CNP

CliffsTestPrep

®

®

NCLEX-PN

An American BookWorks Corporation Project

Contributing Authors/Consultants Amy Anderson, RN, MSN

Cynthia O’Neal, PhD, RN

Texas Tech University Health Sciences Center, School of Nursing, TX

Texas Tech University Health Sciences Center School of Nursing, TX

Wanda Bradshaw, RNC, MSN

Deborah Persell, MSW, RN, CPNP

Duke University, NC

Arkansas State University, AR

Valerie Eschiti, RN, MSN, CHTP, HNC

Vicki A. Schnetter, MSN, RN

Midwestern State University, TX

Texas Tech University Health Sciences Center School of Nursing, TX

Sara Freuchting, RN, MNSc, CCRN, APRN, BC University of Arkansas at Little Rock, AR

Sharon Krumm, RN, MN, CCRN Arkansas State University, AR

Mary Alice Momeyer, MSN, CNP Ohio State University

Brenda Leigh Yolles Smith, EdD RN, MN, CNM, ICCE Arkansas State University, AR

Carolyn Mathis White, RN, MSN, FNP, PNP, JD University of South Alabama, AL

Joan Williams, MS, RN, CS, CNP

Author’s Acknowledgments

Publisher’s Acknowledgments

American BookWorks Corporation would like to acknowledge and thank the contributions of Linda A. Razer to this project.

Editorial Project Editor: Suzanne Snyder Acquisitions Editor: Greg Tubach Copy Editor: Katie Robinson Technical Editor: Sue A. Wise RN, MS, LSW Edison State Community College Production Proofreader: Melissa D. Buddendeck Wiley Publishing, Inc. Composition Services

CliffsTestPrep® NCLEX-PN® Published by: Wiley Publishing, Inc. 111 River Street Hoboken, NJ 07030-5774

Note: If you purchased this book without a cover, you should be aware that this book is stolen property. It was reported as “unsold and destroyed” to the publisher, and neither the author nor the publisher has received any payment for this “stripped book.”

www.wiley.com

Copyright © 2005 Wiley, Hoboken, NJ Published by Wiley, Hoboken, NJ Published simultaneously in Canada Library of Congress Cataloging-in-Publication data is available from the publisher upon request. ISBN-13: 978-0-7645-7287-6 ISBN-10: 0-7645-7287-3 Printed in the United States of America 10 9 8 7 6 5 4 3 2 1 1B/QY/QT/QV/IN No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Sections 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Legal Department, Wiley Publishing, Inc., 10475 Crosspoint Blvd., Indianapolis, IN 46256, 317-572-3447, fax 317-572-4355, or online at http://www.wiley.com/go/ permissions. THE PUBLISHER AND THE AUTHOR MAKE NO REPRESENTATIONS OR WARRANTIES WITH RESPECT TO THE ACCURACY OR COMPLETENESS OF THE CONTENTS OF THIS WORK AND SPECIFICALLY DISCLAIM ALL WARRANTIES, INCLUDING WITHOUT LIMITATION WARRANTIES OF FITNESS FOR A PARTICULAR PURPOSE. NO WARRANTY MAY BE CREATED OR EXTENDED BY SALES OR PROMOTIONAL MATERIALS. THE ADVICE AND STRATEGIES CONTAINED HEREIN MAY NOT BE SUITABLE FOR EVERY SITUATION. THIS WORK IS SOLD WITH THE UNDERSTANDING THAT THE PUBLISHER IS NOT ENGAGED IN RENDERING LEGAL, ACCOUNTING, OR OTHER PROFESSIONAL SERVICES. IF PROFESSIONAL ASSISTANCE IS REQUIRED, THE SERVICES OF A COMPETENT PROFESSIONAL PERSON SHOULD BE SOUGHT. NEITHER THE PUBLISHER NOR THE AUTHOR SHALL BE LIABLE FOR DAMAGES ARISING HEREFROM. THE FACT THAT AN ORGANIZATION OR WEBSITE IS REFERRED TO IN THIS WORK AS A CITATION AND/OR A POTENTIAL SOURCE OF FURTHER INFORMATION DOES NOT MEAN THAT THE AUTHOR OR THE PUBLISHER ENDORSES THE INFORMATION THE ORGANIZATION OR WEBSITE MAY PROVIDE OR RECOMMENDATIONS IT MAY MAKE. FURTHER, READERS SHOULD BE AWARE THAT INTERNET WEBSITES LISTED IN THIS WORK MAY HAVE CHANGED OR DISAPPEARED BETWEEN WHEN THIS WORK WAS WRITTEN AND WHEN IT IS READ. Trademarks: Wiley, the Wiley Publishing logo, CliffsNotes, the CliffsNotes logo, Cliffs, CliffsAP, CliffsComplete, CliffsQuickReview, CliffsStudySolver, CliffsTestPrep, CliffsNote-a-Day, cliffsnotes.com, and all related trademarks, logos, and trade dress are trademarks or registered trademarks of John Wiley & Sons, Inc. and/or its affiliates. All other trademarks are the property of their respective owners. Wiley Publishing, Inc. is not associated with any product or vendor mentioned in this book. For general information on our other products and services or to obtain technical support, please contact our Customer Care Department within the U.S. at 800-762-2974, outside the U.S. at 317-572-3993, or fax 317-572-4002. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. For more information about Wiley products, please visit our web site at www.wiley.com.

Table of Contents Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

PART I: SUBJECT AREA REVIEW CHAPTERS Coordinated Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Advance Directives • Advocacy • Client Care Assignments • Client Rights • Concepts of Management and Supervision • Confidentiality • Consultation with Members of the Health Care Team • Continuity of Care • Establishing Priorities • Ethical Practice • Informed Consent • Legal Responsibilities • Performance Improvement (Quality Assurance) • Referral Process • Resource Management

Safety and Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Accident/Error Prevention • Handling Hazardous and Infectious Materials • Home Safety • Injury Prevention • Internal and External Disaster Plans • Medical and Surgical Asepsis • Reporting of Incident/Event/Irregular Occurrence/Variance • Safe Use of Equipment • Security Plans • Standard/Transmission-Based/Other Precautions • Use of Restraints/Safety Devices

Health Promotion and Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Aging Process • Ante/Intra/Postpartum and Newborn Care • Data Collection Techniques • Developmental Stages and Transitions • Disease Prevention • Expected Body Image Changes • Family Interaction Patterns • Family Planning • Health Promotion/Screening Programs • High Risk Behaviors • Human Sexuality • Immunizations • Lifestyle Choices • Self-Care

Psychosocial Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Abuse or Neglect • Behavioral Interventions • Behavioral Management • Coping Mechanisms • Crisis Intervention • Cultural Awareness • End-of-Life Concepts • Grief and Loss • Mental Health Concepts • Mental Illness Concepts • Religious or Spiritual Influences on Health • Sensory/Perceptual Alterations • Situational Role Changes • Stress Management • Substance-Related Disorders • Suicide/Violence Precautions • Support Systems • Therapeutic Communication • Therapeutic Environment • Unexpected Body Image Changes

Basic Care and Comfort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Assistive Devices • Elimination • Mobility/Immobility • Non-Pharmacological Comfort Interventions • Nutrition and Oral Hydration • Palliative/Comfort Care • Personal Hygiene • Rest and Sleep

Pharmacological Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Adverse Effects • Expected Effects • Medication Administration • Pharmacological Actions • Pharmacological Agents • Side Effects

CliffsTestPrep NCLEX-PN

Reduction of Risk Potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 Diagnostic Tests • Laboratory Values • Potential for Alterations in Body Systems • Potential for Complications of Diagnostic Tests/Treatments/Procedures/Surgery, or Health Alterations • Therapeutic Procedures • Vital Signs

Physiological Adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337 Alterations in Body Systems • Basic Pathophysiology • Fluid and Electrolyte Imbalances • Medical Emergencies • Radiation Therapy • Unexpected Response to Therapies

PART II: NCLEX-PN PRACTICE TESTS NCLEX-PN Practice Test 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393 Answers and Explanations for Practice Test 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

NCLEX-PN Practice Test 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427 Answers and Explanations for Practice Test 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449

NCLEX-PN Practice Test 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465 Answers and Explanations for Practice Test 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487

End-User License Agreement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503

iv

Introduction This book has been written to help you prepare for—and pass—the new NCLEX-PN. The NCLEX (National Council Licensure Examination) is required to obtain a license to practice as a practical or vocational nurse. The exam is administered by the National Council of State Boards of Nursing and assures that your license is acceptable throughout the entire United States and its territories. By passing this test, you will be able to practice as a practical/vocational nurse. The test is based on the specialized knowledge that you should have at this point, and it tests the skills necessary to contribute meaningfully to the nursing process. Because this is a test of basic competency, you are only required to demonstrate your abilities as an entry-level nurse in this exam. It is not a test for the more-experienced nurse because you will not encounter questions about moresophisticated elements of the nursing profession. Neither is it an indicator of how you will fare in the profession. During the computerized examination, you will answer between 85 and 205 questions, so there is a limit to the amount of material that is covered on the test. In this book, we’ve tried to give as much material as possible, based on previous tests. The questions are written by nurse-educators, who are familiar with the material covered on the NCLEX-PN and prepare students for this exam.

The CAT Exam Because the NCLEX-PN is computerized, it is called a CAT test, which stands for Computerized Adaptive Testing. The computer adapts to your responses. You begin with a moderately difficult question, and if you answer correctly, the next question is slightly harder. If you answer incorrectly, the next question is slightly easier. Essentially, the computer selects questions based on your abilities. The more questions you answer, the more the computer understands your responses and can tailor the questions for you. If you answer most of the questions correctly, you might have to answer only 85 questions to demonstrate your mastery of the necessary material to pass the NCLEX-PN. If you answer a significant number of questions incorrectly, the computer keeps trying easier questions until you answer correctly. The maximum number of questions is 205. You cannot skip questions as you work through the test because each new question is predicated on the previous response. You need to read carefully and answer each question. However, if you cannot decide on an answer to a specific question, you have to select any answer to move on to the next question. The entire testing period is five hours. This includes a brief tutorial and sample questions, as well as scheduled breaks during the testing period.

How to Use This Book This book contains eight chapters; each chapter contains questions based on the newest version of the exam. It covers the following topics, based on Client Needs categories. There are four basic Client Needs categories. As you see below, two of these categories are broken down into six subcategories. All the topics and subtopics are covered in this book, although many of them might be combined into similar topic areas. Safe and Effective Care Environment Coordinated Care Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity

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CliffsTestPrep NCLEX-PN

Physiological Integrity Basic Care and Comfort Pharmacological Therapies Reduction of Risk Potential Physiological Adaptation We’ve included explanations with each of the answers to the questions to help you understand the material in greater depth. We’ve explained the correct answers, but in many cases, we’ve explained why the other choices are incorrect. By combining the answers with the questions, you have immediate feedback. You should, of course, know much of this material already, but there are some topics that you might not be as familiar with as you are with others that are presented in this book. The recommended method is to: 1. 2. 3. 4.

Read the question. Try to understand what the question is asking. Try to determine the answer. Check the answer from the choices that accompany each question.

Certain important concepts are integrated throughout the Client Needs categories and subcategories: 1. Clinical Problem-Solving Process (Nursing Process). This is the scientific approach to client care that includes data collection, planning, implementation, and evaluation. 2. Caring. This is the interaction between you, as the practical/vocational nurse, and the clients, their families, or their significant others. It requires mutual respect and trust. 3. Communication and Documentation. It is very important that you be clear and concise in your interactions with clients, their families, and members of your health care team. This requires the ability to communicate both verbally and nonverbally, and to be accountable in keeping and maintaining records and client charts. 4. Teaching and Learning. You must demonstrate the appropriate skills and attitudes that promote change in yourself and others by learning and teaching. The ability to share information with clients and their families appropriately is very important.

About the Content As we said, there are eight Client Needs chapters, and within those chapters are individual subcategories, for which you’ll be responsible. Following is a list of the Client Needs chapters and subcategories and the percentage of questions that appear on the test for each. Keep in mind that the test might include material not covered in these chapters. Safe and Effective Care Environment Coordinated Care (11%–17%) Advance Directives Advocacy Client Care Assignments Client Rights Concepts of Management and Supervision Confidentiality Consultation with Members of the Health Care Team Continuity of Care Establishing Priorities

2

Introduction

Ethical Practice Informed Consent Legal Responsibilities Performance Improvement (Quality Assurance) Referral Process Resource Management Safety and Infection Control (8%–14%) Accident/Error Prevention Handling Hazardous and Infectious Materials Home Safety Injury Prevention Internal and External Disaster Plans Medical and Surgical Asepsis Reporting of Incident/Event/Irregular Occurrence/Variance Safe Use of Equipment Security Plans Standard/Transmission-Based/Other Precautions Use of Restraints/Safety Devices Health Promotion and Maintenance (7%–13%) Aging Process Ante/Intra/Postpartum and Newborn Care Data Collection Techniques Developmental Stages and Transitions Disease Prevention Expected Body Image Changes Family Interaction Patterns Family Planning Health Promotion/Screening Programs High-Risk Behaviors Human Sexuality Immunizations Lifestyle Choices Self-Care Psychosocial Integrity (8%–14%) Abuse or Neglect Behavioral Interventions Behavioral Management Coping Mechanisms Crisis Intervention Cultural Awareness End-of-Life Concepts Grief and Loss

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CliffsTestPrep NCLEX-PN

Mental Health Concepts Mental Illness Concepts Religious or Spiritual Influences on Health Sensory/Perceptual Alterations Situational Role Changes Stress Management Substance-Related Disorders Suicide/Violence Precautions Support Systems Therapeutic Communication Therapeutic Environment Unexpected Body Image Changes Physiological Integrity Basic Care and Comfort (11%–17%) Assistive Devices Elimination Mobility/Immobility Nonpharmacological Comfort Interventions Nutrition and Oral Hydration Palliative/Comfort Care Personal Hygiene Rest and Sleep Pharmacological Therapies (9%–15%) Adverse Effects Expected Effects Medication Administration Pharmacological Actions Pharmacological Agents Side Effects Reduction of Risk Potential (10%–16%) Diagnostic Tests Laboratory Values Potential for Alterations in Body Systems Potential for Complications of Diagnostic Tests/Treatments/Procedures/Surgery or Health Alterations Therapeutic Procedures Vital Signs Physiological Adaptation (12%–18%) Alterations in Body Systems Basic Pathophysiology Fluid and Electrolyte Imbalances Medical Emergencies

4

Introduction

Radiation Therapy Unexpected Response to Therapies All the listed topics and subtopics are covered in this book, although many of them might be combined into similar topic areas.

Types of Questions Most of the questions are multiple choice with four choices. Some alternate-format questions are included here, however, that are similar to those recently added to the NCLEX-PN. The alternate-format questions include fill-in-the-blank questions and hot-spot questions. Hot-spot questions ask you to identify a correct answer choice from an illustration, table, or chart. You click on the correct answer choice with the on-screen cursor. The computer can identify the spot where you’ve clicked.

The Multiple-Choice Format Most of the standardized tests that you’ve taken during your education have contained multiple-choice questions. Multiple-choice questions are difficult for some test-takers. If you approach these questions carefully, following the tips that we give you in this section, they should be easier than you think. Let’s analyze the concept of the multiple-choice question. Keep in mind that these questions are created to test your ability to recognize the correct answer from four choices. Questions are comprised of several parts. ■ ■ ■

the question stem the correct choice distracters

Writers create multiple-choice test questions using the following plan: ■ ■ ■

One choice is absolutely correct. One or two choices are absolutely incorrect (distracters). One or two choices might be similar to the correct answer, but might not answer the specific question—or might contain some information that is not accurate (distracters).

How do you approach the questions? First, read the question and see whether you know the answer. If you know it automatically, you can look at the choices and select the correct one. Let’s look at a very simple example: 1. Mammography is used to detect which of the following conditions? 1. 2. 3. 4.

pain tumor edema epilepsy

This is a very simple question and answer. It’s a question that most people know, without the benefit of a nursing education. You should know that mammography is used to detect tumors or cysts in the breasts (Choice 2). It is not used to detect any of the other conditions. You should know that a mammogram is the image produced by a low-dose X-ray of the breast. If you don’t know the answer, you have certain options, using the process of elimination.

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CliffsTestPrep NCLEX-PN

Are there any choices that you can immediately eliminate? For example, Choice 1 is not likely to be identified by mammography. It’s possible that a client experiencing pain has a mammography to identify the source of the pain, but the mammography cannot detect pain. Thus you can eliminate that answer. Now you’ve improved your odds of answering the question correctly. Instead of having only a 25% chance (one out of four choices) of identifying the correct answer, you now have a 33% chance (one out of three choices). Now move to the next choice. It’s possible that mammography is used to locate tumors. (Yes, we know this is the correct answer, but the exercise here is to demonstrate how to eliminate the choices if you don’t know that answer.) The next choice is edema. If you know that edema is a swelling caused by an abnormal accumulation of fluid in body tissues, you might think it possible that a mammogram can spot the fluid, and that might be a possible answer. Hold on to that choice for a moment, and move to Choice 4, epilepsy. Epilepsy is a disorder of the central nervous system, and you should know this. Is it possible for a mammogram to spot a nervous disorder? This can’t be a correct choice if you know that a mammogram is an X-ray. So you can eliminate that choice also. This leaves only two choices—tumor or edema. At this point, if you really don’t know the answer, you have to guess. But at this stage, having eliminated two very clear incorrect choices, you have a 50% chance (one out of two choices) to guess the correct answer. It is important to read the question carefully. Look at the following: 2. All the following should be performed when fetal heart monitoring indicates fetal distress except: 1. 2. 3. 4.

increasing maternal fluids administering oxygen decreasing maternal fluids turning the mother

How did you answer this question? Did you take note of the word except? All the choices are correct except for Choice 3. This is the only intervention that should not be performed when fetal distress is indicated. Finally, pay attention to words like always, never, and not. You should be careful if a question asks you to choose which of the choices is not. . .! Or, as in the question above, “All are correct except. . .” Some questions might ask about measurements. For example, there is a big difference between 0.401, 4.01, 40.1, and 401. Keep decimal points in mind as you read these types of questions. Make sure, also, that you know measurements like liters, milliliters, and fluid ounces. As you go through this book, take your time with the questions and answers. Try to analyze what you answered incorrectly and learn from the answers and explanations. Identify those questions where you are able to use the process of elimination. Check how well you perform on those questions. How many do you know? Don’t worry about how well or how poorly you do. Take the time to do an analysis of your results. These are some of the secrets to being a successful test-taker. You must be prepared by your education and have the knowledge and skills to take the test. You have a better chance if you practice the techniques of answering multiple-choice questions.

6

Introduction

Alternate-Format Questions As mentioned previously, most of the questions on the test are four-choice, multiple-choice questions. Alternate-format questions have been recently added to the NCLEX-PN to allow test-takers to show their knowledge in different ways. There are four types of alternate-format questions that you might see on the NCLEX-PN: 1. Multiple-choice questions might have more than one correct choice. However, you will see a prompt that tells you to select all the answer choices that apply. There might be more than four choices in these questions. 2. Fill-in-the-blank questions ask you to type in a specific number or word. 3. Calculation or ordered-response questions ask you to compute an answer or itemize answers in the correct order. 4. Hot-spot questions ask you to identify with the cursor the appropriate area on a picture or other graphic on the screen. Why have alternate-format questions been added to the NCLEX-PN? It is believed that you are able to demonstrate your competence in certain areas beyond which multiple-choice questions can test. If, for example, you are asked to do a problem that requires calculations, by actually doing them yourself, you prove yourself more capable than merely selecting the correct answer from four choices (especially because you’ve learned the secrets of answering these types of questions earlier in this section).

Sample Alternate-Format Questions Try the following questions, and then check your answers in the following section. 1. The nurse has auscultated a heart murmur during a routine assessment on a client. Which of the following characteristics of the murmur should indicate to the nurse that the murmur is most likely functional or innocent? Select all that apply. _____ changes with position _____ grade III/VI _____ diastolic _____ rarely transmitted _____ varies in intensity from visit to visit _____ holosystolic _____ general good health _____ disappears with valsalva maneuver

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CliffsTestPrep NCLEX-PN

2. The physician has ordered 350 mg Ampicillin IM. Look at the following label for a 1 gram vial of Ampicillin. How many milliliters of reconstituted Ampicillin should the nurse administer?

NDC 0015-7404-20 NSN 6505-00-993-3518 EQUIVALENT TO

1 gram AMPICILLIN

STERILE AMPICILLIN SODIUM, USP

For IM or IV use

CAUTION: Federal law prohibits dispensing without prescription.

For IM use, add 3.5 mL diluent (read accompanying circular). Resulting solution contains 250 mg ampicillin per mL. Use solution within 1 hour. This vial contains ampicillin sodium equivalent to 1 gram ampicillin. Usual Dosage: Adults–250 to 500 mg IM q. 6h. READ ACCOMPANYING CIRCULAR for detailed indications, IM or IV dosage and precautions.

Cont. Exp. Date:

3. A nurse is documenting the completed health history of a client. In what order should the nurse document the components of the history? 1. 2. 3. 4. 5. 6.

review of systems chief complaint social history past medical history history of present illness family history

Type the numbers for the components in order. _______________

8

Introduction

4. The nurse is completing the growth chart of an 18-month-old male child. The child weighed 13 kg and was 85 cm long. Identify on the growth chart where the nurse should plot the child’s weight. Birth to 36 months: Boys Length-for-age and Weight-for-age percentiles

L E N G T H

Birth in cm 41 40 100 39 38 95 37 36 90 35 34 85 33 32 80 31 30 75 29 28 70 27 26 65 25 24 60 23 22 55 21 20 50 19 18 45 17 16 40 15

16

3

6

9

15

18

RECORD #

21

24

27

30

33

36 cm

AGE (MONTHS) 95 90

100

75

95

50 25 10 5

90

95

17

90

16

in 41 40 39 38 37 36 35

L E N G T H

38 36 34

75

15 32

50

14 30

25

13

28

10

12

5

AGE (MONTHS)

7 12

14 W E I G H T

12

NAME

15

Motherís Stature Fatherís Stature Date Age Birth

6 12 5 10

18

21

Weight

24

27

30

Gestational Age: Weeks Length Head Circ.

33

36

26

11

24

10

22

9

20

8

18

kg

16 lb

W E I G H T

Comment

4 8 6 lb

3 2 kg Birth

3

6

9

Published May 30, 2000 (modified 4/20/01). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts

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CliffsTestPrep NCLEX-PN

Answers to Alternate-Format Questions 1. __X_ changes with position ____ grade III/VI ____ diastolic __X_ rarely transmitted __X_ varies in intensity from visit to visit ____ holosystolic __X_ general good health __X_ disappears with valsalva maneuver Characteristics of functional or innocent murmurs include usually grade I–II/VI; changes with position; varies in loudness or presence from visit to visit; increases in intensity with fever, anemia, exercise, or anxiety; musical or vibratory; systolic; short duration; best heard at the left-lower sternal border or pulmonic area; rarely transmitted; might disappear with valsalva maneuver; vital signs normal; electrocardiograph normal; and general good health. Characteristics of pathologic murmurs include significant medical/cardiac history; loud, harsh, or continuous; diastolic or late systolic; holosystolic or pansystolic; associated abnormalities; associated failure to thrive, congestive heart failure or other systemic illness; and no change with position. 2. For IM use, the nurse must reconstitute the Ampicillin with 3.5 milliliters (mL) of diluent. This results in a concentration of 250 mg/mL. 250mg : 1 mL = 350 mg : x mL (multiply the means by the extremes) 250x = 350 x = 1.4 mL The nurse should administer 1.4 mL 3. 2, 5, 4, 6, 3, 1 The health history begins with the chief complaint, in which the client describes in his or her own words the reason for the visit. The history of the present illness follows and includes the onset, location, duration, character, aggravating/associated factors, relieving factors, and temporal factors. The client’s past medical history follows and includes hospitalizations, surgeries, serious illnesses, usual childhood illnesses, immunizations, food/drug/ environmental allergies, and any recent screening tests. The family history should include three generations and identify serious or hereditary diseases that run in the family. Social history includes habits, sexual history, home conditions, occupation, environmental concerns, religious practices, diet, and substance abuse/use. Finally, the review of systems is included in a complete health history to identify any concerns within a body system.

10

Introduction

4. Birth to 36 months: Boys Length-for-age and Weight-for-age percentiles

L E N G T H

Birth in cm 41 40 100 39 38 95 37 36 90 35 34 85 33 32 80 31 30 75 29 28 70 27 26 65 25 24 60 23 22 55 21 20 50 19 18 45 17 16 40 15

16

3

6

9

15

18

RECORD #

21

24

27

30

33

36 cm

AGE (MONTHS) 95 90

100

75

95

50 25 10 5

90

95

17

90

16

in 41 40 39 38 37 36 35

L E N G T H

38 36 34

75

15 32

50

14

25

13

30 28

10

12

5

AGE (MONTHS)

7 12

14 W E I G H T

12

NAME

15

Motherís Stature Fatherís Stature Date Age Birth

6 12 5 10

18

21

Weight

24

27

30

Gestational Age: Weeks Length Head Circ.

33

36

26

11

24

10

22

9

20

8

18

kg

16 lb

W E I G H T

Comment

4 8 6 lb

3 2 kg Birth

3

6

9

Published May 30, 2000 (modified 4/20/01). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts

The child’s weight should be plotted using the lower portion of the page on the weight graph at the intersection of the vertical line corresponding with 18 months and the horizontal line of 13 kg. The child’s weight is between the 75th and 90th percentile. The upper portion of the graph is for the child’s length and should not be used to plot the weight.

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CliffsTestPrep NCLEX-PN

How did you do? As you can see, they’re not particularly difficult, but do require you to do a little more work. If you know the material, you will have no trouble.

Scoring High on the NCLEX-PN To do well on this exam, there are several steps you can take. First, make sure you understand the material. How do you do that? Recognize that this test is a minimum-skills test and does not require you to use high-tech information or knowledge that an experienced practical/vocational nurse already possesses. Go back to your nursing-school notes. And most important, use this book. It has been set up in such a way that you can continually check your understanding of the material by providing the answers to each and every question. Second, be diligent in your studying. Go through each chapter and answer the questions. Then see how you did after each question. Did you understand the question? Did you know the answer immediately, or did you have to use the process of elimination? Third, take the practice tests. Although the actual NCLEX-PN is a computerized exam, it is still helpful to take a penand-pencil test. Yes, you have to answer the full complement of 205 questions this way, but it serves a couple of purposes. You are able to get an idea of what it’s like to take the NCLEX-PN, and you are exposed to more than 800 additional questions among these four exams—and you acquire understanding of the material presented here. When taking these practice tests, set yourself up in a quiet room under test-taking conditions. Time yourself, and see how long it takes to answer all the questions. Although the length of the actual test experience can be as long as five hours, some of that time is taken up by a tutorial, review practice exams, and breaks. Okay, give yourself a break after you have completed one-third of the practice test. Get up and walk around, have a glass of water, and then return to the test. If you don’t need the break, keep going. After you’ve completed the test, take a break and come back to it the next day after you’ve given yourself a rest. Then check the answers. After checking your score, go back to those questions that were incorrect and try to understand why they were wrong. Were they careless errors? Did you understand the topic? On the actual test, work steadily. Keep in mind that you can’t skip questions on the computer, so you’re forced to provide an answer. Don’t spend too much time on any one question. It’s best to read the question carefully, look at the answer choices, select one, and move on. Be confident. Remember, you’ve studied for the exam, you’ve taken practice tests, and you know the material. There will always be some questions for which you don’t know the answers, but do the best that you can, and continue to believe in your ability to answer as many questions as possible correctly.

Have a Study Plan There is no one, correct way to study. Individuals learn differently. However, if you expect to do well on the test by cramming in the last week prior to the exam, you will be disappointed. The only way to prepare is to follow a sensible study plan that you can create yourself. We suggest reading through the book, chapter by chapter, and answering the questions as you go along. Read the explanations for the answers. In this way, you’ll be reviewing material that you probably know already and, at the same time, learning some information that you might have forgotten. There are eight basic chapters in the book. If you spend one week per chapter, you’ll have plenty of time to absorb the material. At the end of that time, you should take the practice tests—one day to take a test and one day to check your answers. Based on these suggestions, you can get through the entire book in 12 weeks. Finally, keep a record of those questions that you have trouble with. When you’ve completed the entire chapter, go back and review them again. Good luck on the exam!

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PART I

S U BJ E CT AR EA R EVI EW C HAPTE R S There are additional questions and answers for chapters 3 and 4 on the CD-ROM.

Coordinated Care This chapter contains questions and answers from the following topic areas: ■ ■ ■ ■ ■ ■ ■

Advance Directives Advocacy Client Care Assignments Client Rights Concepts of Management and Supervision Confidentiality Consultation with Members of the Health Care Team

■ ■ ■ ■ ■ ■ ■ ■

Continuity of Care Establishing Priorities Ethical Practice Informed Consent Legal Responsibilities Performance Improvement (Quality Assurance) Referral Process Resource Management

1. A 97-year-old man has severe coronary artery disease. His daughter informs you that he has a living will and a durable power of attorney for health care (DPAHC). These documents allow the daughter to: 1. 2. 3. 4.

sell her father’s house for funds to be used in his care. make all decisions if her father becomes incompetent. make health care decisions based on her father’s designated wishes if he is not competent or able to speak for himself. have no say in her father’s care because the documents do not convey legal authority.

(3) A DPAHC designates legal authority for health care decision-making to a specific individual. Decision-making is to be guided by the living will. Choices 1 and 2 are incorrect because the client has only designated authority for health care decision-making, not financial or other decision-making. Choice 4 is incorrect because legal authority is delegated by a DPAHC. 2. While helping Mrs. Smith with her mouth care the evening before she is scheduled for exploratory abdominal surgery, she asks, “What do you think I should do if it’s cancer?” The response, “Let’s hope not. It’s such a bad disease. Almost everyone I’ve taken care of with cancer dies in a short time,” is an expression of: 1. 2. 3. 4.

personal opinion. professional values. ethical values. moral values.

(1) The response conveys a personal opinion based on experience. Choice 2 is incorrect. Professional values are shaped by education and professional standards of practice, which are not conveyed in the response. Choice 3 is incorrect; ethical values are based on beliefs regarding right and wrong. Choice 4 is incorrect; moral values are based on sociocultural influences. 3. It is appropriate to share personal values with a client: 1. 2. 3. 4.

if you believe the client can benefit from your advice. when you need to make a choice for the client. when the client asks for your opinion and you state it as such. to settle a difference of opinion.

(3) It is appropriate to share personal values with a client if he or she seeks your input and understands that it is your personal opinion only. However, nurses should always be judicious when sharing personal values with clients. Choices 1, 2, and 4 are incorrect.

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4. If a client is deemed incompetent, it means that: 1. 2. 3. 4.

he or she can’t afford to pay his or her hospital bill. he or she won’t follow medical direction. a court proceeding has declared him or her unable to make his or her own decisions. as a nurse, you have assessed that he or she is not making good choices or decisions.

(3) Only a court can determine competency status based on medical and psychological evaluations. Choices 1, 2, and 4 are incorrect. Choice 1 speaks to financial status only, which is not an issue of competence. Choice 2 describes nonadherence, not incompetence. Choice 4 falsely implies that a nurse can judge competence based on his or her own perceptions of the quality of the client’s decision-making. 5. A DNRCC code status means: 1. 2. 3. 4.

the client should not have his or her symptoms actively treated. the client’s care is of lower priority than another client who has a full code status. therapies and treatments for the client have been limited to those that promote comfort. it’s no longer necessary to take the client’s vital signs.

(3) Clients with a DNRCC code status should have quality symptom management to ensure comfort without efforts to sustain or prolong life. Choices 1, 2, and 4 are incorrect. All clients should have equal access to care regardless of code status. The nurse is responsible for continuous client assessment and for ensuring that comfort goals are met. 6. An 85-year-old male client is unconscious and unable to speak for himself. His daughter produces his advanced directive stating that she is responsible for making health care decisions on his behalf. This type of advance directive is: 1. 2. 3. 4.

a living will. a durable power of attorney for health care (DPAHC). a durable power of attorney for finance (DPAF). a guardianship.

(2) Choices 1, 3, and 4 are incorrect. A living will is a written expression of personal wishes regarding the end of life. A DPAF gives authority for financial decision-making only. A guardianship is court appointed. 7. Quality of life is: 1. 2. 3. 4.

an individual’s perception of his or her well being. determined by a legally responsible person. based on financial resources. consistent by legal definition in all health care settings.

(1) Quality of life is based on an individual’s personal biopsychosocial and spiritual beliefs. Choices 2, 3, and 4 are incorrect. 8. In dealing with illness, a nurse should pursue values clarification with a client when: 1. 2. 3. 4.

the client and nurse have different opinions. the nurse is unsure of the client’s values. the client has embraced nontraditional values. the client verbalizes personal conflict.

(4) Choices 1, 2, and 3 are incorrect. Differing opinions do not necessarily mean a lack of clarity of values. Unless the client has a value conflict, it is not appropriate for the nurse to address values because the client has the right to privacy and autonomy.

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9. Advance directives are: 1. 2. 3. 4.

a source of information about a client’s values and wishes to be used when he or she is unable to express them. an irrevocable listing of personal wishes. transferable from state to state. legal only if they have been recorded in court proceedings.

(1) Choice 2 is incorrect because advance directives are not irrevocable. Choice 3 is incorrect because the format differs from state to state. Choice 4 is incorrect because advance directives are legally binding if executed according to state guidelines and do not require court action. 10. The term DNR refers to: 1. 2. 3. 4.

CPR only. a decision regarding care in an acute care hospital. the use of artificial nutrition and hydration. the use of medications and treatments to achieve a client’s comfort goals.

(4) Choice 1 is incorrect because, although CPR is a component of DNR, depending on a state’s definitions and protocols, DNR can include other aspects of care. Choice 2 is incorrect because DNR status applies across the entire care continuum. Choice 3 is incorrect because the use of artificial nutrition and hydration is only part of the DNR discussion. 11. A living will addresses a client’s wishes regarding: 1. 2. 3. 4.

fluid and hydration treatment. place of burial. financial disbursements upon death. dispersement of personal property.

(1) Choices 2, 3, and 4 are incorrect. Financial and personal property are not addressed in a living will. 12. Nursing advocacy is: 1. 2. 3. 4.

making decisions for clients. encouraging clients to follow all orders from the doctor. encouraging and supporting client decisions concerning rights and health care choices. completion of all forms for clients.

(3) Nursing advocacy includes encouraging and supporting client decisions concerning rights and health care choices. It is built on the ethical principle of autonomy, which is a client’s right. 13. Nursing advocacy includes all the following activities except: 1. 2. 3. 4.

maintaining clients’ rights in clinical trials. caring for those who cannot care for themselves. educating clients regarding treatment choices. discouraging clients from making decisions based on cost.

(4) Advocacy includes caring for those who cannot care for themselves and emphasizes support in decision-making so that clients who are competent have the information necessary to make informed decisions regarding treatments, costs, care needs, rights in research, and risks of treatment.

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14. Your Emergency Department client is a 10-year-old with contusions that might have been inflicted by a caregiver. A nurse advocate facilitating the client’s care should perform all the following activities except: 1. 2. 3. 4.

identifying and documenting the client’s condition. telling the client’s mother. following the facility’s protocol for mandatory reporting of suspicion of child abuse. discussing the findings with the physician in charge.

(2) In instances of suspected child abuse, the nurse advocate has a responsibility to the client to convey the concern verbally to the physician in charge, in writing through complete factual documentation, and by following the facility’s protocol for reporting the suspicion. 15. An 85-year-old man with end-stage prostate cancer has a living will expressing his desire for a dignified death and comfort care measures without resuscitation. His daughter has concerns about the living will. As a nurse advocate, your role is to: 1. 2. 3. 4.

support the daughter’s decision. encourage the client to revoke his living will. support the client’s decision and encourage him to discuss his feelings with his daughter. ignore the client’s decision to deny resuscitation.

(3) The nurse advocate’s role is to explore the client’s decision with him, support his decision-making authority, and encourage a discussion between the client and his daughter regarding his wishes. 16. A wandering Alzheimer’s client is in restraints in an acute care unit. The nursing advocate finding this situation at the beginning of a shift should perform the following action: 1. 2. 3. 4.

remove the restraints on rounds and continue with rounds. remove the restraints and instruct the client not to wander. call the physician for a prn sedative order for the client. assess the client for safety and arrange for a family member to provide supervision.

(4) The nurse must provide the least-restrictive environment that is safe for the client. The safety of the client must be assessed and, if possible, a family member or caregiver known to the client should be enlisted to assist in maintaining the safety of the client without restraints. 17. The advocacy role of the professional nurse provides the opportunity to impact all the following areas except: 1. 2. 3. 4.

safe standards of practice. safe staffing laws. reasonable workloads. increased cohesiveness of values in society.

(4) Nursing, through professional organizations and political action, has the opportunity to affect standards of practice, safe staffing laws, and reasonable workloads. 18. As a nurse advocate, the nurse might find herself in the role of: 1. 2. 3. 4.

mentor. role model. nurse manager. all of the above.

(4) Nurse advocates function as client advocates, advocates for other nurses, and advocates for the nursing profession as a whole. In these roles, the nurse might function as a role model, mentor, nurse manager, and direct provider of care, among other roles.

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Coordinated Care

19. Nursing advocacy for clients is intended to assist clients in maintaining: 1. 2. 3. 4.

maximal health. an independent living situation. autonomy. a driver’s license.

(3) The nurse advocate assists clients in maintaining as much autonomy as possible. Autonomy is a client’s right. 20. As an advocate for the profession of nursing, the nurse performs all the following activities except: 1. 2. 3. 4.

following the standards of care for the client group with which the nurse works. encouraging others to become nurses. supporting safe working conditions for nurses. encouraging nursing research by nursing educators only.

(4) Being an advocate for the profession of nursing includes encouraging and mentoring others to become nurses, supporting political issues affecting the profession of nurses (such as safe working conditions), following appropriate standards of care for clients, and supporting nursing research by all levels of nurses (including clinicians, educators, administrators, and researchers). 21. A 60-year-old home care client has just lost her husband of 40 years. The nurse advocate should encourage her to: 1. 2. 3. 4.

have her annual gynecologic exam early. return to dating as quickly as possible. visit a bereavement counselor or talk with a trusted family chaplain as necessary. resign from work.

(3) The nurse advocate for a new widow should encourage the widow to work through her grieving process by talking with a counselor or chaplain. Changing work or social relationships quickly might not allow for the grief work this client requires after the loss of her husband. 22. An important influence that a nurse advocate engaged in political and social activities can have is: 1. 2. 3. 4.

encouraging persons to complete advance directives. making contributions to political action committees. assisting his or her son’s soccer team as the first-aid provider. becoming an effective time manager.

(1) One influential and far-reaching activity in which nurse advocates can engage is the encouragement of individuals to complete legal documents and advance directives that define their wishes for their health and illness care, should they be unable to communicate these wishes themselves. Involvement with the patient to improve his or her health care management through clear communication of the patient’s wishes is the best nursing advocacy behavior listed. 23. Coordination of care in case management includes all the following activities except: 1. 2. 3. 4.

organizing resources for use by clients. choosing a treatment option for clients based on proximity to the clients’ homes. securing resources for in-home therapy based on clients’ preferences. integrating client-chosen options for care into the medical treatment plan.

(2) Choosing treatment options for clients based on geography rather than the clients’ choices of a need-based treatment provider is incorrect; all other choices are appropriate.

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Part I: Subject Area Review Chapters

24. A recently widowed 56-year-old client is receiving dialysis and tells the nurse he does not like to cook for himself. As his case manager, the nurse should refer him to: 1. 2. 3. 4.

the local visiting nurses association (VNA). Hospice. American Association of Retired Persons (AARP). Meals on Wheels.

(4) Meals on Wheels is a community provider of nutritional meal assistance. The local VNA provides skilled therapeutic services. Hospice provides terminally ill individuals with palliative care at the end of life. AARP is an organization of older adults that provides education, insurance, information services, and political action for seniors. 25. Case-management services begin with: 1. 2. 3. 4.

implementation of a case-management plan. monitoring of the case-management process to change plans if needed. assessment. evaluation.

(3) The steps in case management are assessment, planning, implementation, coordination, monitoring, and evaluation. 26. An 80-year-old male client is being discharged from the hospital with a new diagnosis of lung cancer. His adult children have made arrangements for him to live with his youngest son. To promote optimal continuity of care, the nurse should: 1. 2. 3. 4.

immediately arrange for Hospice care. convince the family that institutionalized care is better for the client. assist with the discharge as planned. explore options for community health services with the family.

(4) The nurse should explore options for community health services to facilitate care given by family members and assist them in meeting the client’s needs at home. Hospice may not be the most appropriate choice, as criteria for Hospice eligibility have not been clearly met. Institutionalized care might be needed in the future. The family should be assisted in its desire to care for the client at home. 27. When planning for a client’s discharge from the hospital, the nurse needs information about all the following except: 1. 2. 3. 4.

type of insurance. availability of caregivers for the client. transportation available. banking services used.

(4) Information about the client’s financial institution and banking services is not necessary for discharge planning. Information about insurance, transportation, and caregiver availability is important when planning discharge. 28. A client is planning to be admitted to the hospital for elective surgery on Monday. When should her discharge planning begin? 1. 2. 3. 4.

when her physician writes the discharge order at the time of admission after surgery, during the discharge planner’s rounds when the nurse is able to assess her postoperative status

(2) Discharge planning should begin at the time of entry into the health care institution to adequately plan for and meet the client’s anticipated needs.

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Coordinated Care

29. A client has had a total knee replacement. Which of the following statements made by the client indicates the need for further teaching before discharge? 1. 2. 3. 4.

“I have four steps into my house, and I know I’ll be able to do that without my cane—right?” “I will continue my exercise program with my therapist at home.” “I will watch my knee for redness—I don’t want an infection.” “I will let my granddaughter pick my tomatoes—I know I shouldn’t be bending over to do that.”

(1) A client discharged after a total knee replacement should use assistive devices for walking and stair-climbing until mobility and balance are fully restored. Use of such devices is discontinued by the physical therapist. All other choices are appropriate. 30. A discharge planner can be: 1. 2. 3. 4.

a master’s prepared nurse only. a registered nurse or social worker. an insurance company representative. a physician.

(2) Discharge planners are licensed social workers or registered nurses with advanced training in organizing and planning for transitions from one health care facility to another, or from a health care facility to a client’s home. A master’s degree in nursing or medical degree is not required. Insurance company representatives can provide information to discharge planners for use in assisting clients with service choices. 31. Diagnostic-related groups (DRGs) are part of a client classification scheme designed to: 1. 2. 3. 4.

assign clients with the same diagnosis to the same hospital unit. monitor quality of care given to clients. classify clients by diagnosis and relate this information to reimbursement. determine occupancy in a hospital.

(3) DRGs are part of a classification system that groups clients by diagnosis for the purpose of reimbursement for care at a hospital, other health care facility, or home care service. 32. Case management has all the following benefits except: 1. 2. 3. 4.

improved outcomes of care for clients. improved client satisfaction with care received. decreased caregiver education needs. cost-effective care provision.

(3) Case management does not decrease client or caregiver education needs but facilitates meeting these needs earlier and more efficiently in the client encounter. 33. Case management is different than managed care in that: 1. 2. 3. 4.

managed care is a function of a health care reimbursement system, but case management is a structure for providing continuity of care. managed care is an insurance company construct only. case management only applies to areas of reimbursable services. case management occurs only in conjunction with hospitalization.

(1) Managed care refers to management of the business of health care, including the care of many persons. Case management is a system for providing and organizing continuity of care services for individual clients.

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Part I: Subject Area Review Chapters

34. Which of the following was developed by the American Hospital Association (AHA) to define the rights and responsibilities of clients in the acute care setting? 1. 2. 3. 4.

Code of Ethics Hospital Advocacy Patient’s Bill of Rights Omnibus Budget Reconciliation Act (OBRA) Regulations

(3) The Patient’s Bill of Rights, developed by the AHA, defines the rights and responsibilities of clients in acute care settings. The ANA (American Nurses’ Association) Code of Ethics provides ethical guidance for nurses. Hospital Advocacy is a program used by hospitals to assist clients in making decisions concerning their rights and health care choices. The OBRA sets standards related to quality of care in long-term care facilities. 35. The rights of clients described in the AHA’s Patient’s Bill of Rights include all the following rights except: 1. 2. 3. 4.

privacy and confidentiality. the right to refuse to participate in research. care without respect for continuity. the right to refuse treatment.

(3) The Patient’s Bill of Rights describes the rights to privacy and confidentiality, refusal to participate in research, continuity of care, and refusal of treatment. 36. A client is considering participating in a multisite trial of a new cancer drug. According to the AHA’s Patient’s Bill of Rights, it is important for the client to know that: 1. 2. 3. 4.

all costs of research are paid by the client. the client has the right to refuse to participate in research without fearing loss of care. physicians on the team will no longer be caring for the client if the client does not participate in the research. the research study is the client’s only hope of treatment.

(2) The Patient’s Bill of Rights describes the right of the client to refuse to participate in research without fearing loss of care. The client continues to be cared for by physicians and nurses on the team, and other treatment options might be offered. In most cases, the costs of participation in a drug trial are, at least partially, paid from the research study budget. 37. The AHA’s Patient’s Bill of Rights applies in: 1. 2. 3. 4.

a hospital. a nursing home. a free-standing urgent-care facility. home care.

(1) The Patient’s Bill of Rights is specific to the acute care setting. Other types of facilities and health care settings have similar documents that address client rights. 38. A client’s right to care has been a cornerstone in resolving ethical dilemmas related to the cost and affordability of health care. Determining how to protect a client’s right to care has presented challenges to nurses in all the following ways except: 1. 2. 3. 4.

providing considerate and respectful care. providing care when the client refuses care based on cost. preserving continuity of care when the availability of providers is limited due to cost. providing care when the availability of community resources is limited.

(1) The nursing profession is committed to the provision of considerate and respectful care for all clients as specified in the Nursing Code of Ethics and in the AHA’s Patient’s Bill of Rights. The challenge of providing clients with optimum health care is often related to the availability and cost of the care.

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Coordinated Care

39. The client’s right to give informed consent applies to which of the following procedures? 1. 2. 3. 4.

insertion of an internal defibrillator surgical excision of a skin lesion physical therapy exercises all procedures

(4) The AHA’s Patient’s Bill of Rights states that a client has the right to give informed consent for all procedures and to refuse treatment. 40. When entering a hospital, a client signs a general consent form. This consent is used to document the client’s consent for: 1. 2. 3. 4.

all ongoing care in the hospital. general treatment but does not waive the client’s right to refuse specific treatment. the administration of research medications and treatments. waiving the confidentiality of the client’s medical record.

(2) The general consent form signed at hospital admission gives general consent for treatment in the hospital; however, the client maintains the right to refuse specific treatment. The client’s right to confidentiality is not compromised by his refusal of specific treatment. 41. A client has been admitted to a four-bed room with three other clients. Which right might be breached due to the setting? 1. 2. 3. 4.

the right to refuse treatment the right to examine and question the bill the right to privacy and confidentiality the right to information regarding diagnosis, treatment, and prognosis

(3) In a multiclient room setting, the staff must be especially aware of the risk of breaching the client’s right to privacy and confidentiality. 42. A client wishes to leave the hospital against medical advice. Which right is this client exercising? 1. 2. 3. 4.

the right to refuse treatment the right to privacy the right to be given information about a diagnosis the right to confidentiality

(1) When a client chooses to leave the hospital against medical advice, the client is exercising the right to refuse treatment. The rights to privacy, confidentiality, and information regarding care and treatment are not altered by this choice. 43. The AHA’s Patient’s Bill of Rights: 1. 2. 3. 4.

is legally binding. describes rights of nursing home residents. was developed by the American Heart Association. is built around the core concept of autonomy of clients.

(4) Client autonomy is the guiding concept of the AHA’s Patient’s Bill of Rights. It is applicable in acute care hospitals as a guideline and is not law.

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Part I: Subject Area Review Chapters

44. The AHA’s Patient’s Bill of Rights is upheld by all the following nursing activities except: 1. 2. 3. 4.

client education. documentation of refusal of treatment. provision of privacy for treatment procedures and discussions of prognosis. use of restraints.

(4) The use of restraints violates a client’s rights to autonomy and respectful and considerate care. Choices 1, 2, and 3 uphold client rights. 45. Organizational theory includes groups of related concepts that: 1. 2. 3. 4.

provide a structure for determining when to form an organization. are used to explain components of organization. are helpful in defining family dysfunction. are not helpful in defining outcomes for effective organizational functioning.

(2) Organizational theory is a group of related concepts, principles, and hypotheses that is used to explain components of organizations and how they behave. The theory might or might not provide a structure, help to define the dysfunction found in a family, or define outcomes of effective functioning. 46. Motivation can be described in all the following ways except: 1. 2. 3. 4.

providing someone with an incentive. a state of mind in which a person views a task or goal. not possible in assisting a client to achieve a functional outcome. a process that assists a client to achieve a goal based on perceived need.

(3) Motivation can provide incentives to achieve functional outcomes. Motivation can be a state of mind in which a person views a task or goal, as well as an important aspect of assisting a client in the achievement of goals. 47. Which of the following time-management tips is the least useful and productive for a nurse manager? 1. 2. 3. 4.

Adopt a strategy that attempts to take care of all details. Work on the most important task first. Make a written note of tasks, activities, and obligations to be completed. Only accept assignments that the nurse manager is able to complete.

(1) The most important task should be worked on first. Being overly focused on details may interfere with accomplishing the larger task at hand. Often details can be delegated to those doing the work and have more effective outcomes. Written notes can prevent memory lapses. Accepting assignments that the nurse manager is not able to complete leads to the risk of unsafe care, frustration, and poor work performance. 48. A new manager does not seem to trust that assignments will be completed as delegated without significant supervision and direction. This style of management is called: 1. 2. 3. 4.

laissez-faire. autocratic. democratic. diplomatic.

(2) This leader is exhibiting an autocratic leadership style. Laissez-faire leadership is passive without overt intervention. A democratic leader takes information and suggestions from participants into consideration when making decisions. “Diplomatic” describes a communication style, not a style of leadership.

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Coordinated Care

49. Important nursing management functions include: 1. 2. 3. 4.

educating staff and personnel. providing performance feedback. monitoring the quality of nursing care. all of the above.

(4) Education, resource management, performance feedback, and monitoring the quality of nursing care are all important nursing managerial functions. 50. Productivity of staff is reliant on: 1. 2. 3. 4.

adequate space and supplies for job completion. sound knowledge base of expected job duties. appropriate time segments to complete job tasks. all of the above.

(4) All the choices are important components in staff productivity. 51. Setting nursing priorities in client care is not dependent on the: 1. 2. 3. 4.

skills and abilities of the nurse. adequacy of time to make accurate assessments. salary of the nurse. nurse’s ability to interpret significant information accurately.

(3) The nurse’s salary does not determine the nurse’s ability to set appropriate priorities for client care. The nurse’s skills and ability to correctly interpret significant information and the amount of time available to make assessments all affect the quality of priority setting. 52. Maslow’s hierarchy of needs: 1. 2. 3. 4.

looks at human needs from a spiritual standpoint. examines human needs from a social standpoint. organizes human needs from most basic to most sophisticated in a pyramid form. relates to the unconscious needs of groups.

(3) Maslow’s hierarchy depicts human needs from most basic to most complex in a pyramid form. The most basic needs are physiologic and safety needs. The most complex needs are those of self-actualization. 53. The charge nurse for a hospital floor becomes ill and is relieved from duty by the nursing supervisor. The nurse placed in charge by the nursing supervisor has three months’ experience on the unit as a licensed professional. The new charge nurse gathers the personnel currently working to explain the situation, redistributes work assignments with staff input, and lets the team know of administrative support available for its unit. This is an example of: 1. 2. 3. 4.

a democratic leadership style. an authoritarian leadership style. shared responsibility for decision-making. utilization of power to accomplish one’s goals.

(1) A democratic leadership style includes input from followers in decision-making through group discussion with a strong focus on teamwork. In an authoritarian leadership style, the leader makes the decisions and gives orders. Shared responsibility for decision-making occurs when decisions are made with the input of team members. Accomplishment of one’s personal goals is not an expected outcome in this situation; completion of work and job responsibilities is the goal indicated in the question.

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Part I: Subject Area Review Chapters

54. Positive attributes of a nursing leader include all the following qualities except: 1. 2. 3. 4.

attention to detail. ability to be a role model for others. integrity, energy, and inflexibility. self-confidence.

(3) Choices 1, 2, and 4 are positive attributes for a nursing leader. If a leader is to be successful, he or she also needs to be flexible and adaptable to new information and situations. 55. A nurse finds a home care client, who suffers from dementia, at home without a caregiver. The nurse works to find adequate supervision for the client, including a short-term secure location with safe care until the regular caregiver can be located and long-term plans made. This is an example of: 1. 2. 3. 4.

delegation. quality assurance. purposeful inaction. problem solving.

(4) Problem solving is the process of identifying obstacles that inhibit accomplishment of a goal. In this case, the goal is safe care for a demented client. Delegation is the assignment of responsibilities to others. Quality assurance is a process assessment and evaluation that attempts to address organizational problems or needs. Purposeful inaction is a conscious decision not to act. 56. Confidentiality is: 1. 2. 3. 4.

a right of competent clients only. a right that encompasses only the client-physician relationship. a right of the client to have personal information kept private. a right that applies to verbal information only.

(3) Confidentiality is the right of clients to have personal information, both verbal and written, kept private and not disclosed except to those members of the health care team directly involved in the client’s care for the purpose of protecting the safety of the client or others. Confidentiality extends to all clients regardless of their mental competence status. Information about clients who have been deemed mentally incompetent by a court of law is shared only with, or at the discretion of, the legally responsible party for the incompetent client. 57. While attending medical rounds, the nurse is given a written case to use as a part of the teaching-learning process and in a group discussion. In the course of the discussion, the identity of the client becomes known to the group. The nurse should: 1. 2. 3. 4.

dispose of any class notes in the regular trash. stop the discussion immediately after the identity of the client becomes known. participate in the discussion while in class, but dispose of the case information in the shredded trash after the presentation. respect the client’s confidentiality by leaving the presentation at the point at which the identity of the client becomes known.

(3) In many medical teaching-learning situations, the identity of a client becomes known through the presentation information. The teaching-learning process can still occur while maintaining the confidentiality of the client as the case is discussed. The learner need not be removed from this process. The learner must not spread the information in public discussion. Documents that carry information about a specific client must be appropriately shredded after use.

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Coordinated Care

58. The nurse has access to client laboratory reports through a work computer and has accessed a client’s current test results. The nurse should: 1. 2. 3. 4.

make sure the results are not visible on the screen when the nurse steps away from the computer. make sure the results are not visible on the screen where a visitor to the unit might see them. always log out of the computer when it is not in use to prevent access by unauthorized persons. do all of the above.

(4) Computer access to confidential records must be appropriately restricted to protect the privacy of the client. Unauthorized access to information by those not directly involved in the care of the client is considered a breach of privacy and, therefore, of confidentiality. 59. Maintaining the confidentiality of client information is: 1. 2. 3. 4.

a moral obligation. an ethical obligation. expected only in an acute care institution. both a legal and an ethical obligation.

(4) Confidentiality of client information has been upheld in U.S. courts as both a legal and an ethical obligation of health care personnel. 60. A breach of confidentiality can occur: 1. 2. 3. 4.

over the phone. in the form of a person-to-person discussion only. when information is disclosed without the client’s consent. in written form only.

(3) Client confidentiality is breached when information is disclosed without the consent of the client, the client’s legal representative, or court order. A breach of confidentiality can occur in verbal or written form, in person, over the telephone, or via an electronic medium such as a fax transmission. 61. Home care nurses protect clients’ medical records because: 1. 2. 3. 4.

state and federal law requires protection of the confidentiality of clients’ medical records. home care agencies do not require it, but it is the right thing to do. only federal law requires that the confidentiality of medical records be maintained. records from the field need not be kept confidential because they are not yet in the medical record.

(1) State and federal law require health care providers to maintain the confidentiality of medical records. Agencies have policies that follow their specific state law and guide the nurse in his or her responsibility to fulfill the law in that state. Medical records that have been initiated in any setting are still part of the client’s medical record and must be kept confidential. 62. A nurse in a nursing home routinely faxes information to physicians for their review. A physician’s office calls and requests some lab results that were faxed the day before. The nurse investigates and finds that the results were sent to the wrong physician’s office. This is: 1. 2. 3. 4.

not considered a breach of confidentiality because the information was not verbally discussed. not considered a breach of confidentiality because the information was disposed of by the physician’s office that actually received it. considered a breach of confidentiality only if the client finds out. considered a breach of confidentiality because identifiable private medical information was shared with individuals other than the health care providers who are caring for the client, without the consent of the client.

(4) A breach of confidentiality occurs whenever private medical information is shared verbally or in writing with persons not participating in the care of the client, without consent of the client or his or her legal designee.

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63. An exception to a client’s right to confidentiality is: 1. 2. 3. 4.

the police officer investigating an accident asks for results of a blood-alcohol test from the Emergency Department (ED) staff. the client is not considered compliant. the client threatens personal harm or harm to others. there are no exceptions to a client’s right to confidentiality.

(3) There are several exceptions to a client’s right to confidentiality, including the right of courts to require information for legal proceedings (summonses, court orders, litigation information necessary for the court, subpoenas, and so on), state requirements for mandatory reporting of certain illnesses, sharing of information if a client threatens personal harm or harm to others, or if a client is found by a court to be legally incompetent (cannot make a safe and rational decision). 64. The 1996 law that increases regulation protecting the confidentiality of medical records is known as: 1. 2. 3. 4.

OBRA. Patient’s Bill of Rights. HIPAA. Patient Self-Determination Act.

(3) The Health Information Portability and Accountability Act of 1996 (HIPAA) brought greater regulation from the federal government designed to protect medical records and other individually identifiable health information. This includes information communicated electronically, on paper, or orally. The Patient’s Bill of Rights covers the general rights and responsibilities of the patient in relation to the patient’s health care while undergoing hospitalization. The Omnibus Reconciliation Reform Act (OBRA) targets nursing home reform due to quality issues identified. The Patient Self-Determination Act stresses the rights of the patient in decision-making. 65. HIPAA defines “individually identifiable health information” as all but which of the following? 1. 2. 3. 4.

medical test results with a client’s name or identification number any information, including demographic information, collected from a client any information, excluding demographic information, collected from a client any information that could reasonably be believed to identify an individual

(3) HIPAA defines “individually identifiable health information” as any information, including demographic information, collected from a client and/or any information that identifies or could be reasonably believed to identify an individual. 66. Confidentiality is: 1. 2. 3. 4.

not necessary to maintain when talking with a client’s family members. a legal requirement in health care. covered by the state’s HIPAA law. an absolute right of clients.

(2) Confidentiality is an ethical duty in health care and is also a legal requirement covered by federal HIPAA legislation. Confidentiality is not an absolute right of clients, however, and can be overruled or breached in certain specific situations where there is a danger to the client or others, or where the court system decides that a need exists for certain information to be shared. HIPPA legislation is federal, not state, in its origin.

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Coordinated Care

67. A client suffers a cerebrovascular accident that results in aphasia. The most appropriate member of the interdisciplinary health care team to consult is the: 1. 2. 3. 4.

physical therapist. social worker. speech therapist. diabetic nurse educator.

(3) The speech therapist is the most appropriate member of the health care team to deal with the client’s aphasia. Aphasia is the loss or impairment of language in comprehension or expression of words as a result of injury to or degeneration of the language centers in the cerebral cortex. 68. A client with peripheral vascular disease who has leg ulcers should be seen by the: 1. 2. 3. 4.

physical therapist. wound care nurse. durable medical equipment (DME) specialist. neurologist.

(2) The wound care nurse is an appropriate referral for assisting with regimens specific to wound healing. A physical therapist can be called on to assist with mobility concerns, along with a DME specialist if assistive devices are needed. A neurologist is needed if neurological disease is suspected. 69. A client is admitted to the Emergency Department with right-sided weakness and swallowing difficulty. The physician specialist who is expected to evaluate this client is: 1. 2. 3. 4.

a neurologist. a gastroenterologist. a physiatrist. a pulmonologist.

(1) A neurologist should evaluate this client for a possible CVA. A gastroenterologist works with clients who have digestive problems. A physiatrist works with clients who have rehabilitation needs. A pulmonologist works with clients who have respiratory problems. 70. Skilled nursing facilities have the ability to provide which of the following rehabilitation services: 1. 2. 3. 4.

nutrition, nursing, physical therapy, radiation therapy. physical therapy, occupational therapy, nursing, emergency services. nutrition, nursing, physical therapy, occupational therapy, wound care services. nursing, radiation therapy, speech therapy, wound care services.

(3) Nutrition, nursing, physical therapy, occupational therapy, activity therapy, wound care services, speech therapy, and social work services are all available within a skilled nursing facility. Radiation therapy is available in radiation therapy facilities, and emergency services are available in urgent care and emergency care facilities. 71. A client is receiving IV fluids for hydration and begins to have shortness of breath and a cough. The physician orders a chest X-ray, which is interpreted by a: 1. 2. 3. 4.

gastroenterologist. physician’s assistant. cardiologist. radiologist.

(4) X-rays are evaluated by radiologists. Gastroenterologists specialize in the care of clients who have digestive problems. Cardiologists specialize in the care of clients who have heart disease. Physician’s assistants are midlevel health care providers who work under the direction of a physician.

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72. A client is in the hospital for congestive heart failure and regulation of medications to improve heart function. The nurse should expect a consultation with the: 1. 2. 3. 4.

cardiologist. pulmonologist. occupational therapist. exercise physiologist.

(1) A cardiologist is a physician who specializes in the care of clients who have heart problems. A pulmonologist specializes in the care of clients who have respiratory problems. An occupational therapist specializes in skilled therapy related to activities of daily living. An exercise physiologist specializes in exercise regimens as part of disease management and health improvement. 73. A client is having emergency surgery to repair a hip fracture and requires assistance with discharge plans. The nurse should consult the discharge planner: 1. 2. 3. 4.

at the time of discharge. at the time of admission. immediately postoperatively. when the client expresses a need for discharge services.

(2) Discharge planning is initiated at the time of admission to the hospital to meet the discharge needs of the client by the time of discharge. If an admission is planned, rather than an emergency, discharge planning begins before admission to the hospital. 74. The interdisciplinary team that cares for clients with cancer is led by a: 1. 2. 3. 4.

pulmonologist. cardiologist. oncologist. radiation therapist.

(3) An oncologist is a physician who specializes in the care of clients who have cancer and is the leader of an oncology interdisciplinary care team. A pulmonologist specializes in the care of clients who have respiratory problems. A cardiologist specializes the care of clients who have heart problems. A radiation therapist manages the radiation therapy that a client receives as a part of treatment. 75. A physical therapist assists with: 1. 2. 3. 4.

treatment of problems performing activities of daily living. treatment of swallowing disorders. treatment of urinary incontinence. treatment of immobility, gait and balance problems, and assistive-device training.

(4) A physical therapist specializes in the treatment of immobility, gait and balance problems, and assistive-device training. Occupational therapists specialize in assisting clients with problems performing activities of daily living. Speech therapists treat speech problems and swallowing disorders. Urologists manage urinary problems. 76. A client is suffering from renal failure and might need dialysis. The client should have an initial consult with: 1. 2. 3. 4.

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a nephrologist. a social worker. a vascular surgeon. all of the above.

Coordinated Care

(1) A client with renal failure who might need dialysis should be evaluated by a nephrologist. A social work consult provides counseling that might be needed and facilitates contact with the insurance and financial resources needed for treatment. A vascular surgeon places the vascular shunt for access if hemodialysis is chosen as the most appropriate method of dialyzing the client. 77. A home care client sees a primary care physician as well as a cardiologist. The primary care physician’s functions include: 1. 2. 3. 4.

managing the client’s overall care and coordination of the health care team. writing all the prescriptions for the client. managing all the cardiac needs of the client. seeing the client only annually for a physical.

(1) The functions of the primary care physician include managing the overall care of the client and coordination of the health care team. The cardiologist manages cardiac needs and communicates recommendations to the primary care physician. The primary care physician can integrate these treatments into the overall plan of medical care. 78. An individual’s health beliefs and practices are influenced by all the following internal variables except: 1. 2. 3. 4.

developmental stage. intellectual background. family practices. emotional and spiritual factors.

(3) All the choices listed are influential in an individual’s health beliefs and practices; however family practices are considered an external variable. 79. A middle-aged client is concerned about his health and wants to make changes to avoid and minimize health problems in the future. The focus of teaching for this client is on primary preventive care practices, which: 1. 2. 3. 4.

help healthy people stay healthy. help individuals with illness avoid complications. help clients adapt to functional losses. are covered entirely by insurance plans.

(1) Health care practices and lifestyle behaviors that help healthy people stay healthy are referred to as primary prevention. The goal of secondary prevention is to help those with chronic illness manage their disease and avoid complications. Tertiary health care helps clients adapt to losses or complications that result from a disease or chronic illness. Primary preventative care is not covered by all insurance plans. 80. Which of the following activities is an example of practicing primary prevention? 1. 2. 3. 4.

water aerobics for those with osteoarthritis physical therapy following a hip fracture cardiac rehab after open-heart surgery eating a diet moderately low in carbohydrates and low in saturated fat

(4) A healthy diet and exercise are two of the most basic primary prevention health strategies. Primary prevention focuses on keeping healthy people healthy. Water aerobics can control symptoms and strengthen the musculoskeletal system and is a common secondary prevention strategy for those with osteoarthritis. Cardiac rehabilitation after open-heart surgery and physical therapy following a hip fracture are both considered tertiary care because they focus on helping clients deal with losses.

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81. Which of the following statements about arthritis is an example of secondary preventive care? 1. 2. 3. 4.

Exercise cures arthritis. Exercise can help control and manage the symptoms of arthritis and prevent complications. Exercise helps individuals mentally cope with functional losses resulting from arthritis. Individuals should rely heavily on the use of alternative therapies even though they are not proven effective in treating arthritis.

(2) Secondary prevention focuses on strategies to control and manage symptoms of chronic illness and prevention of future complications. Exercise does not reverse the disease process. While exercise might help by providing coping strategies through distraction and decreasing discomfort by possibly easing inflammation, exercise is not a preventative strategy. Alternative drug therapies that have not yet been proven effective should be used cautiously and discussed with a physician. 82. A 71-year-old client fell and broke her left hip. During her hospital stay, she was diagnosed with osteoporosis. After a six-month recovery period, the client has returned to her baseline bone density. The client takes Miacalcin NS, a calcium regulator, and a calcium supplement daily. This is an example of: 1. 2. 3. 4.

primary preventative care. secondary preventative care. tertiary preventative care. excessive medication.

(2) The client is using secondary prevention strategies, recognizing that osteoporosis is a chronic illness. The use of Miacalcin NS, a calcium regulator, and a calcium supplement might prevent further bone loss and can potentially strengthen bones. With her history of osteoporosis and her fracture, the medications are clearly indicated. 83. A focus on tertiary preventative care practices means: 1. 2. 3. 4.

helping healthy people stay healthy. helping individuals with illness avoid complications. helping clients adapt to functional losses. providing therapy in an acute care setting to promote cost effectiveness.

(3) Tertiary care is focused on rehabilitation by helping clients deal with losses and maximizing potential for independence leading to improved quality of life. Primary practices help healthy people stay healthy. Avoiding complications of illness is secondary prevention. Therapies given in acute care, home care, and long-term care settings are more costly than those given in a rehabilitation setting. Reimbursement is not related to the definition of tertiary care. 84. Which of the following rehabilitation clients is participating in a tertiary care practice? 1. 2. 3. 4.

a client in speech therapy for dysphagia following a stroke a client attending a class on heart attack prevention a client playing 18 holes of golf every other day a client getting an annual flu shot and tetanus booster when due

(1) The first client is experiencing a functional loss resulting from a stroke. Speech therapy can help this client learn various strategies for eating and swallowing to regain independence. A class on heart attack prevention, immunizations, and active exercise (in the form of golf) are primary prevention practices.

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Coordinated Care

85. The problem that most commonly interferes with clients achieving the best potential outcome occurs when a client is transferred from one health care setting to another during the course of an illness. This problem is: 1. 2. 3. 4.

loss of personal items. poor communication between the members of the health care team. uncaring staff. separation from family.

(2) Continuity of care can only be achieved with effective communication between all participating professional teams. Communication breakdown can occur during shift change in an acute care setting, hospital-to-rehabilitation unit transfer or rehabilitation-unit-to-home transfer. Effective communication improves a client’s opportunity to reach his or her treatment goals. While separation from family and loss of personal items might be upsetting to a client, causing unnecessary stress, these factors do not have a direct impact on continuity of care. 86. The fastest-growing health care delivery sites are: 1. 2. 3. 4.

rehab units. acute care hospitals. churches. home health care.

(4) Changes in the health care reimbursement structure over the last 20–25 years have shortened the length of hospital stays and shifted care into the community. Home health care continues to experience an explosion in growth as baby boomers age and the need and desire for home-based care increases. Acute care hospitals have downsized and recently reached a plateau in development. Churches, as a community site, have begun to embrace health ministry as a focus with the concept of parish nurses, but this growth is much slower and less intense than in home health care. 87. Which of the following demographics affect the discharge plan for a 75-year-old woman? 1. 2. 3. 4.

Most elder adult women have spouses to help care for them. Most elder adult women live alone. Most elder adult women live within a five-mile radius of one of their children. Women use more health services than men.

(2) Most elder adult women live alone; a majority of them are widowed. This is important to the nurse, and it might impact the woman’s discharge needs and planning. Some elder adult women live in close proximity to their children, but most live in their family home, regardless of current proximity to their children. Population usage of health care services by women would not affect discharge plans for an individual. 88. All the following factors disrupt continuity of care except: 1. 2. 3. 4.

insurance changes. geographic relocation. available transportation. positive client relationships with health care providers.

(4) Positive client relationships with primary health care providers are necessary for continuity of care. Positive relationships with primary health care providers are closely correlated with increased client compliance and positive outcomes. Factors that disrupt continuity include the logistics of transportation and geographic location of the service provider. Insurance plan changes often require a change in health care providers.

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Part I: Subject Area Review Chapters

89. The Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) defines quality improvement as: 1. 2. 3. 4.

the retrospective identification of problems. the continuous study and improvement of the processes of providing health care. a focus on facility outcomes. activities performed on a quarterly basis.

(2) Quality improvement is an ongoing process of studying and improving the processes of providing health care. 90. Quality indicators that might be the focus of unit-based, continuous quality improvement (CQI) activities on a medical-surgical (med-surg) unit include all the following except: 1. 2. 3. 4.

medication errors. incisional wound infections. incidence of postoperative pneumonia. number of readmissions with a primary diagnosis of CHF (congestive heart failure).

(4) A quality indicator is a quantitative measure of an important aspect of care that determines whether standards are being met. It is a standard of performance. On a med-surg unit, specific care indicators could include medication errors, incisional wound infections, or incidence of postoperative pneumonia. The number of clients readmitted with a primary diagnosis of CHF is an institutional quality indicator focused on the volume of admissions in the entire facility, rather than in one unit. 91. All the following are types of quality indicators except: 1. 2. 3. 4.

structure. procedure. process. outcome.

(2) A procedure is a specific type of process indicator. Structure, process, and outcome are the three categories of quality indicators. Structure includes the structure or systems for delivering care. Process indicators evaluate the methods by which care is delivered. Outcome indicators evaluate the outcomes of care delivered. 92. A threshold is a quantitative measure used to determine whether a problem exists. A threshold: 1. 2. 3. 4.

is a measurement that is represented by a number. might be set arbitrarily and changed according to need. must be realistic at any point of the process. includes all of the above.

(4) A threshold is a number (set or calculated from data collection) that defines an acceptable level of practice or performance. It is adjustable depending on the goals and results of the process. A threshold is not a number with absolute meaning; it allows for necessary variability. 93. The two types of quality improvement teams are organization wide and unit based. Which of the following characteristics does not describe unit-based teams? 1. 2. 3. 4.

They are participative. Members identify priorities for the unit. They utilize centralized decision-making. Their efforts lead to improved outcomes for clients.

(3) Unit-based team members are active in identifying issues or concerns, the monitoring focus (indicators), and the evaluation process. Unit-based teams utilize decentralized decision-making. Team members participate in decision-making;

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Coordinated Care

decisions are not simply handed down from a manager, supervisor, or administrator. Unit-based teams have been shown to affect client outcomes positively. 94. Health care organizations use the CQI approach for all the following reasons except: 1. 2. 3. 4.

accreditation requirements. increasing reimbursement. competition for customers including insurance company contracts. cost control.

(2) Three basic goals have been identified for CQI: conforming to requirements, competitive advantage, and process improvement (which is designed to result in improved quality of care and cost control). A CQI program does not impact or increase reimbursement directly. 95. Within a hospital setting, all the following personnel are responsible for a CQI program except: 1. 2. 3. 4.

the bedside nurse. nursing administration. hospital administration. agency staff employed on a per diem basis.

(4) All hospital staff are responsible for contributing to CQI efforts. Because agency staff are hired on a per diem basis, contribution to CQI efforts is not a job expectation. 96. A nursing unit’s scope of service is important in defining meaningful CQI efforts. A scope of service includes: 1. 2. 3. 4.

the types of clients who receive nursing care on the unit and the types of processes used to provide nursing care. the efforts of ancillary departments in supporting a nursing unit’s function. the focus of CQI activity as directed by administration. allowing the staff to focus on general quality issues in the health care facility.

(1) A unit’s scope of service is a definition of the types of clients receiving care on a specific nursing unit and the types of processes used to provide that care. It is unit specific and does not apply to the general health care facility. The scope of service is part of the unit-based activity, with goals of quality improvement identified by staff working on the unit. 97. Which of the following characteristics describe CQI? 1. 2. 3. 4.

The staff works to continuously improve quality. Efforts are directed toward improving client outcomes. Goals are set to raise thresholds. All of the above.

(4) The goal of CQI is increased quality through improved client outcomes. Goal achievement can be monitored by increasing thresholds from those set at the onset of the CQI effort. 98. The specific purpose of data collection and analysis by a unit-based CQI team is to: 1. 2. 3. 4.

allow for accurate analysis of the appropriateness of care. manipulate information about key indicators to demonstrate that nursing goals are being met. contribute to the large database required for the health care organization as a whole in meeting Joint Commission standards. justify the need for unit staff.

(1) Staff must have relevant data to accurately analyze the appropriateness of nursing care. The information is based and focused on the unit, rather than on the institution as a whole. Manipulation of data to achieve results is improper use of data analysis. The purpose of CQI is to improve patient care, whereas staffing issues are more of a secondary concern.

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99. The CQI process does not end with data analysis. After evaluating the data, the next step of the process is: 1. 2. 3. 4.

to consider whether thresholds are met. to identify problems from all the collected information. to communicate the results. to choose another aspect of care to monitor.

(1) After data is collected, it must be analyzed according to appropriate thresholds, which define whether a problem exists. If a problem exists, the next step is problem solving. 100. In the past 20 years, the nursing profession has dealt with an increasing shortage of nurses. Effective delegation has become a vital nursing skill because it is imperative to: 1. 2. 3. 4.

ensure quality client care. utilize available staff appropriately. promote cost effectiveness. all of the above.

(4) The nursing profession uses delegation as a vital management tool to ensure quality care, utilize staff appropriately, and support cost-effective health care. 101. The goal of delegation is: 1. 2. 3. 4.

staff satisfaction. workload distribution. effective management. prioritizing client care needs.

(2) Delegation is an effective method of workload distribution, particularly when used in a team approach to the delivery of nursing care. 102. Delegation is not: 1. 2. 3. 4.

the random assignment of work to others. giving orders or directing the flow of work. shifting control or responsibility. all of the above.

(4) Delegation is the purposeful assignment in distributing workload according to skill level to achieve outcomes. The delegator retains ultimate responsibilities for the choices made in delegating workload. 103. The five rights of delegation are (choose from the following):

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A. B. C. D. E.

right task, right person. right time, right place. right circumstances, right communication. right supervision. right cost.

1. 2. 3. 4.

A, B, and E. A, B, and C. B, C, and D. A, C, and D.

Coordinated Care

(4) The five rights of delegation have been identified by many state boards of nursing as guiding parameters. Right task is a task that can be legally delegated to an LPN (licensed practical nurse) or unlicensed assistive personnel (UAP). Right person means that the task is delegated to a person who can legally perform it, according to practice laws. Right circumstances means that the delegator is responsible for determining whether the delegatee understands the elements of and can safely perform the procedure. Right communication means that the delegator specifies goals and gives clear direction. Right supervision means that the delegator answers questions and provides appropriate follow-up support to the delegatee. 104. The process of delegation involves all the following activities except: 1. 2. 3. 4.

selecting a capable person and explaining the task and desired outcome(s). allowing the selected person to determine the goals of the assignment. providing the means and authority for doing the job. keeping in contact and giving feedback.

(2) Delegation does not involve expecting the delegatee to determine the goals of the assignment. To effectively delegate, clear and specific directions must be given to ensure successful task completion. 105. In delegating nursing activities, all the following factors can be assessed except: 1. 2. 3. 4.

the safety of the patient. the skill of the staff member. the supplies available. the cost of care provided.

(4) At the level of the practical nurse delegating client care, the cost of the care provided is within the scope of management and not usually within the scope of the practical nurse. 106. Delegation can be undermined by all the following factors except: 1. 2. 3. 4.

financial incentives. trust of subordinates. staff who do not follow through appropriately. managers who are reluctant to give up control.

(2) Delegation can be undermined by mistrust of subordinates, staff who do not follow through with designated tasks, and managers who are personally reluctant to assign responsibilities. Financial incentives may also encourage poor choices in delegation. 107. Delegation is defined as: 1. 2. 3. 4.

transferring the authority to perform a selected nursing task in a selected situation to a competent individual. sharing a workload or assignment. providing guidance for performing a task or activity. analyzing competency.

(1) Delegation is a purposeful transfer of authority and responsibility to perform a specific task to a competent individual in a specific situation. Providing guidance can be defined as supervision. Analyzing competence is part of assuring quality client care when delegating. The delegator is responsible for assuring competence of the delegatee to perform the delegated task. 108. In the process of delegation, the delegator has accountability for all the following activities except: 1. 2. 3. 4.

acts of delegation and supervision. assessment of the situation and follow-up. appropriate notification and reporting of progress. corrective action if needed.

(3) Appropriate notification and reporting of progress is the responsibility of the delegatee.

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109. The delegatee, or person being delegated to, has accountability for: 1. 2. 3. 4.

their own actions. appropriate feedback and reporting. accomplishing the task assigned. all of the above.

(4) The delegatee is responsible for their own actions, accomplishing the task assigned, and appropriate feedback and reporting. 110. An example of a responsibility that an RN may delegate to a PN is: 1. 2. 3. 4.

initial health assessments. assisting a post-MI (myocardial infarction) client with ambulation and activities. initiating referrals for additional client services. formulating a discharge teaching plan.

(2) State nursing practice acts identify the scope of practice. In general, RNs are directly responsible for assessing, planning, evaluating, and teaching. The task of assisting a client with ADL (activities of daily living) can be delegated. 111. Maslow’s hierarchy provides a theoretical foundation for establishing priorities. According to Maslow’s theory, which of the following has the highest priority? 1. 2. 3. 4.

the need to be loved by someone the need for physical safety and security the need for a treatment to alleviate dyspnea the need to know that as a nurse you’ve done your best

(3) According to Maslow, physiologic needs are the most basic and of the highest priority because they must be satisfied to sustain life. 112. Priority setting occurs during which step of the nursing process? 1. 2. 3. 4.

assessment planning intervention evaluation

(2) After assessment, formulation of specific diagnoses follows as part of the planning process. The nurse uses criticalthinking skills to establish priorities by ranking them in order of importance. The next step in the nursing process is implementation of the plan, followed by evaluation. 113. All the following criteria should be used by the nurse when setting priorities for a nursing care plan except: 1. 2. 3. 4.

the nurse’s perception of severity or physiological importance. the client’s desires. the physician’s orders. the client’s safety.

(3) The physician’s orders primarily direct the medical care. The nurse’s perception of severity, client desires, and client safety are all important factors in selecting nursing diagnoses, from which the nursing care plan flows.

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Coordinated Care

114. Priorities are classified as high, intermediate, or low. These classifications are determined by: 1. 2. 3. 4.

the urgency of the problem. the nature of the treatment indicated. the relationships between the nursing diagnoses. all of the above.

(4) Nursing decisions regarding priority are made based on the urgency of the problem, nature of treatment indicated, and relationships between the nursing diagnoses. 115. All the following are true when the nurse designates a task as high priority except: 1. 2. 3. 4.

priorities are physiological. priorities are psychological. the situation could result in harm to the client if action is not taken. the situation demands a quick response to needs as determined by the nurse, independent of the client involved.

(4) Priority setting by the nurse always includes the client in decision-making (if the client is able to participate). A nurse’s perception of a high-priority task might be different from the client’s perception. Respecting the client’s right to autonomy requires that the client be involved in decision-making. 116. At 11:00 a.m. a client is brought to the unit from the Emergency Department for admission. Lying on the transport cart, the client complains of severe nausea and vomits into an emesis basin. The client’s family is with him. Which action is the most appropriate for the nurse to take at this time? 1. 2. 3. 4.

Help get the client into bed and orient him to the bed controls. Help get the client into bed and begin to fill out the detailed admission assessment form. Ask the client whether he has valuables for the safe. Help get the client into bed, properly positioned for comfort, and begin focused abdominal assessment targeting his nausea.

(4) Although the process for admission is an important one, in this instance the priority for the nurse becomes intervening on behalf of the client’s comfort. After the symptoms are alleviated, the client can participate in the admission process. 117. An 80-year-old client is admitted to the nursing unit with a diagnosis of Weakness, Status Post Fall. The admission fact sheet indicates that the client is widowed and lives alone. Which of the following is the lowestpriority concern when working through the admission assessment? 1. 2. 3. 4.

asking the client about the details of the fall asking the client whether she likes to read asking the client about her ability to shop for and cook her own food asking the client which medications she has been taking

(2) The client’s reason for admission is weakness and a fall. High-priority concerns in assessment are identifying intrinsic or extrinsic factors that might have led to the fall. The client’s interest in reading, while important when determining possible activities to incorporate in the care plan, is a lower priority. 118. Setting appropriate priorities begins in which step of the nursing process? 1. 2. 3. 4.

assessment planning intervention evaluation

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(2) Priority-setting involves making decisions based on information obtained during a thorough assessment. Prioritysetting is accomplished during the planning phase of the nursing process based upon the assessment. 119. After receiving the change-of-shift report, the PN plans care for an assigned group of clients. Which client should be cared for first? 1. 2. 3. 4.

a client who has a hemoglobin of 9.5 a client who has a temperature of 101.8° F (by tympanic thermometer) a client who is reported to have been acutely confused at the end of the previous shift and pulled out his IV three times a client who needs help getting to the bathroom

(3) Nursing diagnoses that could result in injury to the client or others if untreated have the highest priority. 120. From the preceding question, which of Maslow’s basic needs supports the correct choice of priority? 1. 2. 3. 4.

physiologic need safety and security self-esteem self-actualization

(1) Physiologic needs are of the highest priority, according to Maslow. 121. A client who is on a ventilator in the intensive care unit had a tracheostomy performed earlier in the day. Which of the following actions is of the highest priority? 1. 2. 3. 4.

assisting the client with clear liquids dressing the client in his or her own pajamas per a family member’s request checking the patency of the client’s tracheostomy tube auscultating the client’s heart

(3) The highest priority action for the nurse is to maintain the patency of the client’s airway. 122. The first step in the ethical decision-making process is to: 1. 2. 3. 4.

consider the alternatives. collect, analyze, and interpret data. consider the consequences of actions. make a decision.

(2) The ethical decision-making process is similar to the nursing process. The first step is to collect, analyze, and interpret data, which parallels the assessment step in the nursing process. The second step of ethical decision-making is to identify options and/or consider alternatives, which is similar to the planning step in the nursing process. In ethical decision-making, options are identified and potential consequences are considered. The next sequential step of ethical decision-making is forming a decision, which is similar to the implementation step of the nursing process. 123. A nurse who supports a client and family in making a decision that is right for them is practicing which of the following ethical principles? 1. 2. 3. 4.

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autonomy confidentiality privacy truthfulness

Coordinated Care

(1) Autonomy is the individual’s right to self-determination, and in this case the nurse is playing a supportive role in the decision-making process of the client and the client’s family. Choices 2, 3, and 4 are incorrect. Confidentiality is the duty to protect privileged information. 124. A nurse stops at an accident scene to provide assistance. According to the ethical principle of beneficence, the nurse should: 1. 2. 3. 4.

act in the client’s best interest. allow the client choices. consider the consequences of actions. make a decision.

(1) The ethical principle of beneficence is to do good for others. Choices 2, 3, and 4 are incorrect. Allowing a client choices, considering consequences of actions, and decision-making are steps in the ethical decision-making process. 125. Veracity is: 1. 2. 3. 4.

the basis for informed consent. the basis for the Patient Self-Determination Act. the duty to tell the truth. all of the above.

(4) Truthfulness, or veracity, includes all three choices. Veracity, the duty to tell the truth, is the basis of informed consent and of the Patient Self-Determination Act. 126. A client suffering from heart failure says to the nurse, “I don’t want to have anything done to keep me alive, but my daughter tells me not to worry about it. If something happens, she will want me taken back to the hospital again. I don’t want to be in an intensive care unit or put on machines. Can you help me please?” The ethical principle(s) involved here is: 1. 2. 3. 4.

autonomy. veracity. fidelity. all of the above.

(4) This client is expressing personal wishes and the right to self-determination and autonomy. The nurse is ethically obligated by the principle of fidelity to help the client. As an advocate for the client, the nurse should communicate the client’s wishes appropriately in conversations with the family, the physician, and the nursing supervisor. 127. Which of the following situations present a potential value conflict for a nurse who is caring for an elder adult known to be a victim of abuse? 1. 2. 3. 4.

An abused elder client is admitted to the hospital because of injuries. An abused elder client chooses to go back to the abusive situation. An abused elder client is placed in a nursing home for long-term care. An abused elder client chooses to prosecute the offender.

(2) Recognizing the principle of autonomy, the nurse must support the elder client’s decision to return to the setting where the abuse took place, but the nurse’s own value set might not allow the nurse to personally agree that this is in the client’s best interest. Choices 1 and 3 indicate that the elder client is in a protected care environment, which decreases the client’s vulnerability to harm. Choice 4 implies the ethical principle of justice.

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128. Ethical decision-making is a process that includes all the following activities except: 1. 2. 3. 4.

considering the consequences of an action. collecting data. analyzing and interpreting data. making decisions based on historic policies and law.

(4) Choice 4 is not a step in the ethical decision-making process. Ethical decision-making is accomplished by a process that takes all data regarding the general and unique factors of a particular situation into consideration. A decision is arrived at based on analysis and interpretation of the current reality of the situation. Choices 1, 2, and 3 are individual steps in the ethical decision-making process. 129. Ethics committees perform all the following primary functions except: 1. 2. 3. 4.

assisting institutions in the development of ethical policies. ensuring that policies are being implemented and understood. making determinations of guilt if the right decision is not made. serving as a resource in specific client situations with ethical aspects.

(3) Choice 3 is not a primary function of ethics committees. Ethics committees do not have a role in determining guilt. Choices 1, 2, and 4 are primary functions of ethics committees. 130. The American Nurses’ Association (ANA) Code of Ethics for Nurses is an important professional resource because it: 1. 2. 3. 4.

describes specific behaviors. offers general principles to guide and evaluate nursing care. is based on state nursing practice acts. is a unique document applied universally.

(2) The ANA Code of Ethics for Nurses provides principles to guide and evaluate nursing care. Choice 1 is incorrect because codes are written in general, universal terms; they are not designed to tell nurses what to do in specific situations. Choice 3 is incorrect because state nursing practice acts are defined on the basis of ethical codes. Choice 4 is incorrect because several codes exist for professional nurses, all of which share basic ethical principles. 131. In the past 20–30 years, a main factor contributing to ethical dilemmas in health care has been: 1. 2. 3. 4.

advancement of technology. decreased information sharing. greater homogeneity of cultures in the United States. decreased life expectancy.

(1) Technological advances have greatly influenced health care outcomes and increased life expectancy. These advances have brought many challenges to the forefront regarding issues of life, death, and quality of life. Choices 2, 3, and 4 are incorrect. Increased sharing of information has increased the knowledge base of persons making choices. The increased life expectancy has challenged ethical decision-making because the increased length of life has not necessarily meant increased health. The greater heterogeneity of cultures in the U.S. has increased the number and types of desired choices and potential outcomes for health care. 132. The ANA Code of Ethics for Nurses encourages nurses to perform all the following activities except: 1. 2. 3. 4.

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maintaining competence in nursing. assuming responsibility and accountability for the actions of nursing students. participating in efforts to improve standards of nursing. participating in assisted suicide.

Coordinated Care

(4) Participation in assisted suicide is not encouraged by the ANA Code of Ethics for Nurses. Assisted suicide is not an acceptable ethical form of treatment. Choices 1, 2, and 3 are specifically referenced in the ANA Code of Ethics for Nurses. 133. When witnessing the client’s signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. In doing so, the nurse is verifying that: 1. 2. 3. 4.

the procedure was explained adequately. the client sufficiently comprehended the information. the client gave voluntary consent. the client has full awareness of the postprocedure recovery.

(3) In witnessing a consent, the nurse is indicating that the consent was obtained without coercion. Choices 1, 2, and 4 are incorrect. The nurse is not in a position to judge the adequacy of explanatory information, nor can the nurse measure comprehension to determine whether it is sufficient. The nurse is not in a position to judge the client’s level of awareness of postprocedure recovery. The physician is responsible for informing the client of the nature of the procedure, its risks, potential benefits, and probable outcomes. 134. The nurse asks the client to sign a consent form before undergoing surgery. The client indicates that he was not told about the risks of the surgical procedure. Which of the following statements by the nurse is most appropriate? 1. 2. 3. 4.

“I can answer any of your questions.” “Just sign the form now, and I’ll put a note on the chart that you have some questions.” “Your physician does a good job with this procedure. I’ve taken care of others who have had the same surgery, and they’ve done very well.” “I’ll note your questions and contact the surgeon so that you can talk to him (or her).”

(4) If the client indicates a lack of understanding, it is the nurse’s responsibility to inform the physician so that the client’s questions can be answered. Choices 1, 2, and 3 are incorrect. The nurse cannot answer the client’s questions because the nurse is not the client’s physician. The physician is the only person who can answer the client’s questions about a procedure. A consent cannot be signed until the client indicates understanding and agreement. The nurse must not ignore or minimize the fact that a client indicates a lack of understanding. The nurse is responsible for ensuring that the client gets the information necessary for an informed consent. 135. Informed consent involves all the following requirements except: 1. 2. 3. 4.

The client must be capable of making decisions. When informed consent is given, it cannot be revoked. The decision must be made voluntarily without coercion. The client must understand the potential risks and benefits that might result from consenting to a procedure.

(2) Informed consent can be revoked by the client at any time. Choices 1, 3, and 4 are requirements of informed consent. 136. Which statement is incorrect regarding obtaining informed consent from a client for a nursing research study? 1. 2. 3. 4.

An individual participating in a study must give informed consent to participate in the study. Informed consent for nursing research occurs after the study begins and can occur any time before study completion. Obtaining informed consent is the responsibility of the principal investigator. Informed consent must be documented in writing.

(2) Informed consent for participation in research must occur prior to the initiation of the study or research activity involving a client. Choices 1, 3, and 4 are true and therefore incorrect as the answer. Informed consent is required for research participation. The principal investigator is responsible for obtaining consent from study subjects, and that consent must be documented in writing.

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137. Formal, written consent is required for all the following procedures except: 1. 2. 3. 4.

gall bladder surgery. insertion of a urinary catheter. insertion of a pacemaker. breast biopsy.

(2) A client must give consent for urinary catheter insertion, but in most care settings this consent is implied or expressed by the client allowing the procedure to be done. Insertion of a urinary catheter is covered by the general consent to treatment signed by the client or legal guardian on admission. All surgical procedures—including gall bladder, pacemaker insertion and biopsies—require a formal, written consent. 138. The nurse is responsible for obtaining verbal or implied client consent for: 1. 2. 3. 4.

gall bladder surgery. insertion of a urinary catheter. insertion of a pacemaker. breast biopsy.

(2) The nurse is responsible for obtaining consent, usually verbal or implied, for a urinary catheterization because it is a nursing procedure. All consents for surgical procedures—including gall bladder, pacemaker insertion, and biopsies— need to be obtained by a physician. 139. To force treatment on a client without his or her consent could result in a charge of: 1. 2. 3. 4.

battery. slander. defamation. perjury.

(1) Forced treatment without consent constitutes battery, which is offensive touching. Choices 2, 3, and 4 are incorrect. Slander is a false, malicious statement that injures a person’s reputation. Defamation is to damage one’s reputation by either slander or libel. Perjury is deliberate false testimony under oath. 140. The general consent form signed upon admission to the hospital gives consent for: 1. 2. 3. 4.

any and all treatments. investigative procedures according to defined protocols. surgical procedures. administration of medications.

(4) Medication administration, as a general anticipated component of care, is covered by the general consent to treatment signed on admission. Choices 1, 2, and 3 are incorrect. The general consent form does not give blanket consent for any and all treatments. Investigative and surgical procedures require specific informed consents. 141. Informed consent protects individuals who participate in research by enforcing all the following rights except: 1. 2. 3. 4.

the right to agree to participate without coercion. the right to refuse to participate without jeopardizing the care that the client receives. the right to be protected from harm. none of the above.

(4) Consent for participation in research includes the rights described in Choices 1, 2, and 3.

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Coordinated Care

142. The ethical principle that is the foundation for informed consent is: 1. 2. 3. 4.

veracity. autonomy. fidelity. privacy.

(2) Autonomy refers to the right of self-determination and decision-making for health care. Choices 1, 3, and 4 are incorrect. Veracity is the ethical principle of truth-telling. Fidelity is keeping one’s word. The right to privacy is a client’s right to maintain dignity and respect by keeping personal information confidential. 143. Nurses have an ethical obligation to clients in terms of informed consent. This obligation includes all the following activities except: 1. 2. 3. 4.

assisting, promoting, and supporting client decision-making. supporting clients’ right to informed consent. providing information about advanced directives. following clients’ decisions only if in accordance with a physician’s orders.

(4) The nurse must ethically honor the principle of client autonomy and decision-making. A client has the right to make informed decisions and give or withhold consent based on information provided by the physician. The nurse’s role is to assist, promote, and support that decision-making. With regard to advanced directives, the nurse can give information to clarify and help reinforce the physician’s explanation. If a client’s decision is not reflected in the physician’s orders, the nurse is obligated to inform the physician so that clear agreement can be made. 144. The Omnibus Budget Reconciliation Act of 1987 (OBRA) is important legislation responsible for setting nursing home care and operation standards and goals. Need for the law stemmed from: 1. 2. 3. 4.

centralized control of nursing homes. reports of poor care quality and abuse of nursing home residents. funding problems. decreasing number of elder adults requiring long-term care.

(2) OBRA was passed as a major impetus for nursing home reform. It imposes regulatory oversight in the nursing home industry, driven by reports of poor quality of care. While the regulations imposed by OBRA standardize care to some extent based on goals, nursing homes continue to run as independent businesses. OBRA does not deal with funding problems, but with quality of care. Demographics, while defining the significance of nursing home difficulties, was not a major impetus driving the need for reform. 145. A standard of care defines nursing practice expectations so that care is: 1. 2. 3. 4.

affordable. performed according to physician orders. reasonably safe and appropriate. consistent.

(4) The American Nurses’ Association (ANA) published standards of clinical nursing practice in 1973. These standards define a competent level of behavior for the professional nursing role and are common to all nurses engaged in clinical practice. 146. In which of the following situations does a nurse have the responsibility to complete an incident report? 1. 2. 3. 4.

A client refuses to get out of bed due to fatigue. A client attempts to go to the bathroom alone, and falls when climbing over the side rails. A client becomes dizzy when standing up and complains of blurred vision. A client leaves the unit to buy a newspaper in the gift shop.

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(2) Incident reports are required for unusual or unintentional occurrences. The fall in Choice 2 is accidental, could have caused harm, and meets the criteria for an unusual or unintentional occurrence. Fatigue is not an unusual occurrence. Symptoms of dizziness and blurred vision are not considered unusual. A client leaving the unit to go to the gift shop does not fit the definition of an unusual occurrence. An incident report is not appropriate for the situations described in Choices 1, 3, and 4. 147. The elements of negligence include: 1. 2. 3. 4.

a duty and an injury. a breach of duty. an injury. all of the above.

(4) Elements of negligence are clearly defined as a duty and a breach of that duty with a resultant injury. 148. All the following statements are true of guardianships except: 1. 2. 3. 4.

They are court appointed. They provide for the payment of any medical bills. They assign a family member to help with care and decision-making. They can be temporary or permanent.

(3) Guardians are appointed as the legal spokespersons for health care and financial decision-making when an individual is no longer capable of speaking for him or herself. A guardianship can be either permanent or temporary, depending on the individual situation. A guardian need not be a family member. 149. Nurse practice acts define the scope of nursing practice in a(n): 1. 2. 3. 4.

educational institution. region. state. health care facility.

(3) Nurse practice acts set standards for professional nursing practice. They are established by state boards of nursing, which have jurisdiction for licensing nurses and holding them accountable for standards. Institutions, whether health care, educational, or other, are held to the standards of practice defined in that state. 150. A group that lobbies at the state and federal levels for advancement of the nurse’s role, economic interest, and health care is/are the: 1. 2. 3. 4.

American Nurses’ Association. State boards of nursing. National Student Nurses’ Association. American Hospital Association.

(1) The ANA, in addition to defining practice standards, is responsible for promoting the nurse’s role, economic interest, and health care. 151. A nurse who fails to check an armband prior to administering medications is: 1. 2. 3. 4.

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negligent. liable. following the five rights of medication administration. correctly using principles of time management.

Coordinated Care

(1) The nurse has a duty to correctly administer medications to the correct client. Lack of verification of identity is a failure to follow procedure, thus a breach of duty. 152. A client comes to the nurses’ station asking to read her chart. The nurse’s best response is: 1. 2. 3. 4.

to supply the chart and answer any questions. to ask the client to wait until the doctor comes. to call the doctor for permission. to ask the client why she wants to read the chart, write down the reasons, and any questions the client has and pass them along to the nursing supervisor.

(1) A client legally owns her medical record and should have access to it. Because the client might not understand some of the material contained within the chart, a professional should be available to explain and interpret. The physician should be notified as a courtesy so that he or she can arrange to participate in the chart review with the client; however, the physician does not need to give permission for the chart review. Note: The client must have access to and/or copies of the medical record on request, but the original documents are the property of the facility. 153. A unit secretary asks the charge nurse for help in interpreting a medication order written earlier in the shift by a physician because it’s illegible. The charge nurse’s best action is to: 1. 2. 3. 4.

ask the secretary to make their best guess. clarify the order with a pharmacist. check with the family as to what medications the client has been taking. call the physician for clarification.

(4) If the nurse is unable to decipher or interpret a written order, he or she is obligated to contact the physician for clarification. Clarification should never come from an indirect source such as the pharmacist, client, or family members. Guessing is unacceptable. 154. When administering a client’s 8:00 A.M. medications, the nurse realizes that the client has previously received the wrong medication. Realizing that an error has been made, what should be the nurse’s first action? 1. 2. 3. 4.

Notify the unit manager. Fill out an incident report. Notify the physician. Assess the client’s condition, including vital signs.

(4) While proper notification about the incident is imperative, the nurse should assess the client for any signs or symptoms of reactions or effects, including vital signs, as the first priority. The assessment data can be used in notification and reporting. 155. Organ donation is the donation of specific tissues or organs: 1. 2. 3. 4.

from deceased donors only. from neither living nor deceased donors. from living donors only. from either living or deceased donors.

(4) Organ donation can be made by either living or deceased donors.

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156. You are caring for a comatose woman whose family is being asked to make a donation of one or some of her organs. Which of the following statements about organ donation is true? 1. 2. 3. 4.

The family of a donor can make the decision to donate if there is no indication that the donor is or was opposed to such a donation. The Uniform Anatomical Gift Act allows a person to make a decision before death regarding donation of their organ(s) at the time of death. Existence of a documented desire for organ donation, prior to a client becoming ill, assists the family in making the decision to donate at the time of death. All of the above.

(4) A decision, made and documented before a client becomes ill, and communicated to family and caregivers, helps make the decision for organ donation at the time of death much easier. The Uniform Anatomical Gift Act is the law supporting personal decisions for organ donation. This law also supports decisions made by the legally responsible party to donate organs of appropriate donors when there is no evidence that the donor would have denied the donation. 157. Death appears imminent for an elderly client who has suffered a traumatic brain injury. The client signed paperwork at a prior time expressing wishes for organ donation, no cardiopulmonary resuscitation, and no ventilator. The client’s spouse confides to the nurse that the client wanted organ donation. What is the best course of action for the nurse? 1. 2. 3. 4.

Notify the physician, and obtain orders for notification of the local organ-procurement organization (OPO). Do nothing. The client must die before the organ procurement process can begin. Notify the nursing supervisor. Call the coroner and obtain release of the body for organ harvesting at the time of death.

(1) Prior to an imminent death (when it is known that the person wishes to donate organs and the next of kin agrees), the physician should be notified, and orders should be obtained to notify the local OPO for assessment of the person’s potential as a donor. If the nurse waits until after death, organ harvesting might not be possible. The nursing supervisor should be notified that organ donation is being pursued, but this can be done after obtaining the order to call the OPO depending on organization policy and procedure. The OPO representative or the nursing supervisor obtains release of the body from the coroner if needed. 158. A young gentleman is admitted to the ICU having suffered a head injury in a motorcycle accident. He has no written documentation of his wishes regarding organ donation on his driver’s license. Which of the following statements is not true about organ donation? 1. 2. 3. 4.

In the event of brain death, a legally responsible person can give permission for organ and tissue donation. Documentation of permission for organ donation can only be made by the donor. A verbal discussion between a client and his or her family about the client’s wishes for organ donation, along with written documentation, is the best way to clarify the client’s wishes. Both organ and tissue donations can be made by one donor.

(2) Permission for organ donation does not have to be given in written documentation by the donor. It can be made by the legally responsible party for an individual at the time of death. 159. Which of the following statements is true regarding organ donation by a four-year-old trauma victim on life support who has been declared brain dead by the physician? 1. 2. 3. 4.

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Support people are not necessary for the family when the physician discusses his or her findings with the parents. The OPO in the community does not need to be notified to discuss organ donation with the family until after the client has been pronounced dead. Donors can be any age with appropriate consent from the donor’s legally responsible party. Only one organ can be harvested from a child during organ donation.

Coordinated Care

(3) Organ donation can be made by any age individual with proper consent. The number and amount of organs and tissues donated depends on the medical illness of the client and the permission granted by the legal guardian. The OPO should be involved well before cessation of heart and lung function to preserve organ function for donation. 160. Communication of one’s wishes regarding organ donation is important for all the following reasons except: 1. 2. 3. 4.

Seventeen people die each day while awaiting organ donations. A single tissue donor can provide donations for more than 50 people. Some people are waiting for more than one organ or tissue donation. A donor’s wishes are not followed unless they are written.

(4) The verbal wishes of a donor can be followed if they are known by the person who is the donor’s legal representative. It is true that some people are waiting for more than one tissue or organ donation. The low number of donations does result in 17 deaths each day. The number of tissue or organ donations one donor can make is determined by the donation consent, as well as the medical condition of the donor’s organs. 161. A 35-year-old female patient on your hospital unit is awaiting a liver transplant. All the following statements about organ donation are true except: 1. 2. 3. 4.

More than 85% of adult Americans approve of organ donation. Organ recipients are matched to donors by age and sex. More than 17,000 people were awaiting liver transplants in 2004. Less than 6,000 liver transplants were performed in 2003.

(2) Organ recipients and donors are matched for tissue types and organs needed, but not by age and sex. It is true that more than 85% of adult Americans approve of organ donation. In 2003, 25,640 persons received organ transplants; liver transplants accounted for 5,671 of these. In 2004, more than 17,000 people were awaiting liver transplants. 162. You are the emergency nurse on duty when a young man is brought in after an auto accident with massive head injuries. You know that if he is judged to be brain dead, organ donation is suggested. Which of the following statements is true about organ donation? 1. 2. 3. 4.

The family of a donor is not charged for the cost of organ donation. Organ donation disfigures the donor and potentially alters the funeral arrangements. The family is not asked for organ donation when a client has massive head injuries. The donor’s name and personal information is given to the organ recipient to facilitate communication after the transplant.

(1) The family or donor’s estate is not charged for organ donation. Organ donation does not disfigure the donor. Funeral arrangements, such as open caskets, do not have to be altered because of donation. Often families of clients with massive head injuries who become brain dead are given the opportunity to donate organs because the other organs are still functional. The donor’s information is confidential and not communicated to the recipient under normal circumstances. 163. You are discussing organ donation with your family and are undecided whether you would donate your organs/tissues should the occasion arise. Which of the following statements about organ donation do you know to be true? 1. 2. 3. 4.

Transplants can be purchased. All organs from one donor are utilized by one recipient. A decision to donate organs can be revoked. Organ donation disfigures the body.

(3) A written or verbal decision to donate organs can be revoked until the time of organ harvesting, either in writing or verbally. Organ donation does not disfigure the body. Organ transplants are not available for sale, and the organs of one donor are generally used in more than one recipient, depending on the number of organs harvested.

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164. Organs cannot be donated by: 1. 2. 3. 4.

people with lung disease. people with no medical insurance. people with certain known infectious diseases such as HIV. people over the age of 65.

(3) People with certain known infectious diseases such as hepatitis and HIV cannot be considered for organ and tissue donation. The age and insurance status of donors does not prevent organ donation. Certain types of diseases prevent some specific organs from being donated but do not completely rule out donation. At the time of donation, the OPO makes a determination based on current research knowledge regarding each donation. 165. Organs and tissues that can be transplanted include: 1. 2. 3. 4.

heart, kidney, heart valves, brain, and skin. kidney, pancreas, cornea, heart, and nails. cornea, pancreas, stomach, bone marrow, and heart. heart, kidneys, pancreas, lungs, liver, intestines, and bone marrow.

(4) Organs that can be transplanted include the heart, kidneys, pancreas, lungs, liver, and intestines. Tissues that can be transplanted include the cornea, skin, bone marrow, heart valves, and connective tissue. 166. The overall goal of the discharge planning process is to give clients the knowledge, skills, and resources needed to assume self-care after discharge. The health care team members involved in this process include: 1. 2. 3. 4.

nurses, physicians, and physical therapists. physicians only. nurses, physicians, social workers, and other interdisciplinary team members (including physical and occupational therapists who have been involved in the client’s plan of care). nurses only.

(3) The team of health care professionals assisting with a client’s plan of care (inpatient, outpatient, or interagency) should all be involved in discharge planning for the client. 167. A client is being admitted to the hospital from the emergency room tonight. The client is scheduled for orthopedic surgery for a hip fracture in the morning. When should discharge planning begin? 1. 2. 3. 4.

during the discharge planner’s rounds after the surgery at the time of admission only after the client’s needs can be assessed postoperatively at the time of discharge

(2) Planning for discharge begins during the admission assessment and is based on anticipated discharge and self-care needs. 168. A client does well during orthopedic surgery for a hip fracture, and discharge is anticipated in two to three days. The nurse should expect: 1. 2. 3. 4.

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discharge to the client’s home with home occupational therapy. discharge to a skilled nursing facility with physical and occupational therapy. a home care referral for skilled nursing only. no referrals to be necessary.

Coordinated Care

(2) Following successful surgery for a hip fracture, a common discharge destination is a skilled nursing facility where nursing, PT, and OT can provide intensive rehabilitation. Discharge to the client’s home with either OT or nursing alone is probably not suitable for the rehabilitation needs of the client, and discharge without referral for ongoing therapy and skilled nursing care of the surgical site is highly unlikely. 169. In working with a client’s discharge plan after successful hip fracture surgery, when is it appropriate for the nurse to refer the client to other health care providers? 1. 2. 3. 4.

upon physician’s order only only when the client has insurance to cover the cost of the referral at the request of the client only when referral to other professional disciplines meets a need of the client

(4) Referral to other health care providers is based on the needs of the client. It requires a physician’s order but is not determined only by the physician or by the client’s request. Payment for services is determined based on insurance coverage but can be arranged through other payment means if coverage is not available. 170. Home health agencies typically provide all the following services except: 1. 2. 3. 4.

skilled nursing care. funding for medications. physical and occupational therapy. client education.

(2) Funding for medications is not a service provided by home health care agencies. Skilled nursing care, client education, and skilled therapies (including physical and occupational therapy) are provided by home health agencies. 171. A client with a new diagnosis of lung cancer is deemed terminally ill. During the nurse’s assessment for discharge needs, it is determined that the client has no available caregiver in the home and needs assistance with activities of daily living. What should the nurse discuss with the discharge planner? 1. 2. 3. 4.

home care adult day care long-term care with Hospice services respite care

(3) Home care services without a caregiver for a client requiring ADL assistance might not be sufficient to maintain function and safety. Adult day care provides a limited period of daily care and does not meet the client’s need for caregiver assistance. Respite care is short-term care provided while caregivers rest and is not a long-term option for the client. The most appropriate referral choice is long-term care with the option of Hospice services provided in the facility. 172. Referral to a home care agency requires: 1. 2. 3. 4.

a physician’s order. a client need for skilled nursing or therapy. consent of the client. all of the above.

(4) Home care referral requires a consenting client, a client with a skilled nursing or therapy need, and a written order by a physician.

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173. A 14-year-old first-time mother is going home from the hospital with her newborn. An appropriate referral for support of this mother-infant dyad might be: 1. 2. 3. 4.

a home care agency with maternal-infant services. an adoption agency. Planned Parenthood. a nurse midwife.

(1) Referral to a home care agency with maternal-infant services for education and initiation of community services is the best choice. A nurse midwife might be appropriate prior to delivery, but does not initiate care in the postpartum period. An adoption agency is only a referral choice if the mother is giving the child up for adoption. Referral to Planned Parenthood for family-planning services for a minor child necessitates consent of a parent or guardian. 174. A post-myocardial infarction client has an order for cardiac rehabilitation. When discussing this order with the client, the client responds, “I thought rehab was only for people who had strokes.” The nurse should explain that: 1. 2. 3. 4.

rehab involves only physical and occupational therapy. any service outside an acute care hospital is termed rehab. rehab is just a term used by insurance companies for post-hospital care. rehab is any long-term care service for additional therapy or treatment to assist a client in recovery from an illness or injury.

(4) Rehabilitation involves many professional disciplines including nursing, physical therapy, medicine, occupational therapy, speech therapy, social work, and others. Rehabilitation services are provided as part of an organized plan to assist a client in recovering from an illness or injury. Rehabilitation services can be delivered in a long-term care facility, through a home care agency, or in an outpatient care setting. 175. A newly diagnosed 68-year-old diabetic client is being discharged from the hospital. The home care referral can include all the following services except: 1. 2. 3. 4.

a nutritional consult for diet education and follow-up. a podiatry consult for foot care. a nursing consult for glycemic monitoring instruction. all of the above.

(2) Foot care for diabetics is an important issue but the podiatrist is not usually a member of the home care agency team. A nurse and a dietitian should be on the home care agency team. 176. A 34-year-old migrant worker is without health care insurance and is admitted to an acute care facility with chest pain that is determined to be a gastric complaint and is not life threatening. In preparation for discharge, you refer him to: 1. 2. 3. 4.

legal counsel. a home nursing agency. a social worker. a physical therapist.

(3) Referral to a social worker is the most appropriate choice. The social worker aids the client in obtaining financial assistance and required medications or supplies after discharge.

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177. Managed care is: 1. 2. 3. 4.

a type of private physician’s office. a fee-for-service type of insurance. available only in university health centers. a type of health care provider network that contracts to provide health services.

(4) Managed care is a broad term that describes networks of providers who contractually agree to provide health care services for particular client groups. Managed care can be in place in many different health care delivery sites (including private physician’s offices, skilled nursing facilities, acute care hospitals, and others) as long as the providers belong to the network. Fee-for-service care has a set price (not negotiated) based on the provider’s rates or charges. 178. Which of the following statements is true of health maintenance organizations (HMOs)? 1. 2. 3. 4.

The emphasis in HMOs is on acute care in hospitals. An unlimited choice of providers of health care is available through HMOs. The emphasis in HMOs is on health maintenance and promotion. Clients are required to join HMOs by employers.

(3) The emphasis in HMOs is on the voluntary enrollment of a population of persons in an organization emphasizing health promotion and health maintenance. HMOs have a specific set of providers of care, so choice of providers is limited to those within the HMO. The goal of HMOs is health promotion and wellness, keeping clients healthy and decreasing the need for acute care services. 179. Distributing limited resources equally to provide all clients with some of the services they need is related to which ethical principle? 1. 2. 3. 4.

beneficence justice autonomy nonmaleficence

(2) Justice is the ethical principle of using limited resources for all persons who need them rather than only for those who are able to pay for them. Additional ethical principles include beneficence (the duty to do good for others), autonomy (respect for the individual and the right to self-determination), and nonmaleficence (avoiding harm to others). 180. An 85-year-old client who has renal failure is without family or caregivers. The client is in the workup phase for dialysis and has expressed a desire to utilize dialysis only if it does not impair his lifestyle of travel and social activity. Which of the following statements is true in this situation? 1. 2. 3. 4.

Dialysis does not have to be scheduled in advance. Dialysis clients have no restrictions on nutrition or activity. Dialysis clients require close monitoring for electrolyte and supported renal function. Clients do not require any caregiver assistance postdialysis with transportation or activities of daily living.

(3) Clients undergoing dialysis require a regimen of scheduled treatments that closely monitor health status. Caregiver assistance is a major need because treatment is often fatiguing, and the renal disease itself might be debilitating.

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181. An 85-year-old client who is preparing for dialysis asks the nurse about how dialysis affects quality of life. The client has always been active in travel activities and socializing and wonders who can help him make decisions as he progresses through the disease. Which of the following topics should the nurse discuss with this client regarding health care? 1. 2. 3. 4.

The need for a last will and testament. The need for a living will and/or durable power of attorney for health care. No additional topics for discussion are present at this time. The need for designation of the client’s physician as the decision-maker.

(2) For the client’s wishes regarding health care to be known, the client needs to define and document them in a living will and/or durable power of attorney for health care. The person designated as the decision-maker (if the client is unable to make decisions) should not be a member of the health care team. 182. Nurses deal with all the following resource issues in professional practice except: 1. 2. 3. 4.

family assistance in care of clients. availability of community programs for clients. availability of time to give adequate care to clients. job availability for nurses.

(4) The current nursing shortage is projected to increase in the next three to four decades, and nurses should have no problem finding employment in the near future. 183. Efficient time management refers to: 1. 2. 3. 4.

getting all tasks done without regard to prioritization. only one technique used in time management. using the appropriate resources to do the right task. the principle of doing the right task correctly.

(4) Efficient time management refers to the principle of doing the right task correctly. Efficient time management requires employing multiple techniques. Utilizing appropriate resources is resource management. 184. The facilitation of the best use of time is: 1. 2. 3. 4.

time management. priority setting. stress management. crisis management.

(1) Time management is the facilitation of the best use of time. 185. Time is a limited resource that affects the professional nurse by increasing: 1. 2. 3. 4.

rationing of nursing care. incomplete and fragmented care. inaccuracies of care. all of the above.

(4) The limitation of time as a resource available to professional nurses has many implications for quality of care. Rationing of care, incomplete care, and errors in care (including inaccurate care delivery and documentation) are all possible outcomes.

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186. Professional nurses can increase their effectiveness in time management, resulting in increased professional satisfaction, by: 1. 2. 3. 4.

having a decreased focus on time availability. having an open plan for time utilization. taking responsibility for managing time. waiting for direction from a supervisor for time usage.

(3) Satisfaction in effective time management results when the nurse focuses on the time available, has a specific plan for utilizing time, is responsible for managing time, and takes personal action in time management. 187. Organizing tasks as a time-management strategy involves all the following activities except: 1. 2. 3. 4.

using a to-do list. minimizing environmental distractions. delegating tasks appropriately. prioritizing for completion first those tasks that are easiest to complete.

(4) The tasks that should be completed first are those prioritized as most important, not those that are the easiest to complete. Successful organizational tips for time management include the use of a prioritized list of items to be completed, delegation of tasks to other personnel (where appropriate), and completion of the highest-priority tasks (which are focused on client need and acuity) before lower-priority tasks. 188. Occasionally in a health care facility, disoriented or confused clients wander. The advantage of using a sensor and alarm system for such clients is that the alarm system: 1. 2. 3. 4.

allows clients the freedom of mobility without fear of getting lost. minimizes the direct supervision needs of clients. increases the need for restraints. alerts clients that they are doing something they shouldn’t.

(1) Supervising clients in this situation is challenging. When dealing with a confused or disoriented wandering client, the nurse’s priority is to ensure safety. If the environment is supportive, a personal alarm can allow the client safe, personal freedom while at the same time alerting staff that the client is up and moving. The alarm system does not decrease the requirement for supervision. 189. All the following factors can affect a supervisor’s relationship with those he or she supervises except: 1. 2. 3. 4.

personal style. other relatives working within the facility. ability and experience of the supervisor. physical distance.

(2) Other relatives working in the facility should not affect supervisory relationships. Personal style affects communication style, which is a key in any relationship. The ability and experience of the supervisor contributes to the supervisee’s trust in terms of knowing what can be expected from the supervisor. Physical distance can complicate or decrease the ability for interaction in instances when supervisors are not in physical proximity to the workers. 190. A nurse’s responsibility for completion of client care according to the standard of care means that: 1. 2. 3. 4.

the nurse must perform all client care. the nurse delegates tasks appropriately to other members of the health team, who are then responsible. the nurse delegates tasks, but maintains responsibility for the outcome of the tasks. the nurse delegates tasks and, at the point of delegation, is no longer responsible.

(3) Supervision involves appropriate delegation, while maintaining responsibility for the outcome. A supervising nurse who delegates tasks is responsible for the outcomes.

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191. All the following strategies are methods of indirect client supervision in an acute care setting except: 1. 2. 3. 4.

telemetry. bed alarms. closed-circuit monitoring. emergency announcements relayed over the loudspeaker while the nurse is at lunch.

(4) Indirect client supervision can be accomplished through supportive technology such as telemetry, bed alarms, and closed-circuit monitoring. Loudspeaker announcements are not an appropriate means of communicating client-related information. 192. Supervision is: 1. 2. 3. 4.

the responsibility of being boss. the active process of directing, guiding, and influencing the work of team members. directly observing individuals doing their jobs. a management responsibility only.

(2) Supervision is providing guidance and direction, therefore influencing the result of team members’ performance of tasks. It is more than telling people what to do (being the boss). In the supervisor role, a nurse might be involved in supervision through observation or by more direct involvement. In nursing, supervision occurs at many levels, from the bedside to administration in an organization. 193. The staff nurse is supervising two unlicensed assistive personnel (UAPs) who are turning, bathing, and changing the linens for a client who has a back injury. Which of the following activities is appropriate for the supervisory staff nurse? 1. 2. 3. 4.

standing at the door and watching participating in the client’s care and giving direction and feedback during the process passing medications to other clients, and then coming back to the room to make sure everything is okay signing the UAPs’ time cards at the end of the shift to verify their hours

(2) Supervision includes providing guidance and support, sometimes in the form of assisting with client care. In this situation, assisting with care allows the nurse to give the UAPs direction and immediate feedback. This approach is optimal because it allows the nurse the opportunity to directly assess the newly admitted client. 194. Which of the following statements is true about the successful coordination of a team effort using supervision, delegation, and assignment? 1. 2. 3. 4.

Delegation is not a type of supervision. Assignment includes the shift of responsibility and accountability for a task to all staff involved. UAPs are not assigned responsibility and accountability. UAPs are assigned responsibility and accountability.

(3) UAPs are not assigned responsibility and accountability; therefore, the overall supervisory responsibility remains with the person making the assignment. Delegation is a type of supervision. Assignments can involve the shift of responsibility and accountability when dealing with other licensed personnel. 195. Which of the following factors does not need to be taken into account when deciding how to meet the care needs of a group of clients? 1. 2. 3. 4.

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(4) The core information for decision-making is the staff number, skill mix, and client acuity. Family questions might impact assignments depending on the individual situation. 196. All the following activities are core functions of a supervisory relationship except: 1. 2. 3. 4.

supporting supervisees to make sure they have needed resources and support. enabling the supervisees to have some influence over their work. ensuring the desired outcome(s). maintaining distance from the work site to allow work completion by staff.

(4) To provide supervision, direct presence and some degree of participation is required. The supervisor must be available to serve as a resource who provides direct assistance and staff guidance as needed. 197. All the following activities are purposes of supervision except: 1. 2. 3. 4.

controlling work tasks. forcing staff to perform within their role boundaries. achieving work tasks. coordinating work.

(2) The goal of supervision is accurate work completed in a coordinated and efficient manner. The goal of supervision is not to police the staff’s performance according to boundaries. An active, involved supervisor becomes aware of boundary problems if they exist. 198. Which of the following statements by a supervisory nurse indicates a common problem with supervision? 1. 2. 3. 4.

“The work appears simpler to me because I’ve got more knowledge.” “I didn’t know that the person had already been supervised.” “I’m supervising somebody who is doing a job I’m completely unfamiliar with.” All of the above.

(4) Supervisors can experience difficulties when they don’t understand the work being done or when they don’t know the resources and skills of those they are supervising. A nurse in a supervisory role needs to remember that he or she is not the expert in every situation.

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Safety and Infection Control This chapter contains questions and answers from the following topic areas: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Accident/Error Prevention Handling Hazardous and Infectious Materials Home Safety Injury Prevention Internal and External Disaster Plans Medical and Surgical Asepsis Reporting of Incident/Event/Irregular Occurrence/Variance Safe Use of Equipment Security Plans Standard/Transmission-Based/Other Precautions Use of Restraints/Safety Devices

1. The nurse instructing a new parent on the proper positioning of an infant car seat explains that the infant can be positioned forward-facing in an automobile at which weight? 1. 2. 3. 4.

6 kg (12 lbs) 7.5 kg (15 lbs) 9 kg (20 lbs) 10 kg (22 lbs)

(3) The position of a car seat is based on body weight. Beginning at 9 kg (20 lbs), infants can be placed in a forwardfacing child seat. Items 1 and 2 are incorrect because the infant is not heavy enough to be placed forward-facing. Item 4 is acceptable but not the correct answer to the question. 2. A child with no pulse or respiration is brought to the Emergency Department (ED) with resuscitative efforts in progress. In considering the etiology of childhood deaths, which of the following is the most likely cause? 1. 2. 3. 4.

poisoning head trauma motor vehicle accident influenza

(3) Accidents are the leading cause of death for all age groups from toddlerhood to adulthood. Poisoning, head injury, and other types of trauma, while significant for this age group, are not as prevalent as accidental death from motor vehicle accidents. Influenza deaths, while possible, are much more likely in the elderly population. When assessing a client in a critical illness or injury situation, the nurse brings her/his knowledge of age-specific causes of death. 3. Community accident-prevention education includes which of the following facts regarding the most prevalent cause of accidental death from age 1–4? 1. 2. 3. 4.

drowning burns motor-vehicle accidents firearms

(3) Accidents are the number one cause of death for this age group, with motor-vehicle accidents accounting for the majority of the accidents.

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4. The nurse providing safety instruction for a local daycare explains that the leading cause of death for preschool children is: 1. 2. 3. 4.

drowning. burns. falls. motor-vehicle accidents.

(4) Motor-vehicle accidents are the leading cause of death for all races and both sexes in the 1–4-year-old age group. 5. A frantic caregiver calls and asks the nurse, “What should I do? My 2-year old just drank Drano?” Which should be the nurse’s first response? 1. 2. 3. 4.

“Is the child conscious?” “Relax. It will be okay.” “Is the child breathing?” “Induce vomiting immediately.”

(1) The nurse’s correct first response is having the caregiver determine unresponsiveness, then to initiate basic cardiac life support (BCLS; CPR-cardiopulmonary resuscitation) if needed and call 911. Assessment is the first step in applying the nursing process. 6. To prevent thermal burns, what is the highest acceptable setting for a hot-water thermostat in a home with children? 1. 2. 3. 4.

100° F 120° F 140° F 150° F

(2) To prevent thermal burns and scalding, hot-water thermostats should be set at 120° or lower. Adult skin can tolerate somewhat higher temperatures. 7. Which of the following is the leading cause of accidental injury in elder adults? 1. 2. 3. 4.

falls motor-vehicle accidents firearm-related trauma unintentional overdose

(1) Falls are the leading cause of accidental injury in elder adults and are associated with a large number of nursing home and hospital admissions. The other choices are much less common in elder adults. 8. While eating in the hospital cafeteria, the nurse sees a visitor display the universal sign of choking. What should the nurse do first? 1. 2. 3. 4.

Page a Code Blue emergency. Perform the Heimlich maneuver. Assess for effective breathing by asking, “Are you choking?” Deliver four sharp, back blows between the victim’s scapulae.

(3) The nurse’s first response is to assess that the person is actually choking, and then rapidly proceed to intervene using the Heimlich maneuver. Back blows are not indicated for adults with obstructed airways and can actually create a complete obstruction by dislodging a foreign body that might have been only partially blocking the airway.

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9. While eating in the hospital cafeteria, the nurse sees a visitor fall from his chair to the floor in the midst of tonic-clonic seizure activity. What should the nurse do first? 1. 2. 3. 4.

Page a Code Blue emergency. Position the visitor laterally, and restrain his extremities to prevent injury. Assess for airway effectiveness, and position the visitor laterally. Shake the visitor vigorously to establish unresponsiveness.

(3) The nurse should calmly position the client to protect the airway while assessing the effectiveness of the airway and breathing. During the tonic-clonic phase of a seizure, breathing can be temporarily decreased or absent. Seizure activity is typically brief, and breathing spontaneously returns when it ceases. Occasionally, oxygen support is needed. The client should be evaluated by an emergency services provider and referred to his personal health care provider. 10. The nurse discovers a wastebasket fire in the room of a sleeping client. What should the nurse do first? 1. 2. 3. 4.

Move the client to safety. Report the fire. Extinguish the fire. Check the client for breathing and circulation.

(1) Ensuring client safety from the fire must be the initial action, followed by reporting the fire. If a fire is small, current recommendations are that the nurse should extinguish it by covering the fire with a blanket, closing the door or using an extinguisher aimed at the base of the fire. Nurses should never place themselves in danger. A good rule of thumb can be remembered with the acronym RACE: Remove the client, sound the alarm, contain the fire (or close the door), and extinguish the fire or prepare to evacuate the unit. 11. Which principle correctly describes the use of side rails? 1. 2. 3. 4.

Side rails are used mainly as a precaution against falls in the elderly. Side rails are a form of restraint. Side rails should be up at all times if a client is at risk for falling. No special consent is necessary for the use of side rails.

(2) Side rails are restraining devices and can contribute to falls in some circumstances. Typically, in the hospital setting, side rails are used because an increased risk for falling has been identified and a physician’s order has been obtained prior to their use. The use of side rails should be based on the agency’s policy and the needs of clients. For example, a client who has received a sedative-hypnotic or mood-altering medication likely needs side rails to decrease the risk of falling. 12. An infant car seat should be installed: 1. 2. 3. 4.

in the front seat on the passenger side. in the back seat. in the middle front seat. facing forward.

(2) Infants and children should be positioned in the back seat. At 20 lbs, children and infants can face forward. 13. A client walking with crutches should: 1. 2. 3. 4.

lean forward. position the tips of the crutches at a wide angle away from the body. extend the upper extremities fully as the unaffected leg moves forward. avoid pressure on the axillae.

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(4) To prevent brachial plexus injury, clients should avoid pressure on the axillae. The base of support (position of the tips) should be near the body to prevent falls, and the tips should be in a forward position with the client’s body weight on the unaffected leg as the affected leg swings through. 14. Which of the following is an accurate statement regarding the nursing profession and the prevention of domestic violence? 1. 2. 3. 4.

Nurses play a limited role in the community. Screening of at-risk individuals is associated with decreased incidence of violence. The majority of cases occur in preschool children. Community education generally produces no reduction in incidence.

(2) Nurses are advocates for change in communities and are effective teachers. One of the most significant findings regarding domestic violence is the effectiveness of screening at-risk populations in decreasing the incidence of violence. A significant increase in identifying victims of abuse and instituting interventions to prevent further violence occurs by simply asking, “Do you feel safe in your home?” or “Has your intimate partner engaged in hitting, verbally abusing, or other forms of violence against you?” 15. The nurse notes a two-prong electric appliance in use in a client’s room. Which is the appropriate response? 1. 2. 3. 4.

Notify the physician. Notify the biomedical or electrical maintenance department. Confront the client and explain that such appliances are prohibited due to the risk of electric shock. Obtain a three-prong “cheater” adapter so that the appliance can be used safely.

(3) All electric devices brought into the hospital must be properly grounded. Grounding prongs prevent electrical shock and reduce the risk of injury. The nurse is responsible for the agency’s policies and procedures regarding personal appliances brought into the hospital. Many hospitals require personal electrical devices to be cleared by biomedical services prior to their use. 16. The nurse is demonstrating the correct lifting technique to a caregiver. Which of the following maneuvers does not prevent back injury? 1. 2. 3. 4.

spreading the legs wide apart lifting from the quadriceps muscles avoiding the use of back braces and support belts placing the lifter’s hands under the arms of the client during pivoting

(3) Back braces and safety belts have been shown to decrease back injuries if used properly and serve to remind lifters to use proper body mechanics. A wide base of support by spreading the legs apart and flexing the knees during lifting will allow the best utilization of the quadriceps and decrease the opportunity for lumbar strain. Placing the hands under the client’s arms at the axillae during pivoting is advantageous to the lifter by optimizing upper body strength and giving direction to the lifting movement. 17. What should the nurse do first when planning to move a bed-bound client who cannot assist? 1. 2. 3. 4.

Put on a back-support belt. Obtain a second care provider’s assistance. Assess the client’s skin. Explain the procedure to the client.

(2) The first action the nurse should take is to protect his or her own safety by obtaining help with lifting a nonassistive client. The other choices are correct but should not be the initial action.

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18. The nurse is reinforcing safety rules and precautions regarding bicycles, skates, seatbelts, water sports, and firearms. The client population fitting these instructions is most likely: 1. 2. 3. 4.

preschool students. elementary-school students. middle-school students. high-school students.

(2) Elementary-school students are at greatest risk for death and injury related to these activities because of their level of physical and emotional development. 19. Which of the following is not a risk factor for lead poisoning? 1. 2. 3. 4.

residing near a major highway residing in a home built prior to the 1960s presence of plumbing with lead pipes in the home an infant born to a mother who smokes

(4) Lead poisoning primarily occurs by exposure to environmental lead and is not linked to maternal smoking. Residing in a home built before standards for no-lead paint were enacted poses the greatest risk, while living near a major highway and the presence of lead-pipe plumbing both increase soil and water lead levels. 20. Which of the following is most important when reinforcing client education regarding head injuries? 1. 2. 3. 4.

the use of height-appropriate bicycles mandatory training with purchase of motorcycles and mopeds regulations imposing motor-vehicle standards of operation on users consistent use of helmets

(4) While all the responses are correct, the use of safety helmets is the most important. Helmets have significantly reduced the incidence of closed head trauma related to bicycle and motorcycle accidents. 21. The regulation for safe crib-rail spacing is: 1. 2. 3. 4.

1 1⁄8" 2 3⁄8" 3 1⁄8" 4 3⁄8"

(2) Current regulations require the space between crib rails to be 2 3⁄8." 22. Which of the following strategies is the most important safety precaution for infants? 1. 2. 3. 4.

positioning the infant on its back to sleep child-proofing the home against poisoning preventing animal bites breast-feeding

(1) Placing an infant supine for sleep is associated with a decreased incidence of Sudden Infant Death Syndrome (SIDS), a leading cause of death in infants. Child-proofing the home against poisoning is important for mobile infants who are crawling and climbing. Preventing animal bites, while important, is only important for infants who are exposed to pets or other animals. Breast-feeding is important for all infants but pertains to nutrition; although certain safety measures are relevant regarding preventing aspiration and suffocation.

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23. Which of the following factors is most important in preventing falls in elder adults? 1. 2. 3. 4.

scatter rugs on floors recessed lighting stairs overall physical strength and normal cognition

(4) Chronic illness related to mobility, cognition, and sensory impairment contributes to falls in elder adults more than any other specific factor. Maintaining optimum physical strength and mobility are vital goals of nursing elder individuals. While practical matters such as rubber-stripped tubs and showers, floors free of scatter rugs, good lighting, handrails, and raised toilets are all specific measures to enhance home safety, an ambulatory and mentally alert adult is the most important variable. 24. Which of the following is a correct statement about current therapy related to poisoning or drug overdose? 1. 2. 3. 4.

Ipecac syrup is indicated in most overdose situations involving children. Parents should be instructed to bring the actual container of the product ingested to the emergency room. Emesis is superior to activated charcoal administration for decontamination of the poison. Medication-induced catharsis is superior to other forms of decontamination in most situations.

(2) Emergency providers need to see the actual container so that proper analysis and treatment of an overdose can occur. Parents might not know how much time has elapsed since ingestion and might not know whether the ingested agent is corrosive. Ipecac syrup is no longer recommended for home use. Emesis has not been shown to improve client outcomes in most home situations and is not superior to activated charcoal. Activated charcoal is an absorbent agent that allows for the attachment of the poison in the stomach and removal via excretion in the feces. Catharsis promotes the passage of the poison and may inhibit absorption, but the process has not been shown to improve overall clinical outcome in poisoning and overdosed; therefore it is not recommended. 25. After establishing ABC (airway, breathing, and circulation) for a snakebite victim, the next response by the nurse should be to: 1. 2. 3. 4.

lance the puncture sites and withdraw as much venom as possible. stabilize the affected site by splinting. apply an ice pack. mark the site of envenomation with a pen.

(4) Emergency care beyond ABC includes marking the site of envenomation as soon as possible to determine the degree of spread and swelling. Incisional drainage of the wound and application of ice are not currently recommended; however, splinting the affected part is recommended if it does not delay transfer to an emergency facility. 26. Teaching a wellness class about preventing snakebite injury includes all of the following information except: 1. 2. 3. 4.

Wear boots when walking in endemic areas. A snake can strike the distance of about half its length. Never put your hand where you cannot see. The striking reflex of a snake remains present for up to an hour after death.

(2) A snake can strike the distance of about half its length. Since the lengths of snakes vary, the striking distance varies. For example, a snake of 4' could strike a distance of 2'.

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27. Plumbism refers to: 1. 2. 3. 4.

alkali ingestion. Acetaminophen overdose. lead poisoning. iron ingestion.

(3) Lead poisoning (plumbism) is a possible cause of chronic illness and mental retardation in some children. The exposure to lead typically occurs via the ingestion of lead-based paint chips or plaster manufactured prior to 1970. 28. The most effective method for decreasing the incidence of lead toxicity in children is: 1. 2. 3. 4.

continued legislative mandates regarding the content of paint and paint products. Chelation therapy. prevention of exposure. screening all toddlers during well-child examinations.

(3) Prevention is the key to lowering the incidence of lead poisoning in children. Removing lead from the environment is the only sure way to prevent the effects of exposure to this toxic substance. 29. When teaching a class of middle-school girls about safety precautions to prevent rape, the nurse should emphasize which of the following? 1. 2. 3. 4.

A person who commits rape is generally mentally retarded. The incidence of violence against women is greater in minorities. Rape is about power and anger. A rape poses little risk of acquiring a sexually transmitted disease (STD).

(3) Most perpetrators fall into one or more of the following three categories: the angry, the power oriented, and the sadistic. Rape is always an act of violence, typically perpetrated to gain power and/or express anger by a male against a female. Racial, psychiatric, or mental-retardation disorders are not associated with most perpetrators, and the risk of acquiring an STD is higher during rape than in consensual sexual acts. 30. Viral hemorrhagic fevers (VHFs) are a group of infectious illnesses that can be linked to bioterrorism. A characteristic feature of VHF beyond the prodome is: 1. 2. 3. 4.

bleeding. cough. diarrhea. abdominal pain.

(1) Bleeding is associated with full-blown infection and can begin as conjunctivitis, rash, and sore throat followed by hematuria, hematemesis, melena, and DIC (Disseminated Intravascular Coagulation). Death ensues rapidly as the client develops shock, coma, and multi-organ failure. The other symptoms noted might occur as prodromal symptoms of exposure, typically in the incubation phase. 31. Which of the following events should alert the nurse to a biological terror attack? 1. 2. 3. 4.

a client storing what looks to be loose, white talc in a decorative canister several persons in close proximity becoming ill simultaneously several persons with flu-like symptoms in early January anecdotal reports of dead birds and fish in the local community

(2). Biological terrorism is usually directed at groups of people through the water supply, food supply, ventilation systems, and so on. It should normally result in many people becoming ill at the same time. White talc could be talc,

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narcotics, or something more lethal; it does not normally indicate terrorism. In early January, it is likely that many people will contract the flu. Reports of dead birds and fish are probably the result of something dangerous and toxic, but biological terrorism is not likely to be aimed at wildlife. 32. Smallpox infection can be distinguished from varicella (chickenpox) by: 1. 2. 3. 4.

a vesicular rash about six weeks after being exposed. a nonuniform rash distributed asynchronously over the body. a fever of 103° F and myalgia. a history of IgM titer 1:10.

(2) Smallpox is difficult to distinguish from chickenpox by history, fever, myalgia, and other symptoms of illness. Smallpox has a vesicular, pustular rash caused by one of two species of pox virus. Chickenpox is caused by a herpes virus. It is characterized by crops of pruritic vesicular eruptions on the skin. The vesicles and scabs are infectious until entirely dry. Choices 1, 2, and 3 don’t apply to smallpox or chickenpox. 33. The nurse is working in a refugee camp and notes several clients with high fever; body ache; itching; and diffuse, maculopapular and vesicular rash with lesions in the same stage of development. Which infection is most suspect? 1. 2. 3. 4.

chickenpox smallpox plague anthrax

(2) Smallpox fits the description presented in the question. Smallpox is often mistaken for chickenpox, in which pox are at different stages of development. Plague does not manifest a rash, and anthrax rash (if manifested) is initially papular, and then necrotic and ulcerative. 34. Which of the following statements defines the phenomena of terrorism? 1. 2. 3. 4.

an extension of freedom aimed at protecting human rights a modern-day act of war embraced by many religions a psychological state of narcissism aimed at producing social resilience a deliberate act of violence against civilians to induce fear and social change

(4) Terrorism is defined as an act of violence deliberately taken to induce fear and modify or produce social change. It is not embraced by the religions of the world except when taken out of context and employed as an extreme act of control. Most terrorist acts do not involve narcissism or attempt to produce a stronger society but, in fact, produce just the opposite. Individuals are seen as less valuable than the cause or belief; the goal is to control social behavior and dictate social beliefs. 35. Which of the following emotional responses is not typical at the beginning of a disaster? 1. 2. 3. 4.

fear and anxiety denial and disbelief coping and calmness reluctance to abandon property

(3) While some individuals are amazingly resilient, coping and calmness typically settle in only after the initial stages of shock, anger, panic, and disorientation have been processed and subsided.

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36. Which of the following factors, if present, most impedes the process of emotional recovery after a community disaster? 1. 2. 3. 4.

average socioeconomic status lack of Federal Emergency Management (FEMA)-designated disaster assistance physical symptoms, such as sleep problems and GI disturbances fear of recurrence

(4) The fear of recurrence is generally the greatest impediment to emotional recovery. Personal belief in the possibility of regaining one’s sense of security must exist for recovery to occur. While the factors of poor economics and lack of federal assistance can impact overall recovery, these factors do not necessarily impede recovery. The physical symptoms of sleep and GI disturbances are common initial responses, but do not indicate delayed recovery unless protracted. 37. Which population aggregate is at greater risk after a disaster for physiological and mental-health stress injuries? 1. 2. 3. 4.

previous disaster victims the very young the elderly pregnant women

(1) Those who have previously experienced a disaster, live alone, are homeless, are mentally ill, or do not speak English are at much greater risk than those in choices 2, 3, and 4. 38. The nurse is separating and segregating individuals in groups related to the priority of their injuries. This technique (seen in mass-casualty events) is known as: 1. 2. 3. 4.

categorization. triage. segmenting. prioritization.

(2) Separating injured individuals based on priority of need and expectation of survival is known as triage and is an essential function of initial disaster management. 39. Which of the following nursing interventions represents secondary prevention in disaster management? 1. 2. 3. 4.

making ongoing home visits to identify additional problems that might cause further injuries (for example, unsafe drinking water) triaging clients who have been injured participating in a community-preparedness group participating in mock drills and disaster-readiness training

(2) Triage of clients who have been injured represents secondary prevention. Making home visits after the disaster is an example of tertiary prevention. Training activities and planning represent primary prevention activities. 40. A work-site explosion leaves 26 individuals injured by severe burns and respiratory injury and 13 individuals dead. What should the employee health nurse do first? 1. 2. 3. 4.

Secure employee records for proper identification. Sort and label victims in order of priority. Start CPR on the first victim she comes to who needs it. Call 911 and activate the EMS (emergency management system) and disaster plan.

(4) In an emergency, the call for help is always first. After calling for help, the nurse should rapidly proceed to triage of the wounded in order of contact. Individuals who are mortally wounded and/or with a life expectancy of only a few hours

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are treated last. Those with serious, but not life-threatening, injuries (such as fractures of long bones, head trauma without coma, or burns on less than 1/2 of their body’s surface area) should be transported to a hospital first, followed by the walking wounded (or those whose injuries are such that they can survive a six- to eight-hour wait without serious sequelae). 41. In the epidemiological triad of occupational hazards, the host is represented by: 1. 2. 3. 4.

the manager. the employee health nurse. the workplace environment. the employee.

(4) The epidemiological triad is composed of the host (susceptible person, employee, or anyone who could be affected, such as the employee’s children or spouse), the workplace environment, and the agent of injury (chemical, physiological, ergonomic, and so on). 42. A factory worker is brought to the employee health office after a splash injury by an unidentified liquid. The nurse instructs a co-worker to retrieve the container so that she can determine the offending chemical. Which piece of information guides the emergency care and surveillance of the injury? 1. 2. 3. 4.

Occupational Safety Health Administration (OSHA) guidelines for eye care emergency care found in the personnel handbook Emergency Nurse Association (EMA) guidelines for hazardous emergencies material safety data sheet (MSDS)

(4) The MSDS, an OSHA-mandated regulation, should guide the emergency care and follow-up of this accidental injury. 43. Ecchymotic, bluish markings across the buttocks and sacral region of a dark-skinned infant most likely represent which of the following skin conditions? 1. 2. 3. 4.

early signs of hemorrhage petechiae Mongolian spots Koplik’s spots

(3) Mongolian spots are a normal skin variation often seen in dark-skinned newborns and infants. Petechiae are red, punctate lesions associated with capillary breakage. Koplik’s spots are associated with strep infection and are found in the pharynx. Early signs of bleeding would not be considered when applied to an infant’s skin condition as described. 44. Accessing a 911 system in an emergency is an example of: 1. 2. 3. 4.

first-aid relief. primary prevention. secondary prevention. tertiary prevention.

(3) Accessing a system that is designed to manage emergency response is an example of secondary prevention because the emergency is not prevented, but further harm can be averted at the secondary level by identification and treatment of the problem. 45. A nurse serves on a community planning board to develop a 911-emergency-response system for the area. This is an example of what level of prevention? 1. 2. 3. 4.

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(2) Service on a board aimed at developing a system to address emergency response is an example of primary prevention because it involves planning a response to an emergency that has not yet occurred. 46. Security checks at airports and public areas to prevent acts of violence by terrorists is an example of which type of prevention? 1. 2. 3. 4.

planning primary secondary tertiary

(3) Screening activities occur at the secondary level of prevention and are characterized by identifying measures that target high-risk individuals and reveal weapons, biologic substances, chemicals, or other hazardous materials that could be used to elicit a mass-casualty event. 47. The school nurse receives a call that several vials of smallpox vaccine have been unleashed in the gymnasium of the local high school. She recognizes that: 1. 2. 3. 4.

this is a criminal act. this is a youthful prank. multiple deaths are likely. no immediate threat of smallpox exists.

(4) The smallpox vaccine is not made with smallpox but another virus that is not deadly. The smallpox virus can be lethal if used as a weapon. The nurse should evacuate the school, activate the disaster drill, and have terrorist specialists inspect the area. 48. Terrorism is defined as 1. 2. 3. 4.

an act of freedom ultimately aimed at improving human rights. a religion-based act of violence against Jewish people. a deliberate, violent act against civilians to induce fear and modify social behavior. a criminal act rooted in a psychological state of narcissism aimed at producing a resilient population aggregate.

(3) Terrorism uses fear and violence to motivate human behavior and produce social change. 49. A client in a military division engaged in war is taking Ciprofloxacin (500mg), Doxycycline (100mg), and Tetracycline (250mg) for biological exposure. The client is receiving treatment to prevent: 1. 2. 3. 4.

smallpox. anthrax. botulism. plague.

(4) The antibiotic therapy described is the prophylaxis for plague. Smallpox is not treated with antibiotics because it is a virus, but a vaccine is recommended for high-risk individuals such as military personnel. Botulism is treated prophylactically by vaccine or with antitoxin for illness. Anthrax is treated prophylactically with Ciprofloxacin, Rifampin, and Clindamycin. 50. In an obstetrical emergency, what should the nurse do first after the baby is delivered? 1. 2. 3. 4.

Place extra padding under the mother to absorb blood from the delivery. Cut the umbilical cord using sterile scissors. Suction the baby’s mouth and nose. Wrap the baby in a clean blanket to preserve warmth.

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(3) After the baby is delivered, immediately clear the mouth and nose with gentle suctioning using a bulb aspirator. This is the first and most important intervention. Choice 4 should follow because warmth helps preserve the infant’s body temperature. The cord must be tied in two places before cutting. If the scissors are not sterile, cutting the cord could cause an infection. The cord should not be cut if the mother and infant can be transported in a timely manner. In this obstetrical emergency, Choice 1 is the least of the nurse’s priorities. 51. All the following conditions are causes of vaginal bleeding in late pregnancy except: 1. 2. 3. 4.

placenta previa. eclampsia. abruptio placentae. uterine rupture.

(2) Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizure and/or coma. Choices 1 and 3 are abnormal conditions that can cause bleeding, particularly in the third trimester. Choice 4 is a major obstetrical emergency that can cause bleeding internally and externally. 52. A newborn has been delivered, and an Apgar score is given. What information does this scoring system provide? 1. 2. 3. 4.

heart rate, respiratory effort, color, muscle tone, reflex, irritability heart rate, bleeding, cyanosis, edema bleeding, reflex, edema respiratory effort, heart rate, seizure

(1) The Apgar scoring system was put into place by Dr. Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, reflex, and irritability (taken 1, 5, and sometimes 10 minutes after birth). 53. All the following statements about botulism are correct except: 1. 2. 3. 4.

Symptoms begin within 1 to 12 hours. Excessive secretions are present. Botulism is one of the most lethal poisons that can be ingested. Botulism is not contagious.

(2) Botulinum toxin blocks release of acetylcholine from nerve endings, causing a decrease in secretions. The symptoms include dypsnea, shortness of breath, apnea from paralysis of the diaphragm and intercostal muscles, drooping eyelids, difficulty swallowing, blurred vision, double vision, and dilated pupils. The rate of symptom development is 1 to 12 hours and is a medical emergency If a group of people is exposed, the exposure is categorized as a disaster situation. 54. Smallpox is spread by: 1. 2. 3. 4.

contaminated food. droplets produced by sneezing or coughing. mosquitoes. sexual contact.

(2) Droplets produced by sneezing or coughing transmit the smallpox virus. Also, contact with fluids from smallpox lesions can transmit smallpox. 55. All the following statements about cyanide are correct except: 1. 2. 3. 4.

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Two forms of cyanide are used in chemical warfare: hydrogen cyanide and cyanogen chloride. Cyanide causes severe respiratory distress, abdominal pain, and rash. Cyanide prevents cells from using oxygen. Death can occur within 10 minutes of cyanide exposure.

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(2) Cyanide does not cause abdominal pain or a rash. Cyanosis causes symptoms of severe hypoxia. However, the client does not become cyanotic, and a pulse oximeter does not show decreased oxygen saturation. The military classifies cyanide as a blood agent. Cyanide is toxic because it prevents metabolic use of oxygen, causing asphyxiation at the cellular level. Hydrocyanic acid and cyanogen chloride are highly volatile and evaporate quickly. The vapors of hydrocyanic acid are lighter than air and disperse rapidly. Cyanogen chloride vapor is heavier than air and sinks into lowlying areas. Cyanide interferes with the body’s ability to use oxygen at the cellular level and causes dyspnea, respiratory depression, apnea, hypotension, and acidosis. 56. A 32-year-old male and 28-year-old female are complaining of headache and a cough. A rash consisting of reddened areas surrounding small, fluid-filled blisters is present on their arms, legs, and faces and is beginning to appear on their chests. They spent the last month traveling with a tour group in the Middle East. The clients’ vital signs are as follows: Male: pulse (P) 112, blood pressure (BP) strong and regular at 124/82, respiration (R) regular and unlabored at 18, and temperature (T) 102.6° F. Female: P 118, BP strong and regular at 108/76, R regular and unlabored at 22, and T 103.2° F. The nurse who approaches this situation should: 1. 2. 3. 4.

disregard an initial assessment. call for additional help. assess the situation, quarantine the scene, and call for additional help. disregard concerns about transmission if vaccinated as a child.

(3) The nurse should assess the situation, quarantine the scene, and call for additional help from law enforcement and the health department. The principal objective is to prevent the spread of a possible smallpox outbreak from these clients to others in the community. Investigators from the health department can begin the process of identifying contacts of these clients to locate other possible cases and tracing the origin of the infection. Because smallpox does not occur naturally, it should be considered the result of terrorist activity. Law enforcement should be involved to begin an investigation to identify the parties responsible for the smallpox outbreak. Protection from smallpox vaccination lasts 3 to 10 years. After this time, booster doses should be given if exposure has occurred. Smallpox vaccination is effective up to 1 week after exposure. 57. All the following statements about Ricin are correct except: 1. 2. 3. 4.

Inhaled Ricin attacks the respiratory system, causing pneumonia and pulmonary edema. Ingested Ricin causes gastrointestinal bleeding, which can lead to death. Ricin can be produced in an aerosolized and a solid form. Symptoms of Ricin toxicity begin 48 to 72 hours after exposure.

(4) Symptoms of Ricin toxicity begin 1 to 12 hours after exposure. Ricin is a potent toxin isolated from the mash that remains after castor beans are processed to make castor oil. Two to four castor beans contain enough Ricin to kill an adult. Ingestion of one castor bean can be lethal to a child. Ricin causes tissue necrosis, pneumonia, internal bleeding, and vascular collapse. Ricin is not volatile; therefore, secondary inhalation is not a hazard. Skin contact should be avoided, and the client should be washed with a diluted bleach solution, soap, and water. 58. The symptoms of measles are similar to those of: 1. 2. 3. 4.

mumps. meningitis. botulism. rubeola.

(4) Measles is a viral disease involving the respiratory tract and characterized by a spreading maculopapular cutaneous rash that occurs primarily in young children. It is also called rubeola.

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59. Iatrogenic disease is defined as: 1. 2. 3. 4.

a disease or condition acquired because of hospitalization. a disease or condition produced by medical, nursing, or other care. an uncommon, unpreventable drug response linked to a client’s genetic predisposition. a disease or condition triggered by nosocomial exposure to infection.

(2) The Greek definition for iatrogenic, literally “disease that is physician produced,” has been expanded to encompass the care delivered by all health care professionals including nurses. Nosocomial denotes hospital-caused infection or injury. Idiosyncratic response is the term used to describe a response that is client centered and, when applied to medications, genetically predisposed. 60. Which of the following measures is associated with decreasing hospital clients’ risk for iatrogenic harm? 1. 2. 3. 4.

providing a health-promotion program of annual physical examinations and age-specific screenings for employees requiring nursing personnel to successfully complete a medication-administration test requiring medical personnel to complete a guest-relations/interpersonal-communication training program requiring pharmacists to become specialized in their respective areas of care

(2) Medication errors lead to many deaths and injuries annually. While all the factors described might improve the health care system, requiring nursing personnel to pass a medication-administration test (thereby establishing a process for the identification of unsafe medication administration practices) is most directly associated with decreasing the risk of client injury due to nursing care. Employee health programs, guest relations, and specialization across disciplines further ensure an effective health care infrastructure that discourages iatrogenic harm. The completion of a medication-administration examination is one way to determine the educational needs of nursing staff and ensures that nurses have basic competency to administer medications. Drug errors account for the majority of serious and deadly iatrogenic errors. While nursing does not account for all errors, nurses are the last line of defense between the medication and the client. 61. Which of the following actions assures a client that care is being provided by a competent professional? 1. 2. 3. 4.

a copy of the nurse’s license in plain view at the nurses’ station the original nursing license being worn on the nurses’ person at all times a plaque posting accreditation by the Joint Commission on Accreditation of Healthcare Organizations in the main lobby of the hospital a photo identification worn by the nurse with the title of PN displayed

(4) The most effective means of assuring clients about the safety of nursing care is proper identification of the caregiver. While all the measures are correct, the identification of the properly credentialed nurse most directly influences the client. 62. Which of the following factors are associated with decreased mortality and morbidity among postoperative clients? 1. 2. 3. 4.

education in advanced cardiac life support (ACLS) CDC (Centers for Disease Control) surveillance of nosocomial infections informed consent and advanced directive policies increased RN staffing

(4) All the choices might decrease mortality and morbidity outcomes to some degree, but increasing RN staffing has been shown to most directly and most markedly reduce morbidity and mortality.

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63. When positioning a client to prevent pressure sores, where should soft padding be placed? 1. 2. 3. 4.

between skin folds between the knees between the ankles under the buttocks

(1) Padding between intertriginous skin folds decreases pressure, lessening the likelihood of pressure sores. Generally, soft pillows are used between the ankles and knees, which have bony prominences, to prevent pressure. A sheepskin or special pressure device is sometimes used beneath the buttocks. 64. Which of the following clients should be assigned to the care of an RN? 1. 2. 3. 4.

a 3-year-old client recovering from second-degree burns on a lower extremity a 22-year-old client 12 hours after vaginal delivery who is having difficulty breast-feeding an 86-year-old client 6 days after open reduction hip on IV antibiotics a 78-year-old newly admitted client with an altered sensorium

(4) Care of a newly admitted client with an altered mental state most warrants RN care because frequent neurological assessments and close monitoring of vital signs are likely to be necessary. 65. Which client should be given nursing instruction on the risk of QT interval effects? 1. 2. 3. 4.

a middle-aged male taking sildenofil (Viagra) an elderly female taking atorvastatin (Lipitor) an adult female taking levofloxacin (Levaquin) an elderly male taking diclofenac (Voltaren)

(3) Levofloxacin is associated with changes in the QT interval. Because the female QT interval is normally longer than in males, women are at higher risk. Sildenofil, atorvastatin, and diclofenac have not been associated with QT changes. 66. Which client should be given nursing advice on the risks of a new drug in stage IV of its clinical trials? 1. 2. 3. 4.

a client receiving a drug that is approved for compassionate use a client receiving a drug used in healthy volunteers a client who has the condition that the drug being tested is designed to treat a client receiving a drug given to clients in the population at large, some of whom may manifest a new symptom previously unreported

(4) Stage IV of clinical drug testing involves post-marketing surveillance for new symptoms and/or adverse reactions previously not identified. This phase is ongoing and depends on the voluntary reporting of adverse reactions by health providers. 67. Which of the following factors might indicate an adverse drug reaction? 1. 2. 3. 4.

The symptom(s) occurrence bears no specific link to the medication’s use. The symptom(s) cannot be explained by the illness/condition or a drug-to-drug interaction. The symptom(s) appeared before the medication was first administered. The symptoms(s) occurred shortly after the medication was discontinued.

(2) When the symptoms being experienced cannot be linked to the disorder or the use of other medication, the likelihood of an adverse drug reaction is probable and should be reported. Occasionally, some drugs produce adverse reactions after their use is discontinued, but this is a much less-common event.

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68. Which group of clients is most at risk for adverse drug reaction? 1. 2. 3. 4.

school-age children teenagers females clients with chronic illness

(4) Clients with chronic and/or multiple illnesses are more vulnerable to adverse drug reactions because they are more likely to be on several medications, have a greater incidence of organ impairment and bone marrow depression and are more likely to make a mistake in medication administration due to the complexity of drug regimens. 69. Which of the following actions by a client is likely to lead to a medication error? 1. 2. 3. 4.

questioning his/her health care provider about any concerns regarding the medication reviewing drug literature online failing to notify staff while following regular home patterns of medication use while hospitalized. use of Medic or Med-Alert jewelry

(3) When a client continues to take his/her medications (such as over-the-counter medications [OTCs]) according to home routine while hospitalized, miscommunication and error is likely to occur. Clear and accurate information-sharing about all medications taken at home (including OTCs) and collaboration with health care providers is key to ensuring safe medication use while a client is hospitalized. 70. The nurse witnesses an adverse drug reaction in a client. Which of the following reports is completed voluntarily? 1. 2. 3. 4.

an incident report a medication-administration record in the client’s chart a Food and Drug Administration (FDA) MedWatch Safety Information and Adverse Event Report an entry in the client’s medical record

(3) The FDA MedWatch Safety Information and Adverse Event Report is a systematic tracking system for the voluntary reporting of medication errors and adverse events. An incident report is policy directed; most agencies require that one be completed by the person witnessing the event. This document is prepared in preparation for litigation and is not considered discoverable. The Medication Administration Record (MAR) and the client’s record are two areas where agency protocol will dictate the extent but not the requirements for documentation. Prudent nursing care will warrant that a nurse document the client’s response to the adverse event in the record in one or both of these areas. Charting would not be considered voluntary, but mandatory. 71. Which of the following dietary recommendations is not appropriate for infants and/or toddlers? 1. 2. 3. 4.

Encourage low-fat foods. Do not give honey to children who are less than 12 months old. Start new foods one at a time, and wait one week before adding a new one. Breast milk is best for children between 0 and 6 months old.

(1) Until 2 years of age, children should not be restricted in fat intake as cholesterols are needed to promote myelination of neuronal cells in the actively growing brain. Honey can harbor toxins such as botulism and should not be given to infants. New foods and/or “solids” should be introduced slowly about one per month. Breast-feeding is encouraged until the second year of life by most leading advisory groups such as WHO (World Health Organization) and UNICEF (United Nations International Children Education Fund), and recommended for exclusively for the first year of life by the American Academy of Pediatrics.

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72. When a client is taking more than one drug that is strongly bound to protein, for which of the following clinical outcomes should the nurse monitor? 1. 2. 3. 4.

tachyphylaxis metabolic tolerance allergic drug response toxicity

(4) When drugs compete at binding sites, free drug levels increase and toxicity can result. Metabolic tolerance occurs when a drug induces rapid metabolism by hepatic enzymes. Tachyphylaxis is a type of tolerance manifested by a lessened response to the drug on account of repetitive use. An allergic response relates to the degree of sensitization of the client to the drug and may be manifested by mild physical signs such as itching and rash to anaphylaxis. Toxicity refers to simply poisoning by the drug. 73. Which important fact about the use of transdermal nitroglycerin should be taught by the nurse? 1. 2. 3. 4.

The skin must be prepared by cleansing with an alcohol prep to prevent excoriation. The patch must be removed for a period of time each day to prevent tachyphylaxis. The sites must be rotated twice a day to preserve skin integrity. The patch must be moistened with water prior to application to create a seal.

(2) Tachyphylaxis is a form of drug tolerance that develops within 24 hours of the use of nitrates resulting in an ineffective drug response. To combat this problem, the client is instructed to use the lowest effective dose and to provide 8–12 drug-free hours each day. Alcohol and other skin preparations are not necessary for use of transdermal nitroglycerin; excessively hairy areas should be avoided. 74. A client who has a history of hepatic failure asks the nurse’s advice on an analgesic for headache. Which of the following medications is the best choice? 1. 2. 3. 4.

Codeine acetaminophen (Tylenol) Darvocet ibuprofen (Motrin)

(4) Ibuprofen is not metabolized in the liver and would therefore be the best choice of analgesic. However, nurses cannot prescribe medications, even over-the-counter medications. The nurse would give all the information and allow the client to make the right choice for herself. 75. When preparing to give an anticoagulating agent like warfarin (Coumadin), which of the following pieces of information is necessary? 1. 2. 3. 4.

complete blood count (CBC) prothrombin time (PT) international normalized ratio (INR) bleeding time

(3) Prior to administration of warfarin, the nurse should assess the clotting times of the client with the INR, a more standard PT measurement for clotting, preferable to the once-commonly used PT. The CBC does not measure the effectiveness of anticoagulating agents. Parameters such as the hemoglobin, hematocrit, and platelet count can provide general information regarding the blood’s functional state. The bleeding time is not a measurement of coagulation but of platelet function.

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76. Which of the following clients is most at risk for an adverse drug reaction? 1. 2. 3. 4.

a teenager admitted for substance use a 35-year-old male admitted for femur fracture a 60-year-old male with a respiratory infection a 75-year-old female with cirrhotic hepatocellular disease

(4) Because most drugs are metabolized by hepatic enzymes, liver disease creates the highest risk for an adverse drug reaction among the conditions listed. Additionally, elder adults are impacted by organ impairment due to progressively decreasing levels of function of their vital organs. A teen admitted with a history of substance use does not necessarily pose any increased risk for adverse drug reactions. Middle-aged and elder adults who are not taking any other medications and who do not have chronic illnesses do not have an increased risk for adverse drug reactions. 77. A client is using a drug “off-label.” The nurse understands this to mean that: 1. 2. 3. 4.

the drug is in the investigational stage of testing. the drug is available only for compassionate use in terminal clients. the drug does not have FDA approval. the drug is FDA approved but not for the current use.

(4) Off-label drugs are those approved by the FDA for one use but found to be effective for another. The newly discovered use has not been evaluated by the FDA and received approval during the off-label use. There are many examples of drugs formerly off-label, such as minoxidil (Rogaine) an original anti-hypertensive agent found to stimulate hair growth. An investigational drug has not received FDA approval but may be used in certain circumstances warranted by severe client need and informed consent. Compassionate-use drugs are those that are developed for a select, usually smaller number of clients who do not command a huge market for the drug. Under compassionate use, the FDA approval is “fast tracked.” 78. A client has a history of hypoalbuminemia and is taking warfarin. The client must be observed for: 1. 2. 3. 4.

increased warfarin blood levels. decreased warfarin blood levels. therapeutic levels of warfarin. skewed prothrombin levels.

(1) Hypoalbuminemia can lead to increased blood levels of drugs and possible toxicity. The INR (not prothrombin levels) is the proper measure of clotting time for a client on warfarin. 79. A client is diagnosed with pancreatitis and is in severe pain. To prevent drug toxicity, provide rapid pain relief, and ensure precise drug dosing, the ideal route of analgesic administration is: 1. 2. 3. 4.

intramuscular. sublingual. continuous intravenous. rectal.

(3) Continous IV analgesia (such as via PCA [patient-controlled anesthesia]) is the preferred method for pain management in clients with pancreatitis.

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80. To avoid the first-pass effect in a client with liver failure, which of the following routes of drug administration should not be selected? 1. 2. 3. 4.

intravenous intramuscular sublingual oral gastrostomy

(4) Medications are chiefly absorbed from the small bowel and stomach and subject to enterohepatic circulation. In the face of liver damage, drug metabolism is greatly impaired and drug response is ineffective and unpredictable. 81. A client is taking Phenytoin for the control of seizures. Why is blood-level monitoring for this client essential to therapeutic management? 1. 2. 3. 4.

Free drug measurements give minimal data regarding drug levels in the targeted tissue. Drug levels are the most reliable method for ensuring therapeutic range. The drug level determines the maximal effectiveness of the drug. If the drug level is too low, the client might show signs of toxicity.

(2) Ensuring a therapeutic range of a drug’s blood level is an important means of preventing the development of toxicity and ensuring the drug’s effectiveness. Toxicity is correlated with high blood levels of a drug. Free drug measurements are the standard measurement of therapeutic blood levels of drugs, as direct cellular levels of the drug are not easily measured by standard lab testing. 82. The nurse is counseling a client regarding harmful dietary interactions with drugs. Grapefruit juice may be restricted from the client’s diet if on warfarin because of which effect? 1. 2. 3. 4.

It raises the drug level via inhibition of the CYP (cytochrome P) 450 metabolism by the liver. It competitively antagonizes for cellular binding with receptors. It pharmacologically impacts the body by receptor activation. It decreases absorption by coating the gastric mucousa.

(1) Grapefruit and grapefruit juice is a CYP 450 inducer and may dangerously affect liver metabolism of many drugs. Therefore, it should not be given with a drug such as warfarin known to be metabolized by the CYP 450 system. The adverse effects are not related to antagonizing or blocking the effect of the warfarin or by activation of cellular receptors. Grapefruit juice does not decrease absorption from the mucousa. 83. Phenobarbital is an example of a CYP 450 enzyme that functions as: 1. 2. 3. 4.

a competitive antagonist. an inducing agent. an inhibiting agent. a potentiating agent.

(2) Phenobarbital is a cytochrome P-450 inducing agent that causes blood levels of a drug to be lowered. A competing agonist would exert a blocking effect, while an inhibiting effect would prevent the response of the drug. A potentiating effect would increase or enhance the drug response. 84. When calculating drug dosage based on a client’s size, the nurse should use which of the following parameters? 1. 2. 3. 4.

ideal body weight actual body weight in kilograms body surface area creatine and BUN lab values

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(3) Body surface area is expressed in square meters. Body surface area nomograms and formulas have traditionally been used in calculating pediatric dosages, managing fluids in critical clients (including burn clients), and determining radiation doses. Dosing of medication is beginning to be based on body surface area but has traditionally been calculated using ideal weight. Creatine and BUN are measures of renal function and are important in drug management because the kidneys are the chief organ of excretion. 85. Which of the following measures is essential for clients taking lithium? 1. 2. 3. 4.

complete blood count urinalysis drug blood level potassium (K+) blood level

(3) Measuring the drug blood level is essential when a client is taking lithium because it has a narrow therapeutic index and can become subtherapeutic or toxic quickly. Clients on lithium experience polyuria as a side effect of the drug and need careful monitoring for signs of dehydration. Certainly, the specific gravity of urine is one lab measure of hydration, but ensuring that the drug is in its therapeutic range correlated with the assessment of clinical signs of hydration is most important. 86. Which developmental accomplishment by an infant increases the risk for unintentional death and injury? 1. 2. 3. 4.

loss of the fear of falling fear of strangers social smile walking

(4) The ability to be mobile (crawling, walking, climbing) combined with inquisitiveness, immaturity, and inability to execute reasonable judgment result in increased risk of accidents, even for hospitalized pediatric clients. 87. A test with the capability to correctly identify those who have a disease is considered: 1. 2. 3. 4.

specific. sensitive. invalid unless approved by the FDA. such a test does not exist; most tests are based on extrapolated data.

(2) Sensitivity-testing correctly identifies clients who actually have a disease. Most lab tests are regulated by the Clinical Laboratory Inspection Agency (CLIA) and the Occupational Safety Health Administration (OSHA) and do not fall under the regulation of the FDA. Clinical testing includes some extrapolation and normalization of data for elements such as controls and ranges; however, individual test results are typically based on the actual individual’s test result. 88. If the nurse’s hand becomes soiled with urine while caring for a client who has received a radioactive isotope, which is the best course of action? 1. 2. 3. 4.

Document the occurrence on an incident report. Notify the infection control nurse. Wash both hands liberally with soap and water. Wash both hands liberally with antiseptic gel.

(3) Standard precautions must be observed in caring for all clients. Soiling of intact skin by body fluids requires a soap-and-water scrub. Although the use of antiseptic cleansing gels have been shown to be effective for routine cleaning, after the hands are soiled, vigorous rubbing with soap and water is the best course of action to remove microbes. Generally, the infection control nurse should not be notified nor should an incident report be completed in any situation where the nurse comes in contact with blood or body fluids unless the nurse has received an injury such as a contaminated needle stick or has open lesions on his/her hands that could provide easy entry for human immunodeficiency virus (HIV), hepatitis B (Hep B), and other blood-borne pathogens.

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89. The nurse is teaching a disaster-preparedness class to health care workers. Which of the following infectious diseases could be suspected as a probable biological weapon? 1. 2. 3. 4.

varicella (chickenpox) clostridium botulinum (botulism) haemophilus influenzae (flu) West Nile virus (WNV)

(2) Botulism has been used in biological acts of terror and is a possible form of warfare. At the present time, the other pathogens have not been formerly associated with bioterrorism. Clostridium toxin is the most potent poison known to man. This biotoxin can be transmitted to humans via inhalation or ingestion. A small amount of the substance can infect tens of thousands of people and result in mass mortality. A suspected victim of exposure needs supportive care. The toxin is a neurologically focused poison that interferes with acetylcholine release at its receptors. Recovery can take months if death does not occur. Immediate notification of the local health department to obtain antitoxin should occur. Varicella, H-flu, and WNV are not thought to be appropriate for biological weaponry. 90. Which of the following responses most fully answers the question, “Why should I immunize my child against measles?” 1. 2. 3. 4.

“To prevent infections that could reemerge.” “To prevent outbreaks in schools and communities.” “To protect your child from diseases common in other parts of the world and that continue to occur in small outbreaks in the United States.” “A lot of people stopped immunizing in the 1980s and 1990s, and more than 100 children died.”

(3) The response that immunizations protect against diseases that may still occur in small outbreaks in the United States is the most relevant choice. All the responses are correct; however, Choices 1 and 2 are not specific to the client and Choice 4 is blaming in nature, is a nontherapeutic response and should be avoided. 91. Which of the following statements is incorrect about why DTaP is felt to be the superior form of immunization today? 1. 2. 3. 4.

DTaP can be combined with other vaccinations, reducing the need for multiple injections. DTaP has a safer side-effect profile than the formerly used DTP. Studies indicate that DTaP confers the same pertussis immunization as the DTP when administered correctly. Many forms of immunization are available on the market, and they can all be used interchangeably for all five initial doses.

(4) Not many forms of immunizations are available on the market. The research and development of even one vaccine is expensive and lengthy. Further, the immunizations may only be given together if outlined by guidelines such as the CDC’s Advisory Council on Immunization Practice (ACIP) and must only be given under the umbrella of a prescriber’s directive. 92. Which statement about the varicella vaccine is correct? 1. 2. 3. 4.

The varicella zoster virus is mildly contagious. The risk for complications from chickenpox is highest for school-age children and young adolescents. The varicella vaccination can be safely administered during pregnancy. Adults who experience chickenpox are at high risk for serious sequelae, such as pneumonia and secondary infection.

(4) Adults and the elderly are typically at greatest risk for serious illness resulting from the varicella virus and require hospitalization in many cases. The varicella virus is highly contagious, and persons at risk for the disease should be separated from any person suspected of being contagious. The vaccination cannot be safely administered during pregnancy because it is a live, though attenuated, virus. Complications are not more likely in school-age children and young adolescents.

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93. A 30-month-old child arrives for preschool immunizations. The child’s immunizations are documented as up to date with the exception of varicella and MMR. Unless contraindicated, the nurse should: 1. 2. 3. 4.

administer the varicella, but not the MMR. defer the varicella and the MMR. have the child return at 6 years of age. administer the immunizations.

(4) The child should receive both immunizations unless there is a contraindication such as an allergy to the vaccine or one of its components, or the child is immunocompromised. The risks of illness and death are much greater than the risks of side effects from the vaccines. 94. Which is the immunization recommendation for a 36-month-old child being given Pnuemococcal Conjugate Vaccine (PCV) if the child has only had one dose of PCV at 23 months of age? 1. 2. 3. 4.

one dose of PCV two doses of PCV at least two months apart two doses of PCV six months apart no further immunization

(1) The ACIP recommends that two doses of the vaccine be given until the age of 24 months, after which the decision should be guided by other factors such as degree of risk. Because the child in this scenario was younger than 24 months when he/she received one dose, another dose is indicated. 95. A child received an MMR at age 11 months and 2 weeks. At the 15-month checkup, the nurse notes that besides the MMR, the child has received no immunizations since 4 months of age. To catch up, the nurse should: 1. 2. 3. 4.

administer MMR only. hold MMR, but administer DTaP, PCV7, IPV, and Hep B. administer DTaP, Hib, PCV7, IPV, IV, MMR, VZ, and Hep B. administer DTaP, Hib, PCV7, IPV, VZ, and Hep B.

(3) Today’s visit indicates an opportunity to catch up on the immunizations for the child. Therefore, the child should receive all remaining vaccinations due in his/her age group unless there is a contraindication. 96. Which of the following is correct regarding the microbiology of anthrax? 1. 2. 3. 4.

The anthrax virus is highly contagious. The anthrax pathogen mainly produces neurological and hematologic signs of poisoning. No postexposure prophylaxis is recommended. The anthrax microbe is an aerobic, gram-positive bacillus.

(4) Bacillus anthracis is a gram-positive, aerobic microorganism that is responsive to antibiotic treatment. Treatment, including prophylaxis, should begin as soon as possible after exposure. Many manifestations of anthrax infection exist, but respiratory and cutaneous symptoms are the strongest clinical markers. Anthrax is transmitted via spores that find their way to the lungs where incubation occurs. It is not transmitted by person-to-person contact but by contact with the spores that produce toxins in the host. 97. Which immunizations are commonly recommended for adults older than 65? 1. 2. 3. 4.

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Hib, influenza, pneumococcal Varicella Hep A, MMR, DTaP Td, pneumococcal, influenza

Safety and Infection Control

(4) The Td, pneumococcal, and influenza immunizations are indicated for the elder adults. The remainder of the vaccines apply to childhood illness prevention with the exception of Hepatitis A. Vaccination against Hep A in the elderly is determined based on a risk-benefit ratio. 98. Which of the following immunizations is a live vaccine and poses the greatest risk to a college-bound, immunecompromised 19-year old? 1. 2. 3. 4.

Td booster Meningococcal vaccine Hep B MMR

(4) The MMR is a live vaccine and should not be given to those in immunocompromised states, during pregnancy, or during febrile illness. In addition, the risk-benefit ratio of administering the meningococcal vaccine is analyzed carefully, as with all medications given to a vulnerable group of individuals. 99. Which of the following conditions can be treated with radioactive isotopes? 1. 2. 3. 4.

cancer of the thyroid infectious mononucleosis rhabdomyolysis hyperthyroidism

(4) Hyperthyroidism (Graves’ disease) can be treated nonsurgically with the ingestion of radioactive isotopes. Thryoid cancer can be treated with radioactive isotopes, but because most thyroid cancers do not take up iodine, this is rare. Infectious mononucleosis is treated palliatively with rest and fluids. Rhabdomyolysis (a rare, post-traumatic, skeletal, muscular, and renal condition) is also treated with fluids and intensive medical management. 100. After a mass-casualty event, which of the following is the most serious threat to public health? 1. 2. 3. 4.

looting and random violence post-traumatic stress reaction bacterial infections of water or mold and mildew after flooding downed power lines

(3) The most serious public health threat is the contamination of water supplies. The lack of clean drinking water is the greatest threat to a community after a disaster such as a mass-casualty event. The incidence of injury and death due to Choice 4 is low. Choices 1 and 2 increase after a disaster, but illness due to contaminated water remains the greatest overall threat. 101. Which of the following infectious diseases is a probable biological weapon and requires special handling due to its communicability? 1. 2. 3. 4.

varicella (chickenpox) smallpox haemophilus influenzae (H-flu) West Nile Virus (WNV)

(2) Smallpox is spread from person to person via droplets. Once invading the oral, nasal, and/or pharyngeal mucus membranes, the pathogen makes its way into the lungs. Symptom onset begins within 12–14 days of exposure and typically manifest by high fever 1–4 days prior to the eruption of a vesicular rash. The rash is generally distributed over the body, including the palms and soles. Varicella, H-flu, and West Nile Virus are not thought to be agents of biological warfare currently.

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102. The nurse’s gloves become contaminated by a client’s blood during venapuncture. What should the nurse do first? 1. 2. 3. 4.

Document the occurrence in an incident report. Wash the gloved hands, and then remove the gloves. Remove the gloves, and then wash the hands with antiseptic gel. Remove the gloves, and then wash the hands with soapy, warm water.

(4) Because blood is one of the most dangerous reservoirs of pathogens, gloves should be removed immediately to keep the soiled area from coming in contact with the skin. Hand washing with warm water and soap is recommended when hands have been soiled. Because gloves can be porous or defective, standard hand washing should occur when in doubt. Although antiseptic gels have been shown to be effective in routine hand washing, the better choice in this situation is hand washing with warm water, soap, friction scrubbing, and thorough rinsing. 103. A client begins to bleed profusely from a three-day-old traumatic wound. The floor, bed, and side rails are contaminated. After the client is stabilized, the appropriate choice for cleaning the bed and floor is: 1. 2. 3. 4.

Betadine alcohol soap and water chlorine bleach

(4) A diluted bleach solution is the appropriate choice for cleaning blood spills. Alcohol, soap, and water might not eradicate all pathogens. Betadine (an iodine-based antibacterial product) is not warranted due to expense, potential allergies, and staining. 104. Which of the following nursing measures should be taken when caring for a client who has just received a radioactive medication for treatment of Graves’ disease? 1. 2. 3. 4.

The client must wear a lead apron while the substance is absorbed. The nurse must wear a protective lead-lined apron during client contact. The client must be placed in a closed, hyperbaric room. The nurse does not need to wear any special protection when in direct client contact.

(2) The nurse must wear radioactive protective gear while in direct contact with the client. The client must be quarantined (usually no more than 24 hours). 105. If all of the following events occur in a chemical-weapon disaster, which of the following is specifically linked with chemicals being released into the atmosphere? 1. 2. 3. 4.

toxic gases collecting in low-lying areas mental disturbances leading to violent, deadly acts bacterial contamination of the water supply electrocution from downed power lines

(1) Toxic gases are heavier than air, so they tend to accumulate in low-lying areas. The gases are typically volatile and can produce ventilatory effects. Drinking water can be contaminated and might transmit chemical substances but this would not be bacterial in origin. Stress disorders are likely to increase in incidence after any mass-casualty event, therefore, clinical manifestations of mental disturbance would not be specific to chemical exposure, having the possibility of other etiologies. Downed power lines, if present, can pose an electrical and fire hazard but would not be specific to a chemical weapon disaster.

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106. A true contraindication to receiving MMR is: 1. 2. 3. 4.

pregnancy. a positive Hepatitis B Surface Antigen (HbsAg). a client with a history of a nonanaphylactic reaction to eggs. an immunocompromised family member.

(1) MMR is a live, though attenuated, vaccine that is contraindicated in pregnancy due to the risk of teratogenesis. Choice 2 indicates exposure to the hepatitis antigen, the protein that defines the hepatitis B virus. Choice 3 is considered as with all allergies, but does not present an absolute contraindication. Regarding the possible egg allergy, a further history as to the extent of any past reaction manifested clinically is warranted. Choice 4 might present a contraindication depending on contact between the family member and the person receiving the vaccine, but this situation is analyzed by the prescriber and does not pose an absolute contraindication. 107. The reemergence of a few cases of poliomyelitis in the United States has been related to: 1. 2. 3. 4.

wild-type 1 polio virus (wtPV1). resistant strains of polio. use of the oral polio vaccine (OPV). use of the inactivated polio vaccine (IPV).

(3) OPV was withdrawn from the U.S. market in 2002. Because the vaccine was live, the viral shedding produced a continued communicable threat to others. Because the inactivated vaccine prevents all three of the serotypes of polio and does not transmit disease, all immunization against polio now occurs via the use of IPV, so Choice 4 is incorrect. IPV immunization prevents both wild and resistant strains in addition to the main polio serotype. The wild and resistant strains were two types that formerly reemerged because children were not being immunized or the former OPV used did not convey protection against all types. 108. Which substance in some immunizations is contraindicated in premature infants because of harmful neurological effects? 1. 2. 3. 4.

benzalkonium chloride thimerosal Heparin chlorhexidine

(2) Thimerosal, a mercury-based disinfectant used as a preservative in some vaccinations, is contraindicated in infants, particularly those who are premature and of low birth weight. Benzalkonium chloride and chlorhexidine are antiseptics used in surgical hand scrubs and as local detergent cleaners in the health industry. Heparin is an anti-coagulation agent only given parenterally and is not a component of immunizations. 109. Which is a guiding principle when giving immunizations to premature infants? 1. 2. 3. 4.

Premature infants should receive a reduced dose of vaccine proportionate to body weight. A standard dose of vaccine is necessary to achieve immunity. Premature infants are not immunized due to organ immaturity. Vaccine dose is calculated based on the body surface area.

(2) The standard dose of vaccine is given to all pediatric clients with rare exceptions, such as Hep B. Typically, premature infants do not receive a calculated or decreased dose based on their small size. Despite immaturity of organs, premature infants need to be immunized and are given the standard dosages to convey protection. This is not often done until hospital discharge. A caveat is that in most cases, breastmilk will convey protection for up to six months.

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110. A 12-month-old child is receiving Hep B, Hib, IPV, MMR, PCV, and VZ vaccines today. Which of the following statements regarding additional preventive measures is correct? 1. 2. 3. 4.

PPD testing should occur today, also. Live vaccine immunization cannot occur contemporaneously with PPD testing. Hep A vaccine is indicated in all infants. Influenza vaccine should be administered today, also.

(1) The child should be screened for tuberculosis, and PPD testing is not contraindicated. Hep A and influenza are generally recommended, but not included as an absolute requirement for all children. The decision to give the Hep A and influenza vaccines is determined based on the current risk-benefit ratio. 111. The nurse is giving the following immunizations: Hep B, Td, meningococcal, and varicella (as an initial vaccination). To which age group is she most likely administering the vaccines? 1. 2. 3. 4.

0–2 months 2–4 months 11–12 years College age

(4) The group of immunizations listed is typically given to college-age youth. 112. The National Childhood Vaccine Act requires that the nurse record all but which data when administering childhood immunizations? 1. 2. 3. 4.

Name of vaccine, manufacturer, and lot number Vital signs of the client Route and site of administration Name of the nurse and his/her professional title

(2) While vital signs should be taken and recorded in the client’s medical record, they are not required by the National Childhood Vaccine Act. In addition to the data listed in the other choices, the date of the treatment should be noted. 113. A client’s immunization status should be assessed: 1. 2. 3. 4.

at every well visit. prior to surgery. with each encounter. when gathering a complete history.

(3) The nurse should assess the client’s immunization status at each encounter and document the findings in the medical record. 114. A school-age child is diagnosed with organophosphate poisoning after an accidental spill of pesticides. The nurse should anticipate which clinical manifestations? 1. 2. 3. 4.

agitation, muscle weakness, and confusion coughing, pruritis, and rash abdominal cramps, nausea, and vomiting chest pain, shortness of breath, and generalized swelling

(1) Organophosphate poisoning interferes with acetylcholinesterase, resulting in neurological changes. Even low levels of organophosphates can interfere with neurologic functioning, including neurological development and cognition. Choices 2, 3, and 4 are not examples of neurological changes.

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Safety and Infection Control

115. A 23-year-old pregnant client arrives for her initial prenatal visit. She is at 16-weeks gestation by menstrual history. Which is the appropriate screening for this visit? 1. 2. 3. 4.

chlamydial screen if high risk rubella titer if no history of rubella, red-blood count, and ABO routine finger-stick glucose screening syphilis, GC, chlamydia, ABO, RBC, RH, hepatitis (bsAg), and rubella screening

(4) Syphilis, GC, chlamydia, hepatitis, rubella, red blood count, and ABO screening should be performed at the initial prenatal visit. 116. Td should be given to adults: 1. 2. 3. 4.

at 10 years of age. every 10 years after initial immunization. at 20 years of age. only if the wound is dirty.

(2) Tetanus toxoid is indicated as a booster after antibodies have been produced. Therefore, presuming an adult has received initial tetanus immunizations in childhood, only a booster is needed every 10 years prophylactically, beginning at age 12. In cases of dirty wounds such as punctures, a tetanus toxoid should be administered every five years to ensure protection. 117. A 26-week-pregnant client has felt no fetal movement for several days. The client works long hours standing in an assembly line in a chemical plant that manufactures insecticide. While being prepared for examination, the client asks the nurse what he/she knows about fetal risk and pesticides. The best nursing response is: 1. 2. 3. 4.

“Most of the so-called fetal risk theories have been debunked by recent research.” “All chemicals cross the placenta and cause toxic effects. We can discuss it more after the examination.” “The physician can discuss the risks with you.” “There is a link between pesticides and fetal harm. What do you know about it?”

(4) Assessing the client’s knowledge and then honestly answering the client’s question is the best choice. Obviously, the mother is concerned that her fetus has been harmed via her own occupational exposure to pesticides. Emotional support should be given as the client receives prenatal care. Research continues in the area of links between some pesticides and neurologic injury, including neural tube defects. 118. The main purpose of rubella titer prenatal testing is: 1. 2. 3. 4.

to determine the correct dose of MMR. to screen the population aggregate for history of rubella infection. to offer primary prevention against congenital rubella syndrome. to determine fetal antibodies.

(2) By identifying women who have been exposed to rubella and developed sufficient titers to be considered immune, the risk of rubella infection can be predicted for other pregnant women. Rubella poses severe teratogenic risk and is the causative agent for congenital rubella syndrome. Rubella syndrome is a severe congenital disease that can result in spontaneous abortion or abnormalities of the heart, central nervous system (CNS), vision, and hearing. Immunization against rubella is contraindicated during pregnancy because the rubella vaccine is a live, though attenuated, vaccine.

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119. The nurse is caring for a postoperative client with a temperature of 103.6° F. After collecting a blood specimen for a culture, which of the following types of medications is most likely to be ordered by the client’s physician? 1. 2. 3. 4.

gram positive gram negative antifungal broad spectrum antibiotics

(4) Broad-spectrum antibiotics are likely to be ordered by intravenous infusion. An antipyretic is also likely to be ordered. The nurse must monitor vital signs at regular intervals. Allergies to medications should be assessed preoperatively as well as possible conditions or other medications the client might have been taking that might be incompatible with the antibiotic. Comfort measures are appropriate, including oral fluids in addition to IV fluids if not contraindicated. 120. A client is seen in the emergency room following an indoor party and was diagnosed with active tuberculosis. The nurse should explain to the client that this type of infection is transmitted in which of the following ways? 1. 2. 3. 4.

vehicle vector airborne direct contact

(3) Tuberculosis is an airborne organism that can be transmitted by exposure to the microorganisms in the air— especially in closed areas. Nursing interventions should include medication, universal precautions, and appropriate isolation measures, nutrition, ongoing assessment, and client teaching. 121. The nurse has instructed a group of health care workers about Hepatitis B. The nurse determines that one of the workers needs further instructions when the worker says that the virus is transmitted by: 1. 2. 3. 4.

blood. feces. body fluids. sputum.

(4) Hepatitis B is transmitted by body fluids, including blood and feces. Universal precautions must be observed when caring for a client with hepatitis B, as they must be in the care of any client. 122. A client is hospitalized with a urinary tract infection. The physician orders insertion of an indwelling urinary catheter. The nurse is responsible for doing this procedure. What precautions need to be used? 1. 2. 3. 4.

Utilize a set that has been opened. Utilize a sterile set. Utilize an aseptic set. The type of set is irrelevant as long as the catheter is in place.

(2) Insertion of a urinary catheter is a sterile procedure in a hospital setting. Complications of urinary catheter use include urinary tract infection, septicemia, and skin breakdown. 123. A 30-year-old client is preparing for discharge from the hospital when the client develops a temperature of 102.8° F. Which type of infection is this client likely experiencing? 1. 2. 3. 4.

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nosocomial extracorporeal incidental resistant

Safety and Infection Control

(1) A nosocomial infection is associated with the delivery of health care in a hospital. Nosocomial infections can develop during a client’s stay in a hospital or manifest after discharge. Nosocomial infections can also be acquired by health personnel working in the hospital and can cause serious illness and time lost from work. The hands of personnel are a common vehicle for the spread of microorganisms. Insufficient hand washing is an important factor contributing to the spread of nosocomial infections. 124. A 70-year-old client has had an indwelling urinary catheter for two days following surgery. Before removing the catheter, the nurse sends a urine sample for analysis, culture, and sensitivity to determine whether the client has developed which of the following types of infections? 1. 2. 3. 4.

endogenous viral microbial iatrogenic

(4) Iatrogenic disease is a disease caused unintentionally by medical therapy. A number of factors contribute to nosocomial infections (infections associated with delivery of health care in a hospital). Iatrogenic infections are the direct result of diagnostic or therapeutic procedures. Examples of iatrogenic infections include bacteremia that results from contamination of an intravascular line and urinary tract infections that result from a contaminated urinary catheter. Not all nosocomial infections are iatrogenic, nor are all nosocomial infections preventable. 125. Which of the following statements regarding hospital-acquired infections (HAIs) is false? 1. 2. 3. 4.

Most HAIs are due to bacteria. Indwelling catheters have been implicated in a large percentage of HAIs. HAIs are relatively easy to treat with antibiotics. Frequent hand washing is the best method of preventing HAIs.

(3) Hospital-acquired infection is an infection acquired at least 72 hours after hospitalization, often caused by candida albicans, Escherichia coli, hepatitus virus, herpes zoster virus, pseudomonas, or staphylococcus. These specific infections are not easily treated and may lead to further illness, problems, or disability. Hand washing is the major prevention technique. 126. Medical asepsis is maintained by performing all but which of the following activities? 1. 2. 3. 4.

keeping soiled linens away from the clothing of health care workers placing soiled linens on the floor near a client’s bed using dampened cloths to dust bedside tables using gloves to clean a soiled bed

(2) Placing soiled linens on the floor near a client’s bed is not proper aseptic technique. Medical asepsis includes all practices intended to confine specific microorganisms to a specific area and limiting the number, growth, and transmission of microorganisms. In medical asepsis, objects are referred to as clean, which means the absence of almost all microorganisms, or dirty (soiled, contaminated). Dirty items are likely to have microorganisms, some of which might be capable of causing infection. 127. Before changing the dressing of a home care client, the nurse should: 1. 2. 3. 4.

wash his or her hands with an antibacterial soap. remove any nail polish on the nurse’s fingernails. put on two pairs of clean gloves. remove any wedding rings or other jewelry.

(1) The hands of health care personnel are common vehicles for the spread of microorganisms. Insufficient hand washing is an important factor contributing to the spread of nosocomial infections. For routine client care, the CDC recommends antimicrobial foam, hand gel, or vigorous hand washing under a stream of warm water for at least 10 seconds

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using granule soap, soap-filled sheets, or antimicrobial liquid soap. In health care settings, antimicrobial soaps are usually provided in high-risk areas and are frequently supplied in dispensers at sinks. Studies have shown that the convenience of antimicrobial foams and gels, which require soap and water, can increase health care workers’ adherence to hand washing policies. The CDC recommends antimicrobial hand-washing agents in the following situations: when there are known multiple resistant bacteria, before invasive procedures, in special care units (such as nurseries and ICUs), and before caring for severely immunocompromised clients. 128. The nurse is assessing the sterile field in a client’s delivery room and determines that the field is contaminated when observing which of the following? 1. 2. 3. 4.

an inch of the sterile towel hanging over the side of the table sterile objects held above the waist of the practitioner sterile packages opened so that the first edge is away from the practitioner wetness on the sterile cloth on top of a nonsterile table

(4) Moisture that passes through a sterile object can draw microorganisms from nonsterile surfaces above or below to the sterile surface by capillary action. The nurse must be knowledgeable about sources and modes of transmission of microorganisms. A sterile field is a microorganism-free area. 129. Instruction should be given by the nurse concerning universal precautions when handling client items that are soiled with all the following substances except: 1. 2. 3. 4.

amniotic fluid. vaginal secretions. blood pathogens. saline.

(4) Saline is a solution, not a body fluid. Universal precautions are techniques to be used with all clients to decrease the risk of transmitting unidentified pathogens. 130. The nurse is caring for a client with an open wound. The nurse needs to use which of the following techniques? 1. 2. 3. 4.

clean technique antiseptic technique sterile technique medical technique

(3) Sterile technique must be used. Open wounds are a portal of entry for microorganisms. 131. What does the nurse need to wear when caring for a client with tuberculosis? 1. 2. 3. 4.

a mask sterile gloves a clean gown a sterile gown

(1) Tuberculosis is an airborne bacterial infection (mycobacterium tuberculosis). The droplets from the tuberculosis can be transmitted from the client to the health care worker through the air. 132. An infection control nurse should be concerned when observing: 1. 2. 3. 4.

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needles being placed in a hazard container. gloves being worn by housekeeping staff. blood dried under a client’s mattress and bed. a worker carrying double-bagged, soiled linen.

Safety and Infection Control

(3) Any body fluid must be considered hazardous material and cleaned according to facility policy and procedure following universal precaution principles. 133. While caring for a client who has intermittent diarrhea, the nurse should take precautions to prevent contamination with: 1. 2. 3. 4.

Escherichia coli. Clostridium difficile. Staphylococcus aureus. Neisseria meningitidis.

(1) The microorganism Escherichia coli is found in feces, so precautions to prevent contamination need to be taken when caring for any client who has diarrhea. Spores from soil that become airborne in dust particles can contain the infectious agent Clostridium difficile; these spores are transmitted by air currents to a suitable portal of entry, usually the respiratory tract of another person. Staphylococcus aureus is a species frequently responsible for abscesses, endocarditis, impetigo, osteomyelitis, pneumonia, and septicemia. Neisseria meningitidis is one of the most common causes of infection or inflammation of the membranes covering the brain and spinal cord. 134. Which of the following instructions should nursing students be given about the use of sterile gloves? 1. 2. 3. 4.

Vinyl glove punctures reseal automatically. Latex gloves are used primarily with minor procedures. Vinyl gloves are less costly and easier to put on. Latex gloves can result in allergic reactions.

(4) Nurses need to know that some individuals have allergic reactions to latex products. All sterile gloves can be used for all procedures and their cost differs in different systems and locations. No gloves reseal themselves. 135. Which activity should be performed by the nurse practitioner (certified nurse midwife) when doing a pelvic exam? 1. 2. 3. 4.

Double-bag all used equipment. Obtain a particulate respirator mask. Wear protective eyewear with side shields. Put on a sterile gown.

(3) Protective eyewear with side shields help prevent body fluids from entering the examiner’s eyes. The risk of splashing with body fluids when doing pelvic exams is high enough to warrant this added protection. 136. The nurse receives a needlestick with a contaminated needle following a client injection. What should the nurse do first? 1. 2. 3. 4.

Wash the exposed area with soap and warm water. Report the incident to the appropriate person. Receive a blood test to determine HIV status. Ask the client to consent to an HIV blood test.

(1) Washing the exposed area with soap and warm water can prevent the entry of microorganisms. The next step is to report the incident to the appropriate person. The infection control department records the event, takes a history, and does lab work. If possible, the client should have blood drawn for testing, but consent must be obtained.

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137. The client has a 6-inch laceration on his right forearm that develops signs and symptoms of an inflammatory response. Which of the following is part of the inflammatory process? 1. 2. 3. 4.

a decrease in the number of white blood cells a release of histamine that adds to the pain response blanching of the skin a decrease in temperature at the site of injury

(2) At the first stage of inflammation, constriction of the blood vessels occurs at the site of injury, lasting only a few moments. This initial constriction is rapidly followed by dilation of small blood vessels (occurring as a result of histamine released by the injured tissues), which causes more blood to flow to the injured area. This marked increase in blood supply is referred to as hyperemia and is responsible for characteristic signs of redness and heat. The following series of dynamic events is commonly referred to as the three stages of the inflammatory response: first stage—vascular and cellular responses, second stage—exudate production, third stage—reparative phase. 138. Which of the following clients is most at risk for infection? 1. 2. 3. 4.

a 29-year-old postpartum client a 42-year-old client with a recent uncomplicated appendectomy a 76-year-old client with a hip fracture an 18-year-old athlete with repair of torn knee ligaments

(3) The elder client is more likely to have a compromised immune system. All body systems undergo changes with aging: immune, integumentary, neuromuscular, sensory/perceptual, pulmonary, cardiovascular, gastrointestinal, and genitourinary. A degree of immobility can be expected after a hip fracture, which puts the client at risk for several complications, including infection. 139. The nurse employs surgical aseptic technique when: 1. 2. 3. 4.

placing soiled linen in moisture-resistant bags. inserting an intravenous catheter. disposing of syringes in puncture-proof containers. washing his or her hands before changing a dressing.

(2) Surgical asepsis or sterile technique refers to those practices that keep an area or object free of all microorganisms; it includes practices that destroy all microorganisms and spores. Surgical asepsis is used for all procedures involving sterile areas of the body. Sepsis is the spread of infection from its initial site to the bloodstream. Bacteria are the most common cause, but fungus, parasites, and mycobacteria can also cause sepsis. Immunocompromised clients are at higher risk. Sepsis, if not effectively treated, can be fatal. 140. Which of the following items of personal protective equipment can be reused by the same nurse during a single shift caring for a single client? 1. 2. 3. 4.

goggles gown surgical mask clean gloves

(1) Unless contaminated by material that has been splashed in the nurse’s face and cannot be effectively rinsed off, goggles can be worn repeatedly by the same nurse during a single shift. A gown should be used only once and then discarded. Surgical masks and gloves are never washed or reused.

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141. While donning sterile gloves (open method), the cuff of the first glove rolls under itself about one-fourth inch. The best action for the nurse is to: 1. 2. 3. 4.

remove the glove and start over with a new pair. wait until the second glove is in place and then unroll the cuff. ask a colleague to assist by unrolling the cuff. leave the cuff rolled under.

(4) It is not be necessary to unroll the edge of the cuff. The most important consideration is the sterility of the fingers and hand that are used to perform a sterile procedure. The rolled-under portion is now contaminated and should not be unrolled by the nurse because it then becomes contiguous with the sterile portion of the glove. 142. A client has an open abdominal incision that requires a dressing. The incision is dressed with gauze packing that is soaked in sterile saline and covered with a dry, sterile 4 × 4 gauze. When changing the dressing, the nurse accidentally drops the packing onto the client’s abdomen. The nurse should: 1. 2. 3. 4.

add more saline to the packing and insert it into the incision. throw the packing away, and prepare a new one. pick up the packing with sterile forceps, and gently place it into the incision. rinse the packing with sterile water, and put the packing into the incision with sterile gloves.

(2) Whenever the packing or dressing for a wound is contaminated in any way, a new one should be applied. Sterile technique should be used for dressing changes to prevent infection. 143. Medical asepsis is used when the nurse: 1. 2. 3. 4.

completes hand washing before care. prepares an intramuscular injection. changes a postoperative dressing. suctions a tracheostomy.

(1) Hand washing is essential before and after contact with a client. Studies show that hand washing is the most effective way of increasing safety and infection control with all clients and health care providers. 144. The nurse recognizes that special care must be taken in the handling of which of the following to prevent the transmission of hepatitis A? 1. 2. 3. 4.

blood feces vaginal secretions saliva

(2) Hepatitis A is an infectious disease transmitted through feces and can be prevented with good personal hygiene and sanitation. 145. While working with clients in the postoperative period, the nurse should be very alert to the results of laboratory tests. Which one of the following results is indicative of an infectious process? 1. 2. 3. 4.

iron 80g/100ml white blood cells (WBCs) 18,000/mm3 erythrocyte sedimentation rates (ESR) 15 mm/hr neutrophils 65%

(2) Even though all client laboratory tests are important, the most important test to indicate possible infection is WBCs, which has a normal range of 4,000—10,000/mm3. The body fights infection using WBCs or leukocytes.

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146. Which of the following conditions puts a client at the greatest risk for infection? 1. 2. 3. 4.

second-degree burn diabetes mellitus multiple sclerosis emphysema

(1) Injured skin tissue is a portal for infection. Depending on the degree and surface area affected by the burn, this is the greatest risk for infection. 147. The nurse is splashed in the face with blood when a chest drainage collection device breaks. What should the nurse do first? 1. 2. 3. 4.

Report to the infection control/employee health department. Go immediately to the Emergency Department. Flush the eye area copiously with water. Document an incident report.

(3) The first and most important action is to immediately flush the eye area copiously with water. Use soap and warm water for all other areas. Reporting to the Emergency Department is not necessary unless blood contaminates the eyes because first-aid washing should occur as soon as possible at the site of the occurrence. The occurrence should be documented to protect the client in case of future health problems. Reporting of the incident and further treatment are important follow-up steps. 148. The nurse is transporting a client on droplet isolation to the radiology department. Which of the following individuals must wear a mask? 1. 2. 3. 4.

the nurse only the client only the nurse and client during transport the client and radiology staff who receive the client

(2) Only the client need wear a mask. This form of isolation is used for clients known or suspected to have a serious illness transmitted by large respiratory particles (droplets). Illnesses such as strep pharyngitis, pneumonia, pneumonic plague, pertussis, and mumps are transmitted via droplets. 149. A client is on contact precautions. What personal protective equipment is needed for the client’s routine care? 1. 2. 3. 4.

gloves gloves, gown, mask gloves, gown gloves, gown, goggles

(3) Clients placed on contact precautions (or contact isolation) are known or suspected to have an infectious illness that is transmitted by direct contact with the client or an item that the client has touched or used. Many wound infections, viral illnesses, parasitic infections (such as lice), and infections of the GI tract (such as Clostridium difficile, Shigella, hepatitis A, and respiratory syncytial virus) are transmitted via direct contact with the client’s secretions or contact with an item that has been contaminated by the client’s secretions, such as droplets deposited on the side rail or bedside table. Unless a wound is being irrigated or items that could be splashed in the face are being handled, goggles are not necessary. Gloves and a gown should be sufficient for the protection of the nurse during routine care.

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150. The nurse’s hands are accidentally soiled with urine while assessing a client. What should the nurse do first? 1. 2. 3. 4.

Document the occurrence in the medical record. Wash his or her hands with warm, soapy water. Report to the infection control nurse immediately. Document an incident form for risk management.

(2) Copious flushing of the affected area is the first response to prevent transmission of infection. Reporting the incident and receiving further treatment are important follow-up steps. 151. Where should a nurse dispose of a needle or syringe that has been used? 1. 2. 3. 4.

in the client’s garbage in a red, hazardous material bag in a rigid sharps container in any convenient and safe waste container

(3) Preventing contaminated needlestick injuries and the transmission of blood-borne diseases are the aims of proper needle and syringe disposal. Rigid containers are mandated by OSHA to be mounted on the walls or otherwise available in clinical areas. Biohazard emblems designate their purpose. Other methods to prevent transmission such as needleless systems of syringes and the practice of not recapping needles should also be employed. Most needlesticks occur during improper recapping of needles. 152. Which of the following situations requires the nurse to don gloves? 1. 2. 3. 4.

taking the vital signs of a postoperative client giving a bed bath to a client who has had a myocardial infarction the presence of a small cuticle irritation on the nurse’s hand combing the hair of a client with a fulminating AIDS infection

(3) An open lesion on the nurse’s hand exposes clients to increased risk as well as allowing a portal for microbes to enter the nurse’s body. Taking vital signs postoperatively, giving a bed bath, and combing the hair of a client with AIDS generally do not require gloves except when blood or body fluids might be encountered. 153. Which of the following defines standard precautions? 1. 2. 3. 4.

precautions taken in all situations involving blood and body fluids control measures taken when a client is known to be infectious control measures taken any time a client is suspected of being infectious precautions taken when in direct contact with clients

(1) Standard precautions are taken in all situations with all clients and involve all body secretions except sweat. Standard precautions are designed to reduce the rate of transmission of microbes from one host to another, or one source (for example, a client’s bedside table) to another. Clients with varicella or tuberculosis infections are infectious to others by air-sharing, in addition to blood and body fluids exposure. Although standard precautions are taken for all clients, one known to have a specific illness transmitted by a specific route warrants additional steps to avoid risk to others. 154. Which of the following situations require the nurse to don gloves? 1. 2. 3. 4.

taking a tympanic temperature on a postoperative client giving a subcutaneous injection to a client on Heparin assessing the heart rate of a client with tuberculosis assisting a client to the bedside commode

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(2) Gloves are required, per standard precautions, when the possibility of coming in contact with body fluids exists, whether blood is readily seen or not. The two most likely scenarios for exposure to blood would be the administration of an injection and assisting someone with toileting, with the injection posing the greater likelihood for contact with blood and/or body fluids. 155. The nurse is splashed on the forearm by blood during open chest massage. What should the nurse do first? 1. 2. 3. 4.

Report to the infection control/employee health department. Cleanse the forearm with antiseptic gel solution and dry thoroughly. Flush the forearm area copiously with soap and water. Receive a tetanus booster.

(3) Immediately flushing the contaminated area copiously with soap and water is the first response to being exposed to a biohazard such as blood. While Choice 1 is reasonable, physical safety is the first priority, followed by reporting and documenting. A tetanus booster is not indicated in this scenario. 156. A portal of entry for communicable diseases is: 1. 2. 3. 4.

a vector. a source, like contaminated water. food. the respiratory system.

(4) The path by which a microorganism enters the body is the portal of entry; here, the respiratory system. A vector is a carrier of disease. A source, like contaminated water or food, can be a reservoir of disease. 157. Which of the following microorganisms is considered normal body flora? 1. 2. 3. 4.

staphylococcus on the skin streptococcus in the nares candida albicans in the vagina pseudomonas in the blood

(1) Of the choices given, only staphylococcus is considered normal body flora. 158. Active or primary tuberculosis is spread mostly by what means? 1. 2. 3. 4.

blood droplets airborne contact

(3) The tubercle bacillus is primarily spread by “sharing air” with the infected person, or human-to-human contact. Bovine-to-human transmission via infected cow’s milk is less likely, but also possible. 159. Which type of hepatitis does not produce a carrier state after its acute phase? 1. 2. 3. 4.

A B C D

(1) Hepatitis A does not produce a carrier state. It is transmitted via contaminated water or food via the oral-fecal route and is not blood borne.

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160. Which of the following is associated with acute glomerulonephritis? 1. 2. 3. 4.

a recent case of impetigo a coexisting sore throat a chronic cough dysuria

(1) A recent strep infection, within the past few weeks, is associated with the development of post-streptococcal glomerulonephritis. Acute pharyngitis symptoms are not typical, and cough and dysuria are not associated with glomerulonephritis. The hallmark signs of the disease are proteinuria, hematuria, edema, itching, and decreased urine output. 161. Another name for erythema infectiosum is: 1. 2. 3. 4.

Kawasaki disease. Rheumatic disease. Lupus erythematosus. Fifth disease.

(4) Fifth disease is another name for erythema infectiosum, a mild viral illness that causes a rash (including the classic sign of a “slapped-face” appearance). A low-grade fever, general malaise, and a “cold” might be evident before the rash appears. The illness usually resolves in 7–10 days. The causative agent is Parvovirus B19. Fifth disease is contagious and typically found in children, but adults can also contract the disease. 162. Which of the following statements about erythema infectiosum is correct? 1. 2. 3. 4.

There is no rash. The disorder is uncommon in adults. There is no fever. There is occasionally a “slapped-face” appearance.

(2) Fifth disease, erythema infectiosum, is uncommon in adults. All the other statements are incorrect. 163. Which of the following precautions should be used with secretions and blood? 1. 2. 3. 4.

respiratory standard contact isolation droplet

(2) Standard precautions are followed in all situations with all clients and involve all body secretions except sweat. They are basic protective procedures to minimize risk of infectious disease transmission and are designed to reduce the rate of cross infection from one host to another or from one source (such as a client’s bedside table) to another. 164. Which precautions should be followed for outbreaks of diphtheria, pneumonia, rubeola, rubella, and pertussis? 1. 2. 3. 4.

standard airborne droplet contact

(2) These illnesses are caused by small particles that can be transferred by sharing air with other humans who are infected. Airborne or respiratory precautions should be taken, which means a specially designed facemask with a filter should be worn. If secretions are copious, contact and droplet precautions may be necessary. Standard precautions are taken for all situations with all clients.

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165. An elderly client admitted for acute confusion receives RPR (rapid plasma regain) and treponema pallidum studies. Correlated with the client’s altered mental state, positive findings demonstrate an etiology of which infectious process? 1. 2. 3. 4.

Neurosyphilis Community-acquired pneumonia Streptococcal meningitis Staphylococcus septicemia

(1) Clients with neurosyphilis, secondary and tertiary, might present with altered mental findings. The causative organism of syphilis is treponema pallidum, a spirochete. Testing for syphilis begins with RPR or VDRL (Venereal Disease Research Laboratory ) studies and, if a positive result is confirmed, by treponema pallidum testing. Community acquired pneumonia is diagnosed by XR and history. Streptococcal meningitis is confirmed by lumbar spinal fluid culture, and staphylococcus septicemia by serum blood culture. 166. Which medication is the drug of choice for chlamydia? 1. 2. 3. 4.

Ceftrioxone Metronidazole Amoxicillin Azithromycin

(4) Azithromycin or doxycycline should be used to treat the sexually transmitted disease chlamydia. Ceftrioxone, a cephalosporin, is not active against chlamydia nor is the antifungal Metronidazole. Amoxicillin is resistant to most gram-negative infections. 167. Which medication is the drug of choice for strep pharyngitis? 1. 2. 3. 4.

Penicillin Tetracycline Metronidazole Acyclovir

(1) Penicillin is the drug of choice for most strep pharyngitis. Tetracycline is not active against most strep infections, and Acyclovir is an antiviral drug. Metronidazole is an antifungal. 168. Which medication is the drug of choice for methicillin-resistant staphylococcus aureus? 1. 2. 3. 4.

Aqueous Penicillin intravenously Mefoxin intramuscularly Vancomycin intravenously Rocephin intravenously

(3) Vancomycin is an antibiotic that is reserved for serious infections and used only when necessary for conditions such as methicillin-resistant and Clostridium difficile infections. It is a beta lactam antibiotic that inhibits cell wall synthesis in susceptible bacteria and is active against gram positive bacteria resistant to methicillin. It is the drug of choice for methicillin-resistant pathogens and is given only by the intravenous route. 169. Generally, which of the following disinfectants is used by the nurse for routine hand asepsis? 1. 2. 3. 4.

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(1) The Centers for Disease Control and Prevention (CDC) and Joint Commission on Accreditation of Healthcare Organizations (Joint Commission (JCAHO) recommend alcohol-based hand gels for routine hand hygiene for health care workers, including nurses. Betadine and BAC are too caustic to the skin for routine use, and soap and water is sometimes inconvenient (which might prevent adherence to hand-washing policies). 170. The nurse is changing the abdominal dressing of a client who is two-days post-op following a bowel obstruction. If the nurse’s hands are not visibly soiled after a dressing change, what method of hand washing is appropriate? 1. 2. 3. 4.

household bleach in a 1:4 solution an alcohol-based gel soap and water a hexachlorophil-based cleansing solution

(3) Soap and water are appropriate after a dressing change because blood and body fluids might be present even if they are not visible. A thorough hand washing with warm water and soap is appropriate after removing gloves following a dressing change. 171. A client has been ordered the drug of choice for the treatment of trichomoniasis. The nurse should review the client’s history to ensure that the client is not allergic to which antibiotic? 1. 2. 3. 4.

Ciprofloxacin Augmentin Tetracycline Metronidazole

(4) Metronidazole, an antifungal, is the drug of choice for the sexually transmitted disease trichomoniasis. 172. Which of the following instructions should be given to clients regarding the administration of tetracycline for a skin infection? 1. 2. 3. 4.

The medicine must not be mixed with food. Take the medicine with a large glass of milk. Take the medicine on an empty stomach. Take the medicine with 8 oz of grapefruit juice.

(3) To aid absorption from the GI tract, tetracycline should be taken on an empty stomach. Milk products induce chelation if mixed with tetracycline, and grapefruit juice initiates the CYP 450 system in the liver. 173. Which administration measure should be taught to a client receiving griseofulvin to increase absorption of the drug? 1. 2. 3. 4.

The medication should be taken with food, preferably fatty foods. Do not take the medicine with a large glass of grapefruit juice. Take the medicine only on an empty stomach. Take the medicine with 8 oz of water.

(1) High-fat-content foods enhance the absorption of the antifungal griseofulvin. Griseofulvin is the drug of choice for fungal-related dermatophytosis of the scalp, especially in children according to 2005 Current Pediatric Diagnosis and Treatment. Topical agents do not penetrate hair tissue and are not effective in hair/scalp-affected areas. Grapefruit juice is a poor choice of liquid for the ingestion of most medications secondary to the activation of the CYP 450 system and particularly ineffective with a medication like griseofulvin. Water is a poor choice, also. The drug’s absorption is enhanced by fatty foods, particularly milk and ice cream.

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174. Which of the following medication regimens should the nurse anticipate for a client who has been newly diagnosed with tuberculosis and is beginning antibiotics? 1. 2. 3. 4.

A single drug (monotherapy) is common if the infection is mild. Because the mycobacterium grows slowly, the duration of treatment is 9–18 months. Medication includes the use of three antiviral agents (such as AZT, Saquinivir, and Ritonavir). Typically, the medication regimen includes a combination of three to four drugs (such as Isoniazid, Rifampin, Pyrazinamide, and Ethambutol).

(4) Treatment of tuberculosis is usually a multidrug therapy (typically soniazid, ifampin, Pyrazinamide, and thambutol in a three-or-four drug multimodal therapy). Treatment usually lasts 6 months if the client is not drug resistant and can last up to 24 months if the client is drug resistant. 175. A school-age child is diagnosed with impetigo. The nurse should recommend: 1. 2. 3. 4.

frequent salt-water gargles. a diet high in fatty foods. contact isolation. use of eye protection.

(3) Impetigo is spread by direct contact with secretions from lesions. Teaching such topics as skin care, frequent hand washing, and early quarantine is indicated for the family of a child with an impetigo skin infection. Bacterial pharyngitis if comorbid, may warrant warm salt water gargles for comfort, and increased fluids, but there would be no indication for a high fat diet or use of eye protection. Some infections, including strep, can present with bacterial infections and/or secondary eye infections. 176. Under normal circumstances, the following activities are required whenever a client requires restraint. In an emergency situation, which activity can be completed after the client is secured? 1. 2. 3. 4.

Obtain a physician’s order for restraints. Remove personal articles that the client can use to harm staff. Continuously assess the client’s level of dangerousness. Have adequate staff available to prevent client and staff injury.

(1) Rarely would a physician refuse to write this order after the fact. Such an order also can be included as part of a facility’s protocol for care of potentially violent clients. Unless Choices 2, 3, and 4 are carried out, the staff or the client might be at a greater risk of injury. 177. A hospitalized 65-year-old client has shortness of breath and is on seizure precautions. He is able to ambulate without help, but becomes disoriented at times and tries to get out of bed. What is the most appropriate safety measure for this client? 1. 2. 3. 4.

Restrain the client in his bed. Ask a family member to stay with the client. Check the client every 15 minutes. Use a bed exit-monitoring safety device.

(4) An intervention that allows the client to feel independent and alerts the nursing staff if the client gets up is the best choice for both safety and self-esteem. Choice 1 causes loss of independence. Choice 2 might provide safety, but the responsibility is still with the nursing staff. Choice 3 is unrealistic; nursing staff is unable to check on a client every 15 minutes.

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178. When selecting a restraint, all the following factors are important except: 1. 2. 3. 4.

the restraint is being used for the proper purpose. the restraint does not interfere with the client’s treatment. the restraint is applied safely. family visitors can easily see the restraint.

(4) If possible, restraints should be concealed to prevent the client or the client’s family and visitors from being embarrassed. Choices 1, 2, and 3 are important factors when selecting a restraint. 179. Restraints are used as: 1. 2. 3. 4.

protective devices. relaxation devices. holistic devices. injury devices.

(1) Restraints are protective devices used to limit physical activity of the client or a part of the client’s body. The nurse must understand the purpose of the restraint. A client’s needs and safety are the top priority. 180. Which of the following is an appropriate reason to restrain a client? 1. 2. 3. 4.

A client requests restraint. A client’s family requests restraint. A client poses a danger to self or others. A client requests restraint for his or her roommate.

(3) Clients are restrained for their own protection when they pose a danger to themselves or others. The restraint must be the least-restrictive option possible to provide safety. A physician must order a restraint. Documentation from nursing and physical therapy must support the choice of a restraint, and the family must be notified. 181. The nurse can try all the following methods before applying restraints except: 1. 2. 3. 4.

placing unstable clients in an area that is constantly or closely supervised. lowering all medication dosages so that the client is more stable. wedging pillows or pads against the sides of the client’s wheelchair and bed to keep him or her well positioned. positioning beds at their lowest level to facilitate entry and exit.

(2) Only the physician can order or change medication orders. 182. Which organization publishes standards for the use of restraints? 1. 2. 3. 4.

County Health Department U.S. Centers for Medicare & Medicaid Services (CMS) National Drug and Alcohol Centers American Nurses’ Association

(2) The CMS published revised standards for use of restraints in the United States in 2001. These standards apply to all health care organizations and specify two standards for applying restraints: the Behavior Management Standard and the Acute Medical/Surgical Care Standard.

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183. What time frame must the physician or nurse practitioner use with the Behavior Management Standard for restraint use? 1. 2. 3. 4.

A written restraint order for an adult, following evaluation, is valid for four hours. A written restraint order is valid for only two hours. The nurse can make the decision based on the individual client. A written restraint order has no time element and can be applied as the nurse deems necessary.

(1) A telephoned restraint order for an adult, following evaluation, is valid for only four hours. Visual and audio monitoring of the client’s status must be performed. A PRN order for restraints is prohibited. 184. Within what time frame must the physician or nurse practitioner write a restraint order to be in compliance with the Acute Medical/Surgical Care Standard for restraint use? 1. 2. 3. 4.

A written restraint order is valid for only four hours. A written restraint order must be obtained within 12 hours. The nurse can make the decision based on the individual client. A written request order for restraints has no time element and is whenever the nurse wants, without notification.

(2) The Acute Medical/Surgical Care Standard permits up to 12 hours of restraint before obtaining the physician’s written order for restraint. All orders must be renewed daily. PRN restraining orders are prohibited. 185. When using restraints, the nurse must: 1. 2. 3. 4.

call a nurse tech to sit with the client. ensure safety and infection control. ensure client safety and document appropriately. ensure that a visitor or relative is with the client all the time.

(3) Safety of the client is the first priority when using restraints. The nurse must document reasons for using restraints, the type of restraints, duration of restraint, and other pertinent information. 186. Restrained clients often display _________ behavior. 1. 2. 3. 4.

restless and anxious quiet and controlled comfortable and restful obedient and calm

(1) Restrained clients often become restless and anxious as a result of being restrained. Nurses must document that the need for the restraint was made clear both to the client and support persons. 187. What are restraints? 1. 2. 3. 4.

devices used to bind the body protective devices to limit physical activity mobility devices that have straps confinement devices for a bed

(2) Restraints are protective devices used to limit the physical activity of the client or a part of the client’s body.

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188. What are the classifications of restraints? 1. 2. 3. 4.

behavioral and medical/surgical behavioral and safety environmental and medical physical and chemical

(4) The classifications of restraints are physical and chemical. Physical restraints include any manual, physical, or mechanical device, material, or equipment attached to the client’s body that cannot be removed easily and that restricts the client’s movement. Seclusion is a form of physical restraint. Chemical restraints include medications such as neuroleptics, anxiolytics, sedatives, and psychotropic agents used to control socially disruptive behavior. The purpose of restraints is to prevent clients from injuring themselves or others. 189. Examples of environmental restraints are: 1. 2. 3. 4.

temperature control. pollen control. barriers. dust control.

(3) Environmental restraints are barriers (such as walls, pieces of furniture, or large plants) to keep clients from wandering beyond appropriate areas. 190. Assessment of medical/surgical care clients with restraints should include all the following except: 1. 2. 3. 4.

skin and circulation. client response. range of motion. number of restraints.

(4) Assessment of medical/surgical care clients with restraints must include: when the restraints are removed or applied, skin condition and circulation, toileting, food and fluids, range of motion, repositioning, client response, effect, and continued need. 191. Types of adult restraint include all the following except: 1. 2. 3. 4.

jacket restraints. belt restraints. straight-jacket body restraints. mitt, hand, or limb restraints.

(3) The most common physical restraints for adults include jacket, belt, mitt, or hand and limb restraints. 192. Which of the following statements are true about the use of physical restraints? 1. 2. 3. 4.

An order for a restraint can be implemented until it is no longer required by the client. Restraints can be ordered on a when-necessary basis. No order or consent is necessary for restraints in long-term care facilities. Restraints must be periodically removed to perform range-of-motion activities and repositioning.

(4) One condition of restraints is that the client must be monitored every 30 minutes, and physical restraints must be removed every 2 hours. Because restraints restrict a client’s basic freedom to move, careful assessment and accurate, complete documentation are essential. The client needs to have full range of motion and body movement.

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193. A confused 78-year-old client who has fallen three times in the past month is admitted to the hospital with a fractured hip. The priority nursing diagnosis for this client is: 1. 2. 3. 4.

Impaired Home Maintenance Management (related to falls). Anxiety (related to possible outcomes and hospitalization). Safety (related to secure restraints while hospitalized). Trauma (related to fall and confusion).

(4) Nursing diagnoses related to falls and confusion are based on the concept that falls can break bones and self-confidence, leading to fear of falling and causing a decrease in activity level and muscle strength. All these factors increase the risk of falling again. Nursing management includes those interventions that involve the client (elderly) for promotion of mobility and prevention of disability that is permanent. Education and teaching are key to home care and must be a part of the plan of care. 194. Which of the following statements is not true about the use of restraints within a health care facility? 1. 2. 3. 4.

Using restraints for confused clients usually leads to fewer falls. In some situations, restraints are the only solution. Suffocation is a danger when restraints are used. Pressure ulcers and fractures have been associated with the use of restraints.

(1) Studies suggest that use of restraints actually leads to more injuries. To prevent client injury, the nurse’s role is protective and educative, and desired outcomes reflect the client’s acquisition of knowledge of hazards when possible. Incorporating safety practices and learning skills to perform in the event of certain emergencies are desired outcomes. The nurse needs to individualize these outcomes for clients depending on their cognitive ability and their environment, among other variables. 195. The nurse removes the vest restraint of an 84-year-old female client after two hours. While the client is free of the restraint, the nurse plans to: 1. 2. 3. 4.

keep the restraint tied to the bed rails. feed the client a snack or fruit juice. discuss why the restraint is necessary. encourage the client to exercise.

(4) The nurse needs to encourage the client to exercise, perform range-of-motion activities, and reposition herself in bed. This should take place every two hours while restraints are in use. In addition, the client must be checked every 30 minutes. 196. The nurse is working in a rehabilitation center where several of the clients are restrained. The nurse suggests to the employees that an alternative to a vest restraint is: 1. 2. 3. 4.

maintaining the client’s bed in a high position. providing cool beverages close to the client’s bed. reducing pain medication administration. using a cushioned soft-restraint product or pillows wedged against the side of the client’s chair.

(4) There are a number of alternatives that must be tried before initiating the use of chemical or physical restraints. They include (1) assigning nurses in pairs so that one nurse can observe the client when the other leaves the unit; (2) placing unstable clients in an area that is constantly or closely supervised; (3) preparing clients before a move to limit relocation shock and resultant confusion; (4) staying with clients, using a bedside commode or bathroom, if a client is confused, sedated, has a gait disturbance, or has a high risk score for falling; (5) monitoring all the client’s medications and, if possible, work with the attending physician to attempt to lower or eliminate dosages of sedatives or psychotropics; (6) positioning beds at their lowest level to facilitate entry and exit; (7) replacing full-length side rails with half- or three-quarter-length rails to prevent confused clients from climbing over rails or falling from the end of the bed; (8) using rocking chairs to help confused clients expend some of their energy so that they are less inclined to wander; (9) placing a removable lap tray on a wheelchair to provide support and help keep clients in place; (10) trying a warm beverage, soft lights, a back rub, or a walk to quiet agitated clients; (11) using environmental restraints, such as pieces of furniture

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or large plants as barriers, to keep clients from wandering beyond appropriate areas; (12) placing a picture or other personal item on the door to clients’ rooms to help them identify their room; (13) trying to determine the causes of the client’s sundowner syndrome (nocturnal wandering and disorientation as darkness falls, associated with dementia), possible causes include poor hearing, poor eyesight or pain; (14) establishing ongoing assessment to monitor changes in physical and cognitive functional abilities and risk factors. 197. Which of the following instructions should be given to parents about the use of restraints for children? 1. 2. 3. 4.

Elbow restraints are used to prevent small children from scratching a skin lesion. Restraints are used for discipline reasons. Restraints for children are always used in a hospital setting. Restraints are used to prevent all accidents.

(1) Nurses need to be aware of what constitutes a safe environment for specific children, whether in a facility (hospital), community, or home. Hazards to safety occur at all ages and vary according to the age and development of the individual. Nurses, using the Nursing Process, plan to meet the safety needs of clients, considering physical factors in the environment and the psychological state of the individual. Education of the family and child is a major protection strategy. Restraints should not be used as a disciplinary measure and are not always used. 198. Mary Jones, a 70-year-old woman, lives alone. She has impaired mobility due to a car accident and has vision problems. Her diet does not meet recommended daily allowances. Which factor places elder adults at the highest risk for falls in their home? 1. 2. 3. 4.

intact stairs with treads throw rugs on tile floors a night light in the hallway grab bars in the bathroom

(2) People can fall at any age, but elder adults are particularly prone to falling and incurring serious injury. Most falls occur in the home and are a major threat to the independence of elder adults. Weak leg muscles, weak knees, poor balance, and loss of flexibility contribute to falls in the elderly. 199. The nurse caring for Gertrude Smith is considering using restraints because Ms. Smith tries to get out of bed frequently and has fallen. Which type of restraint should the nurse consider using? 1. 2. 3. 4.

vest restraint jacket belt restraint mitt restraint limb restraint

(1) The vest restraint jackets have straps (tails) that can be tied to a bed frame under the mattress. These body restraints are used to attempt to ensure the safety of a client in bed. 200. Restraints can increase the risk of all the following outcomes except: 1. 2. 3. 4.

complications related to immobility contractures and pressure sores death infection

(4) The risk of injury increases when restraints are applied because restraints tend to increase agitation and combative behavior. Serious injuries and death have been attributed to restraints. Restraints increase risk for complications related to immobility such as pressure ulcers, contractures, and generalized weakness.

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201. Some caregivers have misperceptions about restraints. All of the following are misperceptions except: 1. 2. 3. 4.

failure to restrain clients puts the caregiver and institution at risk for legal liability. restraints increase the risks of infection and surgery. elder clients are generally compliant when restraints are used. restraints are necessary because of inadequate staffing.

(2) Nurse researchers have identified erroneous beliefs that many caregivers hold about restraints. Because of beliefs like the examples in Choices 1, 3, and 4, nurses have often applied restraints without considering other alternatives. However, agencies initiating alternatives to restraints have found that the new approaches result in a decline in the number of falls, injuries, and aggressive or violent behavior, and that social interaction, participation in activities, and nutritional intake improve. 202. The Omnibus Budget Reconciliation Act of 1987 (OBRA), effective October 1990, includes federal legislation concerning restraints. All the following statements about OBRA are true except: 1. 2. 3. 4.

It mandates conditions under which restraints must be used. It insures the right of all residents of nursing home facilities to be free from physical or pharmacologic restraints, unless required for a specified treatment. It guarantees the right to refuse restraint. It states that nursing homes are liable for using restraints for staff convenience or in place of surveillance.

(1) Rather than mandate conditions under which restraints must be used, OBRA ensures the right of all residents of nursing home facilities to be free from physical or pharmacologic restraints unless they represent a specific treatment for a diagnosed condition. It also guarantees the right to refuse to be restrained. Under this law, nursing homes can be found liable for using restraints for staff convenience or in place of surveillance. Statutes in many states set similar standards for the use of restraints in acute care facilities. 203. Home adaptations of restraints include all the following except: 1. 2. 3. 4.

upper and lower side rails for beds. high locks or alarms on doors. covering tubing with towels. flashlights for clients to wear.

(4) Family members can place bells on interior gates, high locks or alarms on exterior doors, and alarms and locks on gates surrounding their homes to alert them to the whereabouts of a client with diminished mental capacity. Fastening ties to a lap robe might appear less confining to clients and their families while maintaining confused clients securely in a chair. A mitten with the thumb sewn closed might sufficiently reduce manual dexterity to prevent removal of tubing. Covering tubing with towels or strategic placement of a pillow might deter some clients. The use of upper and lower side rails must be evaluated for their potential to increase risk of injury if a client climbs over the rail. Introducing side rails as an aid for turning and positioning clients in bed might overcome initial resistance to them. To alert family members that a client is in danger of falling because he or she is attempting to get out of bed unassisted, a string of bells can be fastened to the lower portion of the top cover. Baby monitors and closed-circuit TV are other methods to detect movement and sounds, thereby enabling caregivers to respond promptly. 204. Family members have a variety of negative reactions to the restraint of their relatives in acute care settings. Which of the following reactions would constitute this type of reaction? 1. 2. 3. 4.

“She didn’t do anything, and she’s tied up.” “My mother is pleased with the restraint because it feels secure.” “Restraints are a good thing for elderly people.” “Collaboration concerning restraints is always excellent at this facility.”

(1) Family members of clients being restrained in acute care settings had a variety of negative reactions to this intervention. The authors give examples of family members’ statements like the following: “She didn’t do anything, and she’s tied up.” “It made me mad. They just walked in, put on the restraint and never said a word.” “She didn’t need to be restrained. She couldn’t move her right arm and used her left hand to position her right arm.” “My mother started to cry when they tied her wrist.”

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Health Promotion and Maintenance This chapter contains questions and answers from the following topic areas: ■ ■ ■ ■ ■ ■ ■

Aging Process Ante/Intra/Postpartum and Newborn Care Data Collection Techniques Developmental Stages and Transitions Disease Prevention Expected Body Image Changes Family Interaction Patterns

■ ■ ■ ■ ■ ■ ■

Family Planning Health Promotion/Screening Programs High Risk Behaviors Human Sexuality Immunizations Lifestyle Choices Self-Care

1. When teaching a group of clients whose ages span the life span, which of the following clients should a nurse expect to process information the fastest? 1. 2. 3. 4.

an 11-year-old child a 45-year-old adult a 70-year-old elder an 85-year-old elder

(2) Clients in young-to-middle adulthood process information almost two times as fast as children or the elderly. Children and the elderly process information at the same rate. 2. Which of the following strategies is the most successful for a nurse to utilize when planning a teaching session for elder clients? 1. 2. 3. 4.

Quickly move through the content. Use words that the clients are familiar with. Give the clients a list of important terms. Evaluate the clients by asking them to recall information.

(2) Elder clients do well in situations that utilize familiar words and surroundings. They do poorly when difficult vocabulary is used. Elders do best when they are given time to absorb the information and are not rushed. Rather than giving elders lists of details or terms they should remember, assist them to learn the main points. Evaluation of elder learning is best obtained by using recognition tests, not recall tests. 3. A nurse is planning to utilize reminiscence with an elder client. The nurse’s role in this intervention is to: 1. 2. 3. 4.

remind clients when they repeat themselves. focus on the happy memories, not the sad ones. probe for details of shared memories. use themes or props to stimulate discussion.

(4) Themes or props can be used to stimulate discussion during reminiscence therapy. This can be particularly helpful in group settings. Elder clients should be allowed to repeat themselves during the discussion and not have attention drawn to the repetition. During the process of reminiscence, both sad and happy memories are shared. The sharing of both should be encouraged. The nurse should avoid probing or pushing for details. The elder should be allowed to share informally and spontaneously.

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4. All the following statements, when made by an elder client, indicate successful achievement of ego integrity except: 1. 2. 3. 4.

“I think I’ll volunteer at the library a couple days a week.” “I wish I could change some of the things I’ve done.” “I think I’ll take a ceramics class at the senior center.” “I would like to help people learn to read.”

(2) Ego integrity versus despair is the final stage of Erikson’s psychosocial development. An indication of despair or self-disgust is manifested by the elder believing life has been too short and futile or that the elder wants a chance to redo life. Statement 2 is consistent with despair. Signs of ego integrity are manifested by statements or tasks that bring together all the previous phases of the life cycle. Manifestations of successful ego-integrity mastery include activities such as volunteering at the library (the elder believes he or she still has something to offer), continued learning (those in ego integrity remain creative), and assisting others (helping people learn to read contributes to society). 5. When caring for a dying elder, a nurse should recognize which of the following behaviors as regression? 1. 2. 3. 4.

acceptance denial and projection abstract thinking full use of speech

(2) Dying elders might resist emotional involvement in their care and planning. Their behavior might regress. A clear behavioral sign of regression is denial and projection. Acceptance is not a sign of regression. Rather than being able to think abstractly, dying elders in regression are preoccupied with minutiae and have decreased ability to even engage in simple abstractions. Speech patterns in a dying elder that are consistent with regression include misuse of words, misinterpretations, and utilization of fragments of speech. 6. Which of the following statements, when made by an elder client, should indicate successful aging to a nurse? 1. 2. 3. 4.

“I have so many regrets about my life.” “I don’t know how I’m going to make it financially.” “I’m going to go fishing and have a good time.” “I haven’t talked to my kids in over two months.”

(3) One of the characteristics of successful aging is having a high degree of satisfaction with life. That is evidenced in part by elders being able to relax and enjoy their interests. Expressing regret about how they have lived their life is an indication of dissatisfaction with their life and does not indicate successful aging. Another characteristic of successful aging is having established financial security. If the elder, as in statement 2, is financially insecure, he or she has not attained successful aging. Maintenance of a meaningful social system is another characteristic of successful aging. This includes maintaining involvement with family and friends. Two months is a long time for an elder to go without contact with family and might indicate unsuccessful aging. 7. When teaching the adult children of an elder how to address the elder’s hoarding behavior, what information should a nurse give the children? 1. 2. 3. 4.

“Remind your mother when you see her to throw away what she doesn’t need.” “Send your mother somewhere for a day and go through her belongings to discard what she doesn’t need.” “Set firm limits on what can be kept in the refrigerator.” “Tell your mother that you are going to give her belongings to charity.”

(3) Firm limits should be set when it comes to health issues such as keeping food too long or storing it improperly. The elder could become ill. The same limits apply to insuring clear pathways for walking to avoid falls. Nagging (constant reminding) or arguing about what should be thrown away does not help the elder and might increase the behavior. Belongings should never be discarded without the elder’s consent or participation, unless dementia is present. Allow

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them to reminisce about the meaning of their collections. Statement 4 is wrong because elders should not be told which belongings to keep or to whom to give their belongings. They should be allowed to participate in these decisions. 8. When performing a physical assessment on an elder adult, which of the following clinical manifestations should a nurse relate to aging? 1. 2. 3. 4.

decreased capacity to inhale, hold, and exhale breath increased cough reflex respiratory movement impaired by lordosis decreased inflation of the lungs

(1) The vital capacity of the lungs at 85 years of age is 50 to 65 percent that of someone who is 30 years of age. This is evidenced by a decrease in the elder’s capacity to inhale, hold his breath, and exhale. The cough reflex is decreased in the elderly, and the sensitivity to stimuli that cause a cough is decreased. Respiratory movements in the elderly are impaired by kyphosis, not lordosis. The kyphosis is caused by calcification of the vertebral cartilage and stiffens the chest wall, impairing respiratory movement. Lungs in the elderly have lost elasticity and remain hyperinflated even after exhalation. 9. All the following nursing strategies are successful when caring for an elder who has experienced tactile losses except: 1. 2. 3. 4.

encouraging the use of hot water bottles or heating pads. providing assistive devices such as canes and walkers. frequently changing the elder’s position if he or she is bedridden or wheelchair bound. using firm, gentle pressure when touching the elder.

(1) Tactile losses in the elderly mean that they need to be very careful when using heating pads, hot water bottles, or ice packs. They might not be able to determine when they are being burned or frostbitten. Use of these devices should be discouraged. Assistive devices such as canes and walkers might help the elderly maintain their balance and walk more safely. They should also walk more slowly so that they have careful placement of their feet and fully touch the surface before taking the next step. Frequent position changes help avoid decubitous ulcers and are especially important for the bedridden or wheelchair bound. If tactile sensation is decreased, it takes firm, gentle pressure by the nurse to allow the elder to sense the nurse’s presence. 10. The care plan for an elder client who has papillary and lens changes should include which of these measures? 1. 2. 3. 4.

using direct light for visual work working on white surfaces wearing tinted glasses driving when the sun is shining

(3) Because of the papillary and lens changes associated with aging, the elder has a decreased tolerance to glare or light changes. Wearing tinted glasses or a brimmed hat can reduce the glare or bright light that interferes with an elder’s ability to see. Indirect lighting should be used for visual work because it allows for better perception of stimuli. White or glossy surfaces should be avoided because of decreased perception of stimuli. Encourage the elder to use color contrast for work areas. Caution should be used when the elder is driving. Driving in bright sunlight or at night can be problematic and requires additional safety considerations. If elders must drive in the sun, the use of sunglasses is important. 11. A nurse should plan to teach an elderly client which of the following strategies to care for his or her skin? 1. 2. 3. 4.

Bathe with hot water. Avoid emollients and lotions. Avoid use of cosmetics. Drink adequate water.

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(4) As aging occurs, the number of sweat glands is reduced, which interferes with the ability to sweat and regulate body temperature. The elder client also has decreased ability to retain fluids, causing the skin to become drier and less flexible. The elder should drink adequate water to ensure thermoregulation and hydration of the skin. This helps prevent other complications resulting from aging skin. Elder clients should avoid hot water when bathing and the use of excessive soap. Because pain sensation is decreased, the elder can easily be burned with hot water. Excessive soap dries the skin even more, and this is already a problem of aging skin. Cosmetics can assist the elder with body image changes associated with aging and with restoring some lost color. Their use should not be discouraged. 12. All these generalized physiologic changes are associated with aging except: 1. 2. 3. 4.

stable reserve functional capacity. decreased rate of cell mitosis. deterioration of specialized nondividing cells. increased rigidity and loss of elasticity in connective tissue.

(1) The reserve functional capacity lessens with age. This phenomenon refers to the ability of the body to increase its usual effort when stressed. Choices 2, 3, and 4 are all physiologic changes associated with aging. 13. A nurse should recognize that all the following physical changes of the head and face are associated with aging clients except: 1. 2. 3. 4.

pronounced wrinkles on the face. decreased size of the nose and ears. increased growth of facial hair. neck wrinkles.

(2) The nose and ears of aging clients actually become longer and broader. The chin line is also altered. Wrinkles on the face become more pronounced and tend to take on the general mood of the client over the years: for example, laugh or frown wrinkles about the eyebrows, lips, cheeks, and outer edges of the eye orbit. The change in the androgen-estrogen ratio causes an increase in the growth of facial hair in most elder adults. The aging process shortens the platysma muscle, which contributes to neck wrinkles. 14. An elder client complains to a nurse that he is having more difficulty seeing colors. To assist the client in seeing colors better, the nurse should suggest increased use of which of the following colors? 1. 2. 3. 4.

blue green yellow red

(4) Brighter colors help compensate for the decrease of color discrimination associated with aging, such as yellowing and opacity of the lens. The first color to be affected is blue, followed by green, and then yellow. Red has longer wavelengths and is the last color to be affected by the aging process. 15. The medical record of an elder client reveals presbycusis. Which of these history findings should a nurse expect to identify? 1. 2. 3. 4.

history of a bacterial brain infection prolonged exposure to loud noise inability to distinguish which direction sounds are coming from history of a head injury

(3) Presbycusis is the most common cause of hearing loss in the elderly. It is characterized by progressive hearing loss and sound discrimination. The inability to distinguish which direction a sound comes from is expected with this type of hearing loss. Other manifestations include difficulty hearing consonants such as s, sh, ch, th, dg, z and f; difficulty

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hearing high frequencies; and difficulty hearing people who speak rapidly. Sensorineural deafness is characterized by the findings listed in Choices 1, 2, and 4. 16. The teaching plan for an elderly client with decreased taste and smell sensation includes all the following except: 1. 2. 3. 4.

adding more spices and herbs to food. ensuring that smoke detectors are in working order. adding salt and sugar to food as needed. maintaining an adequate diet.

(3) As people age, they experience an increased desire for spicy foods, salt, and sugar. This can be attributed to the decreased number of taste buds, slower processing of taste perception in the central nervous system, and diminished salivation. Adding more spices and herbs to food can help compensate for these losses and help elders to enjoy their food more. Adding salt and sugar to food should be avoided, as many elders have medical problems like diabetes and hypertension. A contributing factor to decreased taste is a simultaneous decrease in smell. A loss of smell puts elders at risk of not knowing when gas is leaking, when food is spoiled, or when something is burning. Having working smoke detectors is a compensatory safety intervention for the loss of smell. When elders have decreased taste and smell, they are prone to eat inadequate diets. A nurse should encourage them to maintain an adequate diet even if they can’t taste or smell the food they are eating. 17. When an elder client is experiencing musculoskeletal physiologic changes of aging, which of the following interventions should receive priority in the client’s plan of care? 1. 2. 3. 4.

Maintain adequate calcium intake. Place commonly used items within easy reach. Provide assistive devices to extend arm reach. Exercise as tolerated every day.

(1) While all the interventions listed assist the client to cope with the musculoskeletal changes of aging, maintaining adequate calcium intake is the priority intervention. Loss of calcium from bones is the major age-related change in the skeletal system. This causes gradual decreases in height, slower synthesis of bone, decreased calcification, and eventual osteoporosis. Assuring that the elder is getting adequate calcium can prevent these age-associated losses. Placing commonly used items within easy reach and/or providing assistive devices to extend reach are appropriate nursing interventions that can help the elder be self-reliant and avoid injury. As aging occurs, the elasticity of muscle decreases, muscles become less flexible, and stiffness follows. If the elder exercises as tolerated every day, he or she can compensate or prolong the onset of these age-related changes. 18. Which of these strategies should a nurse include when planning care for an elder client with incontinence? 1. 2. 3. 4.

use of fluids at will, P.O. (taken orally) the administration of diuretics in the afternoon pelvic muscle exercises routine hygienic care

(3) Weakening of the pelvic diaphragm is an expected outcome of aging. Because of this, bladder tone and proper closure of the bladder outlet is impaired. Pelvic muscle exercises can strengthen tone and closure, preventing or assisting in managing urinary incontinence. P.O. fluids should be adequate but regulated in amount and timing to avoid overfilling the bladder. Diuretics should be administered in the morning to allow for urination and the recognition of the sensation to void when the elder is fully awake and more mobile. Perineal care can be compromised in the elderly because of limited mobility and other self-care issues. Elders might not have frank bowel incontinence, but staining of the underwear might occur, which can sufficiently contaminate the urethra. More frequent perineal hygiene is indicated in the elderly.

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19. An elder male experiences urinary frequency, difficulty starting the urinary stream, dribbling, and retention of urine. A nurse should recognize these clinical manifestations as indicative of: 1. 2. 3. 4.

normal physiologic changes of aging. prostatic hypertrophy. urinary tract infection (UTI). poor toileting habits.

(2) Prostatic hypertrophy results when changes in the smooth muscle fibers of the prostate occur with age. The symptoms experienced include those listed in the question. While these changes are associated with aging, they are very specific to prostatic hypertrophy. UTIs can result from prostatic hypertrophy because of the stasis of urine, but not every male with prostatic hypertrophy has a UTI. Poor toileting habits can lead to UTIs and incontinence, not to prostatic hypertrophy. 20. Which of the following clinical manifestations should indicate to a nurse that a client is at increased risk for altered nutrition? 1. 2. 3. 4.

increased amounts of acidic saliva progressive gum hypertrophy increased secretion of ptyalin and amylase dental caries

(4) A combination of physiologic changes put elders at risk for altered nutrition, including dental caries. Increased tooth decay leads to tooth loss and/or increased pain when chewing. Lack of teeth, or pain when chewing, ultimately cause elders to ingest less food or to ingest foods with less nutritional value. The saliva of the elderly is more alkaline, and the amount is lessened. Aging causes the gums to recede, not hypertrophy. In the aging adult, less ptyalin and amylase are secreted. Both aid in digestion of food, and the decrease means elders might not get the nutritional value of the food they are eating. 21. Which of these statements, if made by an elder client, is the most important for a nurse to follow up? 1. 2. 3. 4.

“I need to take a laxative every day to have a bowel movement.” “I don’t like to drink much water because it makes me go to the bathroom too much.” “I just don’t feel like eating every meal now that I live alone.” “It’s too expensive for me to buy meat.”

(4) Getting elder adults to eat enough protein each day is the major problem in helping them plan their meals. Many elders don’t eat meat because of financial concerns or because they have trouble chewing. Helping them find alternative protein sources is a priority for the nurse. A daily laxative is not recommended for elder adults, but many of them are already in the habit of taking one. If this has been their habit for some time, they likely need to continue. They are better served, however, to take a stool softener. Additional teaching is needed, but this is not the priority concern in the question. Drinking adequate amounts of water is a concern for elder adults. Many times, elders eat fewer meals, so they don’t drink as often, or they limit their fluid intake because of incontinence or urinary frequency. Providing simple teaching is usually sufficient. Additional financial resources are not required for increased fluid intake, and this issue isn’t as difficult to manage—again, it is important but not the priority. It is common for elders to decrease the number of their meals, especially when they live alone. They continue to eat but might eat more processed foods or ingest excess amounts of carbohydrates. Teaching is needed but providing adequate protein is the priority for follow up. 22. When teaching a group of elders about proper nutrition, a nurse should include which of the following? 1. 2. 3. 4.

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Eat a diet low in complex carbohydrates. Eat foods low in nutrition density. Limit total fat and cholesterol intake. Limit sodium intake to less than 1000 mg daily.

Health Promotion and Maintenance

(3) Generally, the same basic diet can be encouraged for all elders. Limiting the amount of total fat and cholesterol in the diet assists in managing other common health problems of the elderly, such as hypercholesterolemia. The diet should be high in complex carbohydrates. Elders should eat foods high in nutritional density so that when they eat less they are still consuming adequate nutritional values. Moderate sodium intake is necessary and should be limited to 1000–1500 mg daily. 23. When an elder client says to a nurse, “I just don’t get enough sleep anymore,” the best response by the nurse is: 1. 2. 3. 4.

“It’s common for elder adults to feel like they don’t get enough sleep.” “When you get older, you don’t spend as much time in REM sleep, so you awaken still feeling tired.” “You probably are waking up frequently during the night. That can make you feel more tired.” “Tell me about your routine, when and where you sleep, and how things are at home.”

(4) To determine whether a more serious condition exists, such as sleep apnea, depression, or cognitive impairment, a nurse needs more information. Daily activity, environmental conditions, and sleeping patterns can all affect the quality of sleep; for this reason, Choice 4 is the best response because it is an open form of communication, and the nurse gains valuable information to further assist the client. Choice 1 is true, but to say this to the client demeans the nurse’s concern and doesn’t lead the conversation into greater detail. Choice 2 is also a correct statement and might be used in time to explain why the elder is still feeling tired; however, first the nurse needs to gather more information. Choice 3 is also true. Elders do wake more frequently and experience fewer hours of extended sleep. This might not make the elder tired, however, as it still constitutes rest if he or she continues to lie in bed, listen, to music, or engage in restful thoughts. 24. All the following characteristics indicate to a nurse that an elder client might experience undesirable effects of medicines except: 1. 2. 3. 4.

increased oxidative enzyme levels. alcohol taken with medication. medications containing magnesium. decreased serum albumin.

(1) Oxidative enzyme levels decrease in the elderly, which affects the disposition of medication and can alter the therapeutic effects of medication. Alcohol has a smaller water distribution level in the elderly resulting in higher bloodalcohol levels. Alcohol also interacts with various drugs to either potentate or interfere with their effects. Magnesium is contained in many medications that elder clients routinely obtain over the counter. Magnesium toxicity is a real concern. Albumin is the major drug-binding protein. Decreased levels of serum albumin mean that higher levels of the drug remain free, lessening the therapeutic effect and increasing drug interaction. 25. If an elder client drinks alcohol while taking an anticoagulant, for which of the following adverse effects should a nurse observe? 1. 2. 3. 4.

hypoglycemia oversedation hemorrhage CNS depression

(3) When anticoagulants are taken with alcohol, the effect of the anticoagulant is increased and can result in hemorrhage. Hypoglycemia can result when alcohol is combined with antidiabetic agents. Oversedation and CNS depression can occur when alcohol is combined with barbiturates, tranquilizers, narcotics, antidepressants, antihistamines, and anesthetics. 26. Which of the following characteristics should a nurse expect to identify in the “old-old” elder client? 1. 2. 3. 4.

egocentricity flexibility senility childishness

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(1) The old-old elderly are those individuals who are 80–85 years of age and beyond. Many factors contribute to their egocentricity: blindness, deafness, faulty sense perceptions, and having little in common with those around them. They are more aware of their personal needs than at any other time of their life but are less capable of meeting those needs. The old-old are less flexible by necessity, as described in the previous situations. One of the most frequent misconceptions about the old-old is that they are senile. Many of the symptoms leading to that conclusion, such as disorientation, poor judgment, intellectual dysfunction, and incontinence, can be resolved with proper care. The old-old are not childish but childlike. They are focused on the quality in others and can sense when someone is being dishonest or not genuine. They also focus on tangible issues such as someone being late or the room being too cold when these are just symptoms of their loss of control. 27. Which of the following personality types should a nurse expect to identify in most elderly people? 1. 2. 3. 4.

defended passive-dependent disintegrated integrated

(4) Most elderly people have an integrated personality type as evidenced by a high level of functioning, intact cognition, and competent egos. They are satisfied with their lives and have voluntarily let go of many of their roles. Defended elders are those who have always pushed themselves hard and continue to do so as they age. They plan to continue to work and exhibit a high degree of control over their impulses. Defended doesn’t mean dissatisfied with life; these elders are very resourceful and healthy. Passive-dependent elders have strong dependency needs. They manage fairly well if they have at least one or two people as a constant support system. If they are apathetic, they have little social interaction or activity. They have a low satisfaction with life. Disintegrated elders represent a small number of the elderly. They have abnormalities in psychological function and deterioration in thought processes. They might or might not be institutionalized. 28. An elder client expressed a desire to die. The family made a decision to withhold medically necessary care that resulted in the elder’s death. This is known as: 1. 2. 3. 4.

active euthanasia. passive euthanasia. assisted suicide. physician-assisted suicide.

(2) Passive euthanasia is defined as the omission of care on inaction to prolong life. In this situation care was not provided, and the client died. Active euthanasia is deliberately hastening death and is considered first-degree murder in most countries. Nurses who engage in active euthanasia are convicted of murder in the United States. Assisted suicide is defined as making a means of suicide available to the patient, knowing that the person is going to use it to end his or her life. Physician-assisted suicide occurs when the physician prescribes medication or provides the client with knowledge that results in the client’s death. 29. The daughter of an elder client has been his faithful caregiver. Which of the following statements, if made by the daughter, should alert a nurse that the caregiver needs assistance? 1. 2. 3. 4.

“My dad seems to be getting worse no matter what I do.” “My brother came to relieve me last night.” “I need at least 30 minutes each day to myself.” “Even though I’m tired, I feel so good that I have been able to do this.”

(1) When caregivers report that their relative is worsening no matter what they do, how much time they spend with them, and so on, it can be a sign that the caregiver feels totally responsible for the outcome and that no matter how much care they provide, it doesn’t make a difference. Caregivers who express this feeling need some assistance. When caregivers allow others to contribute to care, it is a healthy sign that they recognize they need breaks and can’t do it all.

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If they start refusing help, it is a sign that they do need assistance. Acknowledging personal needs is healthy in caregivers. When caregivers no longer provide for their own needs, it signals that they are not able to recognize those needs or have put the relative’s care above their own. They might become ill themselves, and this is a dangerous signal that they need assistance. Feeling pride in the care they are providing is another healthy sign for caregivers. When they no longer feel good about themselves or take pride in what they are doing, it signals a need for assistance. 30. If a pregnant client is receiving a pregnancy-risk Category C medication, the nurse should observe the fetus for which of the following? 1. 2. 3. 4.

Normal development. Category C drugs have shown no risk to fetal development. Probable normal development. Category C drugs have not been tested in pregnant women but have shown no adverse fetal effects in animals. Potential adverse effects. Category C drugs have shown adverse fetal effects in animals but have not been tested in pregnant women. Adverse effects. Category C drugs have been proven to put the human fetus at risk.

(3) Category C drugs have shown adverse fetal effects in animals but have not been sufficiently studied to assess risk to the human fetus. In some situations, the potential benefit to the mother outweighs the potential risk to the fetus. Category A drugs have been shown to pose no risk to the human fetus during the first trimester. There is also no evidence of risk in the last two trimesters. Category B drugs have been studied for fetal effects in animals and have not shown any adverse effects. However, sufficient studies in pregnant women have not been done. There is evidence to show that risk to the human fetus exists for Category D drugs; however, the maternal benefit might outweigh potential risk to the fetus. 31. The nurse is teaching a prenatal class about the effects of medication on fetal development. Which of the following statements, when made by the client, indicates that the teaching was effective? 1. 2. 3. 4.

“If my doctor prescribes the medicine, it is safe for my baby.” “I should always check with my doctor or nurse before I take any medicine.” “When I’m in my second trimester, I don’t have to worry that medicine will hurt my baby.” “Any medicine I take when I’m pregnant will hurt my baby.”

(2) Pregnant women should always check with their doctor or nurse before taking any medicine, including over-thecounter medications. Checking first lets the woman know about any risk of teratogenic effects. Many women have medical conditions requiring pharmacologic management, which might or might not carry a teratogenic risk. Most teratogenic effects occur during the first trimester; however, it is important to monitor all medication use throughout the entire pregnancy. Pregnancy-risk Category A medications have failed to demonstrate a risk to the human fetus at any time during pregnancy. 32. At the 24-week visit, a pregnant woman demonstrates a less-than-expected growth in uterine size, an easily palpable fetus that can be outlined by the nurse, and the absence of fetal ballottement. A nurse should recognize that this is most likely related to the development of: 1. 2. 3. 4.

hydramnios. oligohydramnios. amniotic fluid embolism. macrosomia.

(2) Oligohydramnios occurs when the amount of amniotic fluid is severely reduced. This condition results in less than expected uterine growth, a fetus surrounded by little amniotic fluid and therefore easily palpated and outlined, and an absence of fetal ballottement (rebound when displaced by a light tap of an examining finger through the vagina). Hydramnios is an excess of amniotic fluid and is evidenced by overdistention of the uterus. This condition is accompanied by an increased incidence of prolapsed cord and malpresentation at the time of delivery. Macrosomia is the term applied to babies who are too large for gestational age.

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33. Which of the following clinical manifestations should the nurse document as a positive sign of pregnancy? 1. 2. 3. 4.

amenorrhea uterine soufflé positive pregnancy test fetal heartbeat

(4) Fetal heartbeat can be detected with Doppler echocardiography as early as 10–12 weeks of pregnancy and is considered a positive or diagnostic sign of pregnancy. Amenorrhea, the absence of menses, is considered a presumptive sign of pregnancy. It is a more predictive sign when more than one cycle has been missed. Uterine soufflé, the sound heard on auscultation over the uterus, is caused by blood flow through the placenta, but can also be caused by other conditions such as ovarian tumors or uterine myomas. It is present during pregnancy, but other conditions, such as those mentioned, can also cause it to be elevated. A positive pregnancy test is based on the detection of Human Chorionic Gonadotropin, which is present during pregnancy, but other conditions can cause it to be elevated, so it is considered a probable sign of pregnancy. 34. Which of the following factors, if identified in the history of a pregnant Vietnamese-American woman, is most likely related to cultural beliefs about pregnancy? 1. 2. 3. 4.

avoids eye contact (mal de ojo or evil eye) and satisfies all cravings (antojos) avoids lifting her arms above her head avoids standing in open doorways avoids going to the zoo

(2) A common health belief for many Vietnamese-Americans is that lifting the arms above the head when pregnant can increase the risk of premature birth. Mexican-American women might avoid mal de ojo (direct eye contact without touching) because of a belief that it can cause a sudden decline in the physical or emotional condition of one of the people involved. Satisfying cravings (antojos) when pregnant prevents defects or injury to the fetus, according to the health beliefs of some Mexican-Americans. A common health belief among some Cambodian-Americans is that a baby can get stuck in the birth canal if the pregnant woman stands in a doorway. Some Chinese-American women have a health belief that going to the zoo while pregnant might cause the baby to look like one of the animals. 35. A woman who is 20 weeks pregnant has been taught about fetal development. Which of the following statements, if made by her, indicates that she correctly understood the teaching? 1. 2. 3. 4.

“My baby is able to breathe now.” “My baby can open his eyes.” “My baby is about 7 1⁄2 inches long.” “My baby is starting to grow fingernails.”

(3) By 20-weeks gestation, the fetus is approximately 10 cm (or 7 1⁄2 inches) long. Fetal lungs do not begin the movements of respiration until the 24th week. Because oxygen is provided through the placenta, the function of the lungs for breathing does not begin until birth. The fetus can open its eyes at 28-weeks gestation. Fingernails begin to grow at 10-weeks gestation but are not complete until the 38th week. 36. Which of the following self-care measures should a nurse suggest first for a woman in her third trimester of pregnancy experiencing ankle edema, leg cramps, and faintness? 1. 2. 3. 4.

Practice frequent dorsi-flexion of the feet. Wear support hose. Avoid standing for long periods of time. Elevate the legs when sitting.

(1) The first self-care measure that should be suggested is practicing frequent dorsi-flexion of the feet. If this is done, it provides relief for two of the three symptoms the woman is experiencing: ankle edema and leg cramps. Wearing support

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hose is a valid self-care measure if the woman is experiencing varicose veins but has no effect on the symptoms listed. Avoiding standing for long periods of time is helpful for those with varicose veins. Avoiding standing in warm or stuffy environments might help with feelings of faintness. Again, the dorsi-flexion helps avoid ankle edema if the woman has to stand for long periods of time. Elevating the legs is helpful for ankle edema but is not a self-care measure for leg cramps or faintness. 37. When a pregnant woman says to her nurse, “I’m worried that my baby isn’t moving as much as it did,” the best response by the nurse is: 1. 2. 3. 4.

“I want you to go to the hospital, and we’ll put you on a monitor to see whether your baby is moving.” “I want you to count how many times your baby moves in the next 12 hours, and call me if it is less than 10.” “As your baby grows, you will start to feel it move more. I’ll check with you again at your next visit.” “I’m sure your baby is all right. Let me see if I can hear the fetal heart tones.”

(2) Fetal movement varies a great deal, but in general women feel the fetus move at least 10 times within a 12-hour period. Establishing this base line is the first assessment to make when determining whether further evaluation is needed. If there are not sufficient fetal movements within a 3-hour time frame, it may be necessary to do a non-stress test for fetal movement at the hospital or in the physician’s office; but a non-stress test would not be the first action and may convey a more serious concern to the woman than is warranted. Fetal movements are first felt around 18-weeks gestation and are experienced as a flutter. As the baby grows, the movements get stronger and easier to detect. So, it is true that movement is felt more as the fetus grows (Choice 3), but this does not address the concern expressed, and to delay further assessment until the next visit could mean missing fetal distress. Choice 4 offers false reassurance. The mother’s concern warrants further assessment. 38. Which of the following self-care measures should the nurse include when teaching a pregnant woman about exercise? 1. 2. 3. 4.

Check your pulse while exercising and slow your pace if your heart rate reaches 160. It is safe to exercise to the point of fatigue, but avoid exhaustion. Avoid exercising in the supine position after the first trimester. Relax in a hot tub or sauna for 10 minutes after exercise.

(3) After the first trimester, a pregnant woman should avoid exercising in the supine position. This is associated with decreased cardiac output. As a general rule, pregnant women should not engage in exercise that causes their heart rate to exceed a maximum of 140 beats per minute. Per the American College of Obstetricians and Gynecologists, pregnant women should not exercise to the point of fatigue or exhaustion. Hyperthermia can have teratogenic effects on the fetus, so pregnant women should avoid hot tubs and saunas. 39. Which of the following strategies should the nurse include when teaching a pregnant woman about sexual activity? 1. 2. 3. 4.

You should avoid sexual intercourse during the last six to eight weeks of your pregnancy. After your fourth month of pregnancy, you should place a pillow under your right hip during intercourse. Your orgasms will become less intense during the last weeks of pregnancy. Many women experience decreased sexual desire during their second trimester.

(2) Because of the pressure placed on the vena cava by an enlarging uterus, a pillow should be placed under the right hip of the woman if she is lying on her back during intercourse. This moves the uterus off the vena cava. Couples are no longer counseled to avoid sexual intercourse during the last six to eight weeks of pregnancy. It is now known that if there are no complications (such as a multiple pregnancy, threatened abortion, incompetent cervix, and so on), there is no reason to limit sexual activity during the last weeks. Orgasms are typically much more intense during the last weeks of pregnancy and might even be followed by cramping. During the first and third trimesters, many women experience a decreased sexual desire. During the second trimester, sexual desire might increase.

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40. When a pregnant couple is over the age of 35, the nurse should expect the couple to demonstrate which of the following behaviors? 1. 2. 3. 4.

increased financial concern related to costs associated with the birth increased confidence related to previous childbirth experiences increased anxiety of physical risk related to maternal age moderate anxiety related to uncertainty about fetal well-being

(4) In addition to nursing diagnoses applicable to all pregnant women, the pregnant couple over the age of 35 might have additional concerns about the well-being of their baby as it relates to Down syndrome or other genetic disorders. Most couples over the age of 35 are more financially secure and have fewer concerns related to the cost of a birth. Couples over the age of 35 might have experienced infertility problems, extended periods between births, or problem births. These couples might not have had the opportunity to build confidence. If several years have passed since a previous birth, the current pregnancy might seem like the first. Unless there is a pre-existing health problem, the woman should not be at increased risk of physical injury related to her age. 41. Which of the following assessment findings, if identified in a pregnant woman, should a nurse report to the physician immediately? 1. 2. 3. 4.

a report of decreased fetal movement a temperature of 100°F vaginal bleeding two episodes of vomiting over two days

(3) Vaginal bleeding can be a sign of abruptio placenta, placenta previa, or the onset of labor and should be reported immediately to the physician. The total absence of fetal movement is a danger sign of fetal demise and should be reported immediately; however, decreased movement is cause for further evaluation but is not sufficient cause for urgent concern. Persistent vomiting can be a danger sign of hyperemesis gravidarum and should be reported immediately; however, two episodes of vomiting over two days requires further evaluation, not urgent concern. 42. Which of the following strategies should the nurse include when planning care for a pregnant woman who has a decreased MSAFP (maternal serum alpha-fetoprotein), an increase in hCG (human chorionic gonadotropin), and a decreased Estriol level? 1. 2. 3. 4.

referral to the physician instructing the woman to increase her folic acid intake referral for amniocentesis ordering a plasma glucose level

(1) The combination of results presented in this situation might indicate a fetus with Down syndrome. A neural tube defect can be indicated by an elevated MSAFP, but after the defect has occurred, an increase in folic acid intake does not affect the condition. Taking folic acid before becoming pregnant and continuing through the pregnancy is associated with a lower incidence of neural tube defects. The physician needs to be notified of the results, and the nurse should anticipate referral for an amniocentesis. The parents must be consulted to be sure this is a test they would like performed. If the initial glucose screen is positive, the nurse can order a glucose-tolerance test, per protocol. The laboratory tests mentioned in the question have no impact on ordering a plasma glucose level. 43. Which of the following factors is the most critical in influencing the outcome of pregnancy in an adolescent? 1. 2. 3. 4.

cigarette smoking sexually transmitted infection prenatal care parental support

(3) All the options listed are important factors in the outcome of adolescent pregnancy, but prenatal care is the most critical factor. Adequate prenatal care identifies cigarette smoking and offers the adolescent support for quitting; it also

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identifies and treats sexually transmitted infections, reducing the risks to the fetus. Parental support is important but does not replace prenatal care. Adequate prenatal care can identify those adolescents who lack parental support or need additional support and make the proper referrals. 44. The teaching plan for a pregnant woman who was obese prior to pregnancy should include which of the following instructions? 1. 2. 3. 4.

You should gain 28–40 pounds (12–18 kg). You should gain 25–35 pounds (11–16 kg). You should gain 15–25 pounds (7–11 kg). You should gain 15 pounds or less (≤ 7 kg).

(4) Women who are already obese should be counseled to gain 15 or fewer pounds during their pregnancy. The higher priority is meeting the recommended daily allowance described in the food pyramid. Women who are underweight before becoming pregnant should gain 28–40 pounds during their pregnancy. Women who are of normal weight should gain 25–35 pounds, and women who are overweight but not obese should gain 15–25 pounds. 45. Which of the following strategies should a nurse anticipate when caring for a laboring woman who has an anthropoid pelvis? 1. 2. 3. 4.

preparation for a vaginal birth anticipation of a cesarean (C-) section administration of IV oxytocin a precipitous labor

(2) An anthropoid pelvis is not favorable for vaginal birth, and a C-section should be anticipated. The administration of oxytocin augments labor and facilitates vaginal birth. It is not appropriate in this instance because a vaginal birth is unlikely. A precipitous labor is a vaginal birth occurring within three hours of the onset of labor. Because a vaginal birth is not likely in this instance, the nurse should not anticipate this type of labor. 46. When reviewing a chart, the nurse notes that the fetus of a laboring woman is in a transverse lie. The nurse should anticipate which part of the fetus delivering first? 1. 2. 3. 4.

the shoulder the occiput the buttocks the sinciput

(1) In a transverse lie, the shoulder is the most common presenting part. The back, abdomen, or an arm might also present in a transverse lie. If the occiput delivers first, the fetus is considered to be in the most common presentation, vertex. A frank breech is when the buttocks are the presenting part. In a brow presentation, the sinciput is the presenting part. 47. Which of the following should the nurse include when teaching a pregnant woman about the onset of labor? 1. 2. 3. 4.

You might experience an increase in fatigue about 24–48 hours prior to labor. If you develop a “bloody show,” you can expect labor to begin in 12–24 hours. If your “bag of water” breaks, labor will begin almost immediately. If your contractions go away with a hot shower, you might be in false labor.

(4) Differentiating between true and false labor can be difficult. Contractions in false labor are relieved by ambulation, changes in position, or a hot shower. The only valid way to differentiate between true and false labor is to have a vaginal exam to see whether cervical dilatation and effacement are occurring. Many women experience a burst of energy, not fatigue, during the 24–48 hours preceding the onset of labor. When a bloody show begins, labor generally ensues within 24–48 hours. About 80% of women whose membranes rupture before the onset of labor start having contractions within 24 hours. If labor does not begin within 12–24 hours, the woman might need to have labor induced to avoid infection.

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48. A pregnant woman who is in labor has contractions that last 40–60 seconds and are 2–3 minutes apart. She describes her contractions as being strong. By IUPC (intrauterine pressure catheter), the contractions are 50–70 mm Hg. The nurse should document that the woman is in which stage of labor? 1. 2. 3. 4.

first stage, latent phase first stage, active phase first stage, transition phase second stage

(2) A woman who is in the first stage, active phase of labor has findings consistent with those given in the question. First stage, latent-phase contractions occur every 3–30 minutes with a duration of 20–40 seconds and are described as mild, progressing to moderate. With an IUPC, they measure 25–40 mm Hg. First stage, transition-phase labor is characterized by contractions every 1 1⁄2–2 minutes that last 60–90 seconds, are strong by palpation and measure 70–90 mm Hg. Second stage labor begins when the cervix is completely dilated and ends with the birth of the baby. Contractions occur every 1 1⁄2–2 minutes, last 60–90 seconds, are strong by palpation, and measure 70–100 mm Hg. 49. During the second stage of labor, the nurse should expect to identify which of the following cardinal movements first? 1. 2. 3. 4.

internal rotation descent extension restitution

(2) The fetus transitions through a total of seven cardinal movements during the birth process. Of the movements listed in the question, descent is the first to occur and is characterized by the head entering the inlet. Internal rotation occurs after flexion and involves the fetal head rotating to fit the diameter of the pelvic cavity. Extension occurs after internal rotation and is the fourth cardinal movement. The fetus extends its head to allow passage under the symphysis pubis. Restitution occurs after extension and is characterized by the head turning to one side to align with the position of the back in the birth canal. The order of the cardinal movements is descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion. 50. When assessing a woman in the third stage of labor, the nurse should expect to obtain which of the following findings? 1. 2. 3. 4.

delivery of the placenta within 30–45 minutes crowning blood loss of 500–750 ml Schultze mechanism

(4) The Schultze mechanism is one of two ways the placenta presents upon delivery. In the Schultze mechanism, the fetal side of the placenta delivers and appears shiny. This is consistent with the third stage of labor, which is defined as the stage of placental delivery. If the placenta does not deliver within 30 minutes after the fetus delivers, it is considered retained. Blood losses associated with delivery range from 250–500 ml. Crowning is associated with the second stage of labor. 51. A pregnant woman who has diabetes is about to deliver her baby. A nurse should plan to observe the mother for which of the following complications? 1. 2. 3. 4.

preeclampsia-eclampsia seizures HELLP syndrome uterine rupture

(1) A diabetic pregnant woman is at increased risk for preeclampsia-eclampsia, hydramnios, and hypoglycemia or hyperglycemia. Seizures and HELLP syndrome are complications of pregnancy-induced hypertension. Uterine rupture is a complication of induction of labor.

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52. When obtaining the health history of a woman who is about to deliver a full-term baby, the nurse notes a 25–pound weight loss. The nurse should recognize that the baby is at risk for which of the following complications? 1. 2. 3. 4.

congenital heart defect amniotic bands cognitive impairment hearing loss

(3) Potential adverse effects of maternal malnutrition include low birth weight, increased chance of mental retardation, lower IQ, attention deficits, rickets, epilepsy, and cerebral palsy. Congenital heart defects can be caused by maternal rubella infection, maternal ingestion of anticonvulsants, sex hormones, and nuclear radiation. Amniotic bands result when the amnion forms constrictive bands around the limbs. This causes decreased circulation and abnormal development. It is not caused by malnutrition. Hearing loss can result if there is maternal rubella infection. 53. When a pregnant woman presents in labor, which of the following findings is most important for the nurse to follow up? 1. 2. 3. 4.

Nitrazine test strip with pH of 5.5 Proteinuria of 2+ fetal heart rate of 150 beats per minute white blood cell count of 14,000

(2) Normal urine is negative for proteins. Proteinuria of 2+ or greater found in uncontaminated urine might be a sign of impending preeclampsia. A 5.5 pH on a Nitrazine test strip means that the membranes are probably intact and is a normal finding. Normal fetal heart rate varies from 120–160 beats per minute, so a rate of 150 is considered normal. Normal white blood cell counts are between 4,500 and 10,000. However, it is not unusual to have a white blood cell count of up to 20,000. 54. All the following are indications that electronic fetal monitoring should be used except: 1. 2. 3. 4.

meconium staining of amniotic fluid. decreased fetal movement. AROM (artificial rupture of membranes). induction of labor.

(3) All the choices except Choice 3 are indications that electronic fetal monitoring should be used. AROM is not an indication to use electronic fetal monitoring by itself; it means that the physician ruptured the membranes with an amniohook for the purpose of speeding up labor. 55. When an electronic fetal monitor is in place, the nurse should evaluate which of the following findings first? 1. 2. 3. 4.

uterine resting tone fetal heart tone variability intensity of contractions presence or absence of a sinusoidal pattern

(1) The first step in evaluating a fetal monitoring strip is determining the uterine resting tone. Next, the contractions should be assessed for frequency, duration, and intensity. Then, the baseline for the fetal heart rate should be evaluated for rate, then variability, then sinusoidal pattern, and—finally—for periodic changes. The correct order of the options listed is 1, 3, 2, and 4.

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56. When performing an assessment of fetal monitor tracings, which of the following observations indicates to the nurse a nonreassuring (worrisome) pattern? 1. 2. 3. 4.

STV (short-term variability) LTV (long-term variability) of 3–5 cycles baseline rate of 140 absence of variability

(4) Absence of variability means that no short-term or long-term variability exists and is an indication of fetal distress. The first three choices represent normal findings and are not reasons for concern. 57. A pregnant woman receives prostaglandin E2 prior to the induction of labor. A nurse should plan to assess for contraindications, which include: 1. 2. 3. 4.

impending C-section. a client with six or more previous pregnancies. a client with a bloody show. a client already receiving oxytocin.

(4) Prostaglandin E2 is used to ripen the cervix and to stimulate the smooth muscle of the uterus to encourage contractions. The prostaglandin E2 is removed when contractions begin. If a client is already receiving oxytocin, contractions should already have begun. If a C-section is anticipated, the nurse should not want to encourage the onset of labor, so this drug should not be given. Women who have had six or more term pregnancies (grand multiparae) are not candidates for this drug because their chance of having a precipitous labor is already increased. Prostaglandin E2 is contraindicated for clients with unexplained bleeding during pregnancy. A bloody show is normal. 58. When assessing a woman who is about to have a forceps delivery, a nurse should expect to identify which of the following clinical manifestations? 1. 2. 3. 4.

ruptured membranes cephalopelvic disproportion minimum cervical dilation of 9 cm full bladder

(1) The membranes must be ruptured before forceps can be applied to allow a firm grasp on the fetal head. There can be no degree of cephalopelvic disproportion for a forceps-assisted delivery. The cervix must be completely dilated, and the bladder should be empty. 59. Which of the following actions, if performed by the parents of a three-month-old, best indicates correct understanding of activities that provide auditory stimulation for their child? 1. 2. 3. 4.

naming body parts using rattles or wind chimes showing how to clap hands crinkling different papers by the infant’s ear

(2) At three months of age, the use of rattles or wind chimes is the best choice. The sounds are distinctive enough for the infant to discriminate between them. Naming body parts at this age has little meaning for infants. An infant is able to start associating body parts with the names for them at six–nine months of age. Clapping does produce noise but also requires fine motor skills on the part of the infant. This is more appropriate at six–nine months of age. The infant is certainly able to hear the crinkling of different papers, but the sounds are very similar; therefore, the exercise is more appropriate at four–six months of age.

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60. The parents of a newborn have been given instructions about which toys are appropriate for their infant. Which of the following statements, if made by the parents, indicates that they correctly understand the instructions? 1. 2. 3. 4.

“It will be so much fun picking out a jack-in-the-box.” “I bet he’d enjoy one of those animals that squeaks when you squeeze it.” “Let’s get him one of those teething rings that we can put in the freezer.” “We should hunt for a mirror that won’t break.”

(4) Newborns and young infants enjoy looking at themselves in a mirror. The human face is pleasing to them. Nurses must instruct parents to buy unbreakable mirrors to prevent injury. A jack-in-the-box is too advanced for a newborn; newborns do not have the capacity to turn the handle and make it work. Newborns and young infants do not possess the fine motor skills necessary to squeeze, nor do they have the capacity to associate squeezing a squeak toy with the sound it makes. Tooth eruption begins at around six months of age, so a newborn does not yet need a teething ring. 61. Which of the following strategies should a nurse suggest parents add to their activities to promote tactile stimulation for an 11-month-old? 1. 2. 3. 4.

Give the infant finger foods of different textures. Provide soft squeeze toys of various textures. Allow the infant to play nude on a soft, furry rug. Comb the infant’s hair with a soft brush.

(1) Finger foods are now being introduced into the infant’s diet. Providing finger foods with different textures is a natural way to promote tactile stimulation. The remaining choices provide tactile stimulation, but the question asks which activities to add. Having his or her hair combed with a soft brush is not a new stimulation for an 11-month-old infant. An 11-month-old infant has probably had soft squeeze toys since he or she was 4–6 months of age, so this is not a new stimulation. Playing nude on a soft, furry rug is also not a new stimulation for an 11-month-old infant. 62. Which of the following nursing actions is most successful in securing friendly cooperation from a toddler? 1. 2. 3. 4.

Offer the toddler a toy upon entering the room. Go to the toddler and call him by name. Visit with the parent and place a toy within reach of the toddler. Tell the toddler that you are his nurse and pick him up.

(3) Toddlers are very wary of strangers entering a room and need time to adjust. By placing a toy within reach and visiting with the parent, the nurse allows the toddler to acclimate at his own pace. This is a nonthreatening approach and acknowledges the toddler’s need for control. To directly offer the toddler a toy upon entering the room calls for the toddler to immediately accept the nurse and is a loss of control for the toddler. Calling the toddler by name and approaching him gives him the sense that he does not have control, and a negative reaction can be expected. Identifying yourself is always appropriate but better done with the parent in this instance. Picking up the toddler without time for adjustment causes the toddler to refuse the overture, and the resulting negative reaction might interfere with the nurse’s ability to further assess the child. 63. Which nursing measure should assume priority when performing a physical examination on an eight-month-old infant who is sitting contentedly on his mother’s lap chewing on a toy? 1. 2. 3. 4.

Take the toy away so that the infant’s mouth can be observed. Begin a systematic physical exam, beginning at the head and moving to the feet. Remove all the infant’s clothing so that a thorough exam can be performed. Auscultate the infant’s heart and lungs, and then proceed with the rest of the exam.

(4) The order of the physical exam should be adjusted to accommodate the developmental age of the infant and the infant’s response to being examined. Assess the heart and lungs while the child is quiet and distracted with the toy. Taking

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the toy away might cause the infant to cry, and, while the nurse might get a good look in the mouth, the respiratory, cardiac, and abdominal assessments are compromised. Children are usually late-preschool or school-age before the nurse can do a complete head-to-toe exam without making adjustments in the order of the exam. Ear and mouth assessment is viewed as invasive and might prompt crying in infants, toddlers, and many preschoolers. Delay ear and mouth assessment until after respiratory, cardiac, and abdominal sections are completed. By delaying this until the end, good respiratory, cardiac, and abdominal assessments can be done. Remove the infant’s clothing one item at a time. Removing all the infant’s clothing at once might prompt crying. The stethoscope can be slipped under clothing without prompting crying. 64. At which age does a positive Babinski sign indicate the need for further evaluation by the nurse? 1. 2. 3. 4.

4 months 8 months 12 months 16 months

(4) A positive Babinski sign is a normal finding in children 12 months of age and younger. A positive Babinski sign in a 16-month-old indicates the need for further evaluation. 65. The parents of a preschool child have been given instructions about the Denver II test. Which of the following statements, if made by the parents, indicates that they correctly understand the teaching? 1. 2. 3. 4.

“This test tells me whether my child’s IQ is normal.” “This test tells me what developmental tasks my child can do today.” “This test measures my child’s development.” “This test lets me know whether my child’s development is normal.”

(2) The Denver II is a screening test, not a diagnostic test. The results describe the tasks a child is able to perform only on the day of the test. Denver II is not an intelligence test. IQ is not measured by the Denver II test, nor does the Denver II determine developmental delays. A child scoring other than normal findings on the Denver II requires repeat screening or evaluation by a developmental specialist to determine whether development is within normal range. 66. When teaching the parents of toddlers about expected developmental milestones, at which age should the nurse tell the parents most children are walking? 1. 2. 3. 4.

12 months 15 months 18 months 24 months

(2) Most children walk between 11 and 15 months of age. Telling parents that children walk by 12 months of age might cause needless concern. A child who walks by 15 months of age meets the expected developmental milestone. Children not walking by 18 or 24 months of age have not met the expected developmental milestone and require further evaluation. 67. If a school-age child’s growth and development is within normal range, which of the following developmental stages should the nurse expect to identify? 1. 2. 3. 4.

trust industry initiative autonomy

(3) Industry versus inferiority is the developmental stage of school-age children. Trust versus mistrust is the developmental stage of infancy. Initiative versus guilt is the developmental stage of preschoolers. Autonomy versus shame and doubt is the developmental stage of toddlers.

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68. When teaching parents about the pros and cons of sleeping with their children, which of the following pieces of information should the nurse give? 1. 2. 3. 4.

If you give your child more attention during the day, they will not want to sleep with you at night. Sleeping with parents can contribute to Sudden Infant Death Syndrome. Children should never be allowed to sleep with their parents. You could be accused of sexual abuse if you allow your child to sleep with you.

(2) Research has shown that sleeping with adults can contribute to Sudden Infant Death Syndrome. Cases of infants “smothering” while pressed against a parent have frequently been found to be associated with drug/alcohol use by the parent and sleeping on a narrow bed, couch, or reclining chair. Increased attention during the day does not stop a child from wanting to sleep with his or her parent. In some cultures, it is the norm for children to sleep with their parents. Some reasons a parent might want a child to sleep with them include illness, nightmares, or night fears, and lack of bedroom space. Parents who do not wish co-sleeping to become a normalized behavior should make sure that the co-sleeping ceases when the illness, fear, or other reason is resolved. Sleeping with a parent (or co-sleeping) does not indicate abuse. Concerns about behaviors consistent with sexual abuse require further investigation. 69. A 14-month-old girl recently received a shock by sticking her finger in an electrical outlet at her grandparent’s house. Today in her own house, her parents find her about to put her finger into an outlet. Which of the following statements offers the best explanation of the girl’s behavior? 1. 2. 3. 4.

She does not understand that the same response will occur because this is a new situation. She should know not to repeat an act that previously caused her pain. Toddlers are ritualistic; it is normal for her to put objects into electrical outlets, and she will continue to do so. She is showing clinical manifestations of delayed cognitive development.

(1) Toddlers do not fully understand causality. The girl might be able to understand that sticking her finger in the outlet at her grandparent’s house resulted in the shock, but, because this is a different outlet, she might not be able to reason that the same thing will happen at her own house. Because it is a different situation, she cannot yet associate sticking her finger into any outlet with the pain of a shock. Toddlers are ritualistic, but the behavior described is not an example of ritualistic behavior. If the behavior is repeated, extra steps are required to protect the toddler, and the parents need appropriate counseling. This is normal toddler behavior and is not a sign of delayed cognitive development. Because the behavior is normal, families should receive anticipatory guidance from nurses to prevent injury. 70. Two toddlers are playing at daycare. One child suddenly takes a toy from the other. A nurse should recognize this behavior as: 1. 2. 3. 4.

aggressive. egocentric. imitation. centration.

(2) Toddlers engage in egocentric behavior. They believe that what they want is all that matters and that everyone else wants them to have what they want. In the situation described, the child took the toy simply because she wanted it. The toddler does not have the capacity to understand the feelings of another child. Imitation is mimicking the behaviors of other children or adults. Typically, imitation is seen in facial expressions or in domestic activities such as picking up toys or housework. Centration is concentration on one aspect of a situation, rather than considering multiple factors. An example of centration is a child who refuses to play with a blue block because of its color, even when the child wants to play with blocks.

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71. Of the following statements by a preschooler, which statement can be taken as evidence that the child is engaged in magical thinking? 1. 2. 3. 4.

“I can’t play outside because it is raining.” “God will make it stop raining.” “I can make it stop raining.” “Maybe it won’t rain tomorrow.”

(3) Magical thinking is defined as believing that thoughts are all-powerful and that thoughts can cause events. A child who engages in magical thinking believes they can make it rain. Preschoolers do not fully understand the cause and effect of events; for example, a preschooler does not understand canceling a picnic because it is raining. Children engaged in magical thinking believe they can make the rain stop for a picnic. Believing that God can stop the rain is not an example of magical thinking. Acknowledging that it won’t rain tomorrow is not an example of magical thinking. 72. A preschool-age child tells the nurse about her friend named Cassi who comes to play when she gets home from daycare. The parents shake their heads and explain to the nurse that their child has started talking about a friend who doesn’t exist. The nurse should recognize this behavior as an indication of: 1. 2. 3. 4.

purposeful lying. absence of other social interactions. need for a pet. creation of a friend.

(4) Creating imaginary playmates is normal behavior for preschoolers. An imaginary playmate provides the preschoolage child with a diversion, provides companionship when the child is lonely, allows the child to succeed in areas in which the child is not yet successful, and provides a friend to blame when things go wrong. The creation of imaginary friends is not an example of purposeful lying in a preschool-age child. Children with imaginary playmates are typically very social and have many other friends. Imaginary friends are not created out of a social need but are an example of normal developmental behavior in preschoolers. A pet might create a diversion, but many preschoolers are not suited to having pets. The presence of a pet does not replace an imaginary friend for a preschooler. 73. When assessing the language skills of a child, a nurse should expect use of 6- to 8-word sentences at which of the following ages? 1. 2. 3. 4.

18 months 24 months 3 years 5 years

(4) By the age of 5, children have fully developed adult speech and are capable of multiple-word sentences using all parts of speech. Generally, an 18-month-old uses 2-word sentences, a 24-month-old uses 2- to 3-word sentences and a 3-year-old uses 3- to 4-word sentences. 74. When assessing the cognitive abilities of a school-age child, the nurse should expect to identify which of the following abilities? 1. 2. 3. 4.

hypothetical thought abstract reasoning formal logic perceptual thinking

(4) Perceptual thinking involves making judgments on what is seen, not what is reasoned. School-age children are concrete and egocentric in their thinking and are more influenced by what they can see than by what they can think about. Hypothetical thought is a prerequisite to abstract thinking, but neither develops until adolescence. Formal logic is a cognitive development of adolescence.

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75. A group of 9- and 10-year-old girls has formed a girls-only club that is open to church and school friends who have a particular computer game. The nurse should interpret this behavior as evidence of: 1. 2. 3. 4.

sexist and bullying behavior poor peer relationships normal social development increased risk of gang membership

(3) Making up rules and requirements for membership in clubs among children of the same gender is normal social behavior for school-age children. It is not until early adolescence that mixed-gender groups have formal relationships with each other. Therefore, there is nothing sexist about this arrangement. Bullying behavior includes pressuring and threatening a child to behave in antisocial ways. The situation in the question describes normal peer behavior. School-age children want to belong to peer groups. School-age children not included in peer groups are at risk for joining gangs. 76. When assessing clients who have experienced injuries to the speech center of the brain, which of the following clients should the nurse expect recover most quickly? 1. 2. 3. 4.

a preschooler an adolescent a middle-age woman a middle-age man

(1) Before brain cells become specialized, they are more plastic, or have greater capacity to work on multiple tasks. As the brain ages, the cells become more specialized and lose their plasticity. Plasticity makes a child who suffers a brain injury more likely to recover physically and psychologically than an adult who suffers the same kind of brain injury. A five-year-old recovers more quickly than any of the other individuals listed. Children up to age eight who sustain damage to the speech center of the brain often have no permanent speech impairment because the brain can utilize unspecialized cells in the right hemisphere. Adults usually have permanent damage when the speech center of the brain is injured. 77. After assessing the muscle strength of a 55-year-old man, the nurse should expect to document which of the following findings? 1. 2. 3. 4.

increase in muscle strength by 10–20% decrease in muscle strength by 20–30% decrease in muscle strength by 30–40% no change in muscle strength

(3) Most people lose between 30% and 40% of their muscle strength between the ages of 30 and 60. Maximum muscle strength is usually achieved by age 30. The rate of muscle loss increases after age 45. A 20–30% loss is less than expected. Due to the aging process, it is very rare to have no change in muscle strength. 78. The nurse is evaluating the sensorimotor development of a 6-month-old child. The expected findings are consistent with which of the following stages of sensorimotor development? 1. 2. 3. 4.

use of reflexes primary circular reactions secondary circular reactions coordination of secondary schemas

(3) The secondary circular reactions occur between 4 and 8 months of age. Use of reflexes is expected between birth and 1 month of age. Primary circular reactions are expected between 1 and 4 months of age. Coordination of secondary schemas is expected between 9 and 12 months of age.

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79. A child engages in parallel play, enjoys a routine schedule, and imitates domestic chores. The nurse correctly documents in the record that the child is in which of the following stages of development? 1. 2. 3. 4.

secondary circular reactions tertiary circular reactions use of new mental combinations preconceptual

(3) All the behaviors listed are associated with the invention of new means through the use of new mental combinations. New mental combinations are expected between 19 and 24 months of age. Secondary circular reactions, expected between 4 and 8 months of age, are characterized by imitating sounds and simple gestures, looking in a mirror and being unhappy if play is interrupted. Tertiary circular reactions, expected between 13 and 18 months of age, are characterized by a toddler showing curiosity about the environment, finding hidden objects, and putting items into containers and taking them out. The preconceptual stage, expected between 2 and 4 years of age, includes behaviors such as increased use of words, following prepositional directions, and using future-oriented words. 80. At which of the following ages should the nurse expect an infant to demonstrate the fine motor skill of transferring an object from one hand to the other? 1. 2. 3. 4.

four months five months six months seven months

(4) At seven months of age, an infant should transfer an object, such as a block, from one hand to the other. At four months of age, an infant grasps an object with both hands. At five months of age, the infant can hold an object, such as a block, in one hand. At six months of age, the infant holds an object (such as a block) with one hand, drops it to take another block but does not move it from one hand to the other. 81. Which assessment finding, if identified in a child who is 11 months of age, requires immediate follow-up by the nurse? 1. 2. 3. 4.

walks holding onto furniture does not respond to simple verbal commands rolls a ball to another person when asked to do so drops an object deliberately for it to be picked up

(2) A child should be able to respond to simple verbal commands by the age of 9 months. Absence of response to simple verbal commands in a 9-month old indicates the need for further evaluation. Choices 1, 3, and 4 are all normal behaviors for an 11-month-old and do not require further evaluation. 82. The parents of an infant tell the nurse that their child falls asleep in their bed and when they take him to his own bed, he awakens and begins to cry. The child falls asleep again when returned to the parents’ bed. The nurse should recognize this behavior as an indication of: 1. 2. 3. 4.

developmental night crying. refusal to go to sleep. nighttime fears. trained night crying.

(4) The behavior described is trained night crying, also known as inappropriate sleep association. Typically, the child falls asleep in the parents’ bed or while being rocked and remains asleep during the transfer to his own bed. The child awakens after the transfer and cries until being returned to the parents’ bed or being rocked. Developmental night

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crying typically occurs between 6 and 12 months of age and is evidenced by an infant who has undisturbed nighttime sleep and suddenly awakens. Refusal to go to sleep is characterized by a child resisting going to bed and coming out of his or her room repeatedly. When sleep does come, the child awakens frequently and refuses to go back to sleep. Nighttime fears might be the cause of refusal to go to bed and/or awakening due to fear. The child might fall asleep easily when a parent is nearby. 83. Which of the following cultures is the least likely to accept the practice of infants and children sleeping with their parents? 1. 2. 3. 4.

Asian Hispanic Caucasian African-American

(3) Caucasians in the United States are the least likely to accept infants or children sleeping with parents. Of this group, single parents, working parents, or parents who have experienced sleep disturbances as children are the most likely to institute this practice. The cultural practice of the “family bed” is accepted most among Asian, Hispanic, and African-American cultures. 84. When parents of a five-year-old express concern about their child attending kindergarten for the first time, the best response by the nurse is: 1. 2. 3. 4.

“Tell your child about when you went to school and that will help her see that there is nothing to be afraid of.” “Take your child to the school before the first day so that she can see where her class is.” “Tell your child you will stay with her the first day of school so that she won’t feel you are abandoning her.” “Explain to your child that you will ask the teacher to let her call you if he or she misses you too much.”

(2) Many schools provide an orientation day prior to the start of school for children to see their classroom and meet their teacher. Parents should be encouraged to take advantage of orientation days. They allow children to see for themselves what their teacher looks like and where they will be spending their time. This should allay fears. Choice 1 is incorrect because children at this age are still egocentric and are not reassured by what school was like for their parents. The egocentric child is only interested in what school is like for them. Choice 3 is incorrect because parents are encouraged not to stay with their child. It only prolongs the dependence, and it becomes harder each day for the parent and child to separate. Choice 4 is incorrect because, in general, children are not allowed to call their parents from school. Allowing such a phone call indicates to the child that parents expect the child to miss them so much that the teacher might need to call. Make sure the child knows when she will see her parents again. 85. When assessing a school-age child, which of the following developmental characteristics should the nurse recognize as a developmental cause of increased risk of injury? 1. 2. 3. 4.

increased involvement in activities away from home confidence equals physical ability awareness of environmental hazards skeletal and muscular growth parallel each other

(1) School-age children are increasingly involved in activities away from home and out of their parents’ direct control. This puts the child at increased risk of injury. School-age children’s confidence exceeds their physical ability, so they might try activities that they do not have the physical development to participate in, putting them at increased risk for injury. The school-age child can be distracted by environmental stimuli and unaware of hazards. Skeletal growth exceeds muscular growth in the school-age child and creates additional tension on tendons and ligaments, increasing the risk of injury.

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86. The nurse should recognize all the following situations as developmental characteristics that increase the risk of injury in adolescents except: 1. 2. 3. 4.

strong need for peer approval. beginning to drive. limited participation in sports. increased access to complex tools.

(3) Adolescence is the peak age for practice and participation in sports activities. Most injuries occur during practice and can be related to trying to make the team, not using proper protective equipment, and heat. Choices 1, 2, and 4 are all developmental characteristics that increase the risk of injury. Adolescents have a strong need for peer approval and might attempt risky activities when encouraged by peers. Adolescents reach the legal age to drive and many engage in risk-taking driving behaviors, especially with peers. Adolescence are at increased risk of injury as they begin to use more complex tools. 87. The parents of an infant ask the nurse what kind of shoes they should buy for their child. The best response by the nurse is: 1. 2. 3. 4.

“Children need high-top shoes to prevent the ankle from being injured as they begin to walk.” “Your child’s shoes should be hard leather and difficult to bend in the middle.” “You should buy your child shoes that leave at least an inch between the end of the longest toe and the shoe.” “You should buy your child new shoes about every three months between the ages of two and three.”

(4) A small child’s foot experiences rapid growth between the ages of two and three and the child should have his or her foot measured for new shoes at least every three months. Signs that a child needs new shoes include curled toes, redness, and irritation of the skin. High-top shoes are not necessary for support of the ankle or foot. The child’s shoes should be soft and able to flex in the middle with pressure applied by the thumb and index finger. At the time of purchase, there should be 1/2 inch between the child’s longest toe and the shoe. A shorter distance than 1/2 inch does not allow for sufficient growth before the next pair of shoes is purchased. A longer distance impedes the child’s balance while the child is trying to walk. 88. Which of the following statements, when made by a client, should the nurse recognize as a major defining characteristic of Body Image Disturbance? 1. 2. 3. 4.

“I am so ashamed of how I look since I’ve gained weight.” “I don’t think I can lose weight, even though I want to.” “I have stopped looking in the mirror since I’ve gained weight.” “It seems all I think about anymore is being fat.”

(1) A verbal or nonverbal negative response to actual or perceived changes in structure or body function is the only major defining characteristic of Body Image Disturbance. This is expressed as shame, embarrassment, guilt, or revulsion. The first statement says how ashamed the client is. Minor characteristics of Body Image Disturbance include not looking at the body part (Choice 3), feelings of hopelessness about the body (Choice 2), and preoccupation with change or loss (Choice 4). 89. Which of the following statements, if made by a cancer patient with hair loss secondary to chemotherapy, indicates that the goal for new coping patterns is being met? 1. 2. 3. 4.

“I think I’ll get some new barrettes for my hair.” “I washed my wig today.” “I asked my mom to bring my shampoo.” “I’m thinking about changing my hair color.”

(2) One of the two indicators that the goal for implementing new coping patterns has been met is a willingness and ability to resume self-care responsibilities. Choice 2 shows that the client is taking care of the wig, a new self-care

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responsibility. Choice 1 indicates denial that there has been hair loss and that inappropriate self-care goals exist. Choices 3 and 4 also deny hair loss. The statements denying hair loss are evidence of the minor defining characteristics of Body Image Disturbance, so the goal is not being met. 90. A client has experienced a traumatic amputation and subsequent Body Image Disturbance. In the record, the nurse documents the nursing diagnosis of Body Image Disturbance related to changes in appearance secondary to: 1. 2. 3. 4.

chronic disease. severe trauma. loss of body part. loss of body function.

(3) The most immediate cause of Body Image Disturbance is loss of a body part. The answer is not trauma because that was the event that caused the loss of the body part. The loss of the body part is still primary. A chronic condition may result as a loss of the body part but it is the missing part that would precipitate the chronic condition so the loss of the body part is still the focus. And while there may be loss of function secondary to the loss of the body part, the loss of function is secondary—particularly in the initial stages of the injury. 91. Which of the following statements, when made by a client with anorexia nervosa, indicates Body Image Distortion instead of Body Image Dissatisfaction? 1. 2. 3. 4.

“I don’t like how my body looks.” “I wish I looked like my sister.” “I’m sad I can’t wear halter tops.” “I am so overweight.”

(4) Choice 4 is the only statement that reflects a distorted image of the body. Clients with anorexia nervosa look in the mirror and see themselves as heavier than they really are. They cannot see that they are too thin. Choices 2–4 indicate that the client is dissatisfied with aspects of her body, but do not indicate a distorted body image. 92. Which of the following questions, when asked by the nurse, assesses for the major defining characteristic of Body Image Disturbance? 1. 2. 3. 4.

“How do you feel about this disability?” “How would you describe your usual mood?” “How does your family feel about your illness?” “Do you feel fearful, anxious, or nervous?”

(1) The major defining characteristic of Body Image Disturbance is verbal or nonverbal negative responses to actual or perceived changes in structure and/or function of the body. Asking how the client feels about his or her disability gives the nurse an opportunity to assess whether the client’s response to the change is positive or negative. Mood can reflect how clients feel about themselves and/or their circumstances, and can represent minor defining characteristics of Body Image Disturbance. Families can have a great impact on how clients feel about themselves. Choice 3 helps determine the level of familial support, but family perceptions are not included in major or minor defining characteristics of Body Image Disturbance. Asking whether the client is fearful, anxious, or nervous can help the nurse identify somatic problems associated with Body Image Disturbance, but they are not major or minor defining characteristics. 93. Which of the following nursing interventions helps minimize the amount of hair loss for chemotherapy patients? 1. 2. 3. 4.

Style and spray hair in place. Use a hair dryer to dry hair. Cut hair short. Use a fine-toothed comb.

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(3) Keeping hair short minimizes hair loss. Fine or thin hair appears fuller and has more body when it is short, giving the illusion of more hair. Hair spray and hair dye should be avoided, as both can further damage hair and increase hair loss. Hair should be allowed to air dry because heat causes damage and increases hair loss. A fine-toothed comb can get caught in tangles and pull hair out. Clients should be taught to use a wide-toothed comb and avoid vigorous brushing. 94. The teaching plan for a client with hair loss secondary to chemotherapy should include which of the following instructions on obtaining a wig? 1. 2. 3. 4.

“Wait until your hair comes out before purchasing a wig.” “Treatments are tax deductible, but wigs are not.” “You can purchase a wig at the American Cancer Society.” “A beautician can give you tips on how to style a wig.”

(4) Beauticians are excellent referral sources for the care and styling of wigs. They can show clients how to use combs, clips, and otherwise style and care for wigs. Clients should purchase and begin wearing wigs before all their hair falls out to get ideas about preferred styles. This also helps clients prepare for the unpredictable timing of hair loss. Wigs are considered medical prostheses and are tax deductible if the client keeps the receipt and otherwise qualifies for the medical expense deduction. The American Cancer Society provides clients with their first wig. 95. A client who is receiving chemotherapy has a nursing diagnosis of Body Image Disturbance related to changes in appearance secondary to chemotherapy. Which of the following nursing measures should be included in this client’s care plan? 1. 2. 3. 4.

Discourage use of turbans or scarves for hair loss. Explain that hair grows back the way it was before chemotherapy. Let friends and relatives initiate offers of assistance. Allow significant others to share their feelings and fears.

(4) The client is concerned about how others view them and might anticipate negative reactions. Allowing significant others to share their feelings and fears provides a forum for them to offer support to the client despite their feelings and fears. The nurse is then in a position to assist the client and significant others in developing new coping patterns. Turbans and scarves should be encouraged when the client doesn’t want to wear a wig. Most clients prefer not to be seen bald, and many times wigs feel hot. Hair usually grows back but is often a different color or texture. The nurse can encourage the client to consider how he or she would want to help if the situation were reversed and to ask for assistance from friends and relatives. 96. Which of the following nursing measures should be included in the care of a client who has experienced the loss of a body part or function? 1. 2. 3. 4.

Explain to the client what the loss should mean to him. Use role-playing to assist the client in sharing his feelings. Encourage the client to “get over it” and assume self-care. Expect the client to respond to the loss with acceptance.

(2) Role-playing can assist clients in sharing their feelings about the lost body part or function. The nurse and client can take turns being the client and significant others. The nurse should assess what the loss means to the client instead of telling the client what it should mean. Clients should be allowed to express their feelings and to grieve. Telling clients to “get over it” communicates that their grief isn’t valid. Clients should gradually be encouraged to assume selfcare responsibilities. A client who has experienced the loss of a body part or function might respond with denial, shock, anger, and/or depression.

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97. The nurse should prepare a woman who is pregnant for the first time to expect which of the following changes in her breasts during the first trimester? 1. 2. 3. 4.

striae development on the breasts presence of a tingling sensation leakage of colostrum appearance of secondary areola

(2) During the first trimester, which is the first 12 weeks after conception, the woman might experience a tingling sensation in her breasts. This is normal. The tingling sensation is also present in the third trimester. Striae develop on the breasts during pregnancy but are most common in multiparas rather than primimparas. Colostrum is not present until after the 12th week of gestation. After 20 weeks of gestation, secondary areola might appear and are characterized by washed-out spots surrounding the primary areola. 98. When teaching a pregnant woman about the expected enlargement of her abdomen, the nurse should include which of the following pieces of information? 1. 2. 3. 4.

The fundus cannot be felt during weeks 10–12. During weeks 20–22 the fundus is half-way between the symphysis and umbilicus. At 28 weeks the fundus is one finger breadth above the umbilicus. At 36 weeks the fundus is just below the ensiform cartilage.

(4) At 36 weeks gestation the pregnant woman can anticipate her fundus to be just below the ensiform cartilage. However, the size of the uterus can be inconsistent with the length of gestation. During weeks 10–12 the fundus can be palpated slightly above the symphysis pubis. During weeks 20–22 the fundus is at the umbilicus. At 28 weeks the fundus is three finger breadths above the umbilicus. 99. When a pregnant woman says to the nurse, “I bought some cream to try to bleach this brown line on my stomach,” the best response by the nurse is: 1. 2. 3. 4.

“The line is called striae gravidarum and is normal in pregnancy.” “The cream has no effect on the brown line and might hurt your baby.” “The line is called melasma gravidarum and disappears on its own after the baby is born.” “One of the possible skin changes in pregnancy can be a brown line down the center of your abdomen, and it is normal.”

(4) Linea nigra is the correct name for a brown line down the center of the abdomen that sometimes occurs during pregnancy. The line usually extends from the umbilicus or above the pubic area. Striae gravidarum are commonly called stretch marks and develop in many women as the abdomen is stretched to accommodate the enlarging uterus. Their appearance is reddish and wavy when new, and silver or white when older. They appear on the abdomen, thighs, buttocks, and breasts. Applying cream to linea nigra does not cause it to disappear. The nurse needs to know the ingredients of the cream to identify possible components that are harmful to the fetus if absorbed into the bloodstream. Melasma gravidarum is commonly called the facemask of pregnancy and usually fades or disappears entirely after the baby is born. 100. When a pregnant woman expresses concern that her forehead is getting darker, which of the following interventions is most appropriate for the nurse to recommend? 1. 2. 3. 4.

Teach her that makeup might help mask the increased pigmentation. Explain that it will go away. Tell the woman it is normal. Avoid sun exposure.

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(4) Melasma gravidarum is the darkening of skin on the forehead and around the eyes that develops during pregnancy. It is more prominent in dark-haired women and fades or becomes less visible soon after childbirth. It is aggravated by sun exposure, so avoiding the sun can help prevent progression. Teaching is always an appropriate nursing intervention, but in this scenario it is most appropriate to tell the woman what she can do to minimize or decrease the pigmentation. It is difficult to eliminate the appearance of melasma gravidarum with makeup, and the use of makeup might cause or exacerbate acne because the sebaceous glands are more active during pregnancy. Melasma fades after the child is born, but that does not address the woman’s immediate concern regarding her appearance. Melasma gravidarum is normal during pregnancy, but explaining this does not address the woman’s primary concern. 101. Which of the following behaviors, when displayed by a pregnant adolescent, indicates to the nurse that the adolescent is experiencing Body Image Disturbance related to the effects of pregnancy on appearance? 1. 2. 3. 4.

wearing maternity clothing during the second trimester wearing restrictive clothing to conceal her changing body agreeing to gain the recommended weight buying supportive bras to accommodate breast enlargement

(2) When a pregnant adolescent begins to experience the body changes associated with pregnancy, she might wear restrictive clothing to attempt to conceal her changing body and/or the pregnancy. This behavior is a minor defining characteristic of the nursing diagnosis Body Image Disturbance. Wearing maternity clothes during the second trimester indicates that the adolescent acknowledges the increased abdominal growth and is making the appropriate accommodations. Many pregnant adolescents try to maintain their prepregnant weight because they fear becoming obese or disclosing their pregnancy. It is difficult and sometimes frightening for a pregnant adolescent to see the changes her body goes through and to distinguish between changes associated with puberty and changes associated with pregnancy. Buying a supportive bra demonstrates the adolescent’s recognition that her breasts are enlarging and need support. 102. What should the nurse do first when responding to parents of a newborn who express concern that the infant’s head is misshapen? 1. 2. 3. 4.

Help the parents find a cap that disguises how the head looks. Explain to the parents that molding diminishes within a few days. Ask the parents why they are concerned about it. Remeasure the head after the molding has resolved.

(3) Assessing the parents’ concerns gives the nurse needed information and direction for intervention. Stocking caps are placed on newborns to prevent heat loss but can help disguise molding while it resolves. Usually, explaining that the infant’s head will look normal in a few days is sufficient to allay parental fears or concerns. The nurse should remeasure the head after molding has resolved, but this should not be the first intervention. 103. Which of the following clinical manifestations should the nurse expect to identify in an adolescent female with Tanner Stage IV breast development? 1. 2. 3. 4.

breast tissue 2–4 centimeters in diameter elevation of areola from breast contour adult appearance breast buds

(2) Tanner Stage IV breast development is manifested by enlarged breast tissue with a separation between the contour of the breast tissue and areola. The areola appears to be elevated or sitting on top of the breast tissue. Tanner Staging is not determined by measuring centimeters but by the appearance of the breast as it develops. Full adult appearance is Tanner Stage V. Breast buds are Tanner Stage II.

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104. When assessing an adolescent female, the nurse identifies soft, downy hair along the labia majora. The nurse correctly documents this finding as: 1. 2. 3. 4.

Tanner Stage I. Tanner Stage II. Tanner Stage III. Tanner Stage IV.

(2) Tanner Stage II pubic hair growth is evidenced by soft, downy, slightly pigmented hair along the labia majora. Tanner Stage I is prepubescent and evidenced by absence of pubic hair. As pubic hair increases in pigmentation and coarseness, it increases in Tanner Staging. The difference between Tanner Stages II and III is increased pigmentation and coarseness. Tanner Stage IV pubic hair growth includes a thickening and extension of the pubic hair to the mons and lateral labia majora. 105. When assessing a male adolescent who is Tanner Stage III, the nurse should expect to identify which of the following clinical manifestations? 1. 2. 3. 4.

increased scrotal size, prepubescent penis, and downy hair at the base of the penis increased scrotal size, increased penis size, and coarse, pigmented hair at the base of the penis increased scrotal size, increased penis size, and coarse, pigmented hair at the base of the penis with extending perimeters adult scrotal size, adult penis size, and coarse, thick, pigmented hair extending to the abdomen and inner thighs

(2) Tanner Stage III is evidenced by increased scrotal size, increased penis size, and coarse, pigmented hair at the base of the penis. Choice 1 describes Tanner Stage II. Choice 3 describes Tanner Stage IV. Choice 4 describes Tanner Stage V (for penis and scrotal growth), and Tanner Stage VI (for pubic hair distribution). 106. An adolescent girl wishes to get a tattoo because she believes it will enhance how she is viewed by her peers and how she feels about herself. The teaching plan for this client should include all the following interventions except: 1. 2. 3. 4.

asking the adolescent to consider whether the tattoo is something she wants for a lifetime. ensuring that the adolescent’s Hepatitis C vaccine is up to date. telling the adolescent to watch a tattoo performed on someone else first. being sure the studio and artist are licensed and trained.

(2) There is no immunization available to protect against the risk of contracting Hepatitis C or HIV. It is possible to contract both during the process of receiving a tattoo. Choices 1, 3, and 4 should be considered by people wishing to get tattoos. 107. The nurse should include all the following pieces of information when teaching a client how to care for a new tattoo except: 1. 2. 3. 4.

Use heat to minimize discomfort during the first two days. Avoid contact with another person’s body fluids until the tattoo is well healed. Touch the area only after carefully washing your hands. Watch for signs of infection such as increased redness and discharge.

(1) The client should keep the affected area elevated and use ice to minimize swelling for two days after receiving a tattoo or body piercing. Choices 2, 3, and 4 are all self-care measures the nurse should teach a client who has gotten a new tattoo.

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108. Which of the following, when identified in a client with a medical diagnosis of anorexia nervosa, does not contribute to a nursing diagnosis of Body Image Disturbance? 1. 2. 3. 4.

intense fear of becoming obese amenorrhea body weight that is less than 85% of the client’s estimate undue influence of body shape on the client’s self-evaluation

(3) Body Image Disturbance is manifested by negative verbal and nonverbal responses by the client to perceived or actual changes in body function or structure. Actual body weight that is less than 85% of the client’s estimate is included in the DSM-IV criteria for the medical diagnosis of anorexia nervosa, but the question asks about Body Image Disturbance. The anorexic client has Body Image Disturbance because she believes that she is overweight. Having an intense fear of becoming obese is a minor defining characteristic of Body Image Disturbance. Diagnostic criteria for DSM-IV is a medical diagnosis for anorexia and amenorrhea is one of the criteria. In the nursing diagnosis of Body Image Disturbance it is a related factor, not criteria. The focus of the question is the nursing diagnosis of Body Image Disturbance. Allowing the body shape to negatively influence self-evaluation is a major defining characteristic of Body Image Disturbance. 109. Which of the following clinical manifestations is an expected body image change for a client with bulimia nervosa? 1. 2. 3. 4.

Body Image Disturbance occurs exclusively during episodes of anorexia nervosa. Self-evaluation is unduly influenced by body weight and shape. Compensatory behaviors to prevent weight gain occur at least once a week for two months. Abdominal discomfort precipitates the end of a binge.

(2) When self-evaluation is unduly influenced by body weight and shape, defining characteristics for the nursing diagnosis of Body Image Disturbance have been met. When the client has bulimia nervosa, the Body Image Disturbance is not exclusive to episodes of anorexia nervosa. Compensatory behaviors, such as vomiting and misuse of laxatives, meet defining characteristics of Body Image Disturbance but are not consistent with bulimia nervosa. To meet the diagnostic criteria for bulimia nervosa, the client must engage in compensatory behaviors at least twice a week for three months. It is true that bingeing is usually stopped by abdominal discomfort, the presence of another person, or vomiting. Choice 4 refers to bingeing, not body image. 110. Which of the following stressors for hospitalized children is not related to body image? 1. 2. 3. 4.

separation from parents or primary caretaker loss of control, autonomy, and privacy being subjected to multiple painful and invasive procedures fear of bodily injury and disfigurement

(1) Separation anxiety is one of the four major stressors for hospitalized children, particularly young children. However, the cause of the separation is rarely related to body image. Choices 2, 3, and 4 all relate to the way children feel about the structure and function of their body and can lead to Body Image Disturbance. The nurse must assess for these stressors and intervene to prevent Body Image Disturbance. 111. Which of the following children (experiencing Body Image Disturbance related to the normal developmental process) is most likely to fear that their body parts might leak out? 1. 2. 3. 4.

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(2) Preschoolers have an underdeveloped sense of body integrity, which might cause them to fear that their body parts will leak out. An example of this is a child who sees medication tracking out of an injection site and thinks he or she is losing part of themselves. Toddlers do not have the ability to think about their bodies yet. School-age children are concerned about bodily injury and painful procedures but have a good sense of body integrity and understand that they are not losing part of themselves. Young adolescents have a fear of disfigurement and altered body image but are not afraid that their body parts will leak out. 112. Which of the following factors, if identified in the history of a client who has AIDS, is most likely related to the development of Body Image Disturbance? 1. 2. 3. 4.

hepatosplenomegaly skin disorders oral candidiasis pneumocystis carnii pneumonia

(2) Common skin disorders for clients with AIDS are eczema and dermatitis. These skin conditions are very visible and might cause negative reactions by the client and others, potentially leading to Body Image Disturbance. Hepatosplenomegaly and pneumocystis carnii pneumonia are both clinical manifestations of AIDS and can be linked to Body Image Disturbance, but it is less likely because these conditions are not visible to the casual observer. Oral candidiasis is obvious when looking in the mouth and can be linked to Body Image Disturbance, but this is less likely because it is not visible to the casual observer. 113. Which of the expected side effects of long-term steroid use is least likely to be associated with Body Image Disturbance? 1. 2. 3. 4.

bone loss hair loss moon face ecchymosis

(1) Bone loss is a side effect of long-term steroid use, but, because it is not visible to the naked eye, it is the least likely of those listed to be associated with Body Image Disturbance. Choices 2, 3, and 4 are all side effects of long term steroid use that are associated with Body Image Disturbance. Ecchymosis is superficial bleeding under the skin and has a purple-to-deep-red color. It can cover large areas and often appears on the abdomen. 114. A client with Systemic Lupus Erythematosus (SLE) demonstrates rash, petechiae, cyanosis, skin ulcers, joint deformity, and edema. These conditions substantiate a nursing diagnosis of: 1. 2. 3. 4.

risk for Altered Tissue Perfusion. risk for Impaired Skin Integrity. risk for Body Image Disturbance. risk for infection.

(3) As a group, the nursing diagnoses listed have a common denominator of visibility. When clients have visible symptoms, their condition is much more likely to impact how they view themselves and how others view them. Visible symptoms can put a client at risk for Body Image Disturbance. Risk for Altered Tissue Perfusion is an appropriate nursing diagnosis for patients with SLE, but it is related to interrupted blood flow in the kidneys. Edema is the only manifestation listed that relates to interrupted blood flow in the kidneys. Clients with SLE are at risk for Impaired Skin Integrity, but in this scenario the client already has Impaired Skin Integrity. Risk for Infection is an expected nursing diagnosis for SLE patients but is not common to all the clinical manifestations listed.

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115. A child who has juvenile rheumatoid arthritis (JRA) exhibits rash, limp, loss of joint motion, and swelling over large joints. A nurse should recognize these findings as indicative of: 1. 2. 3. 4.

impaired physical mobility. activity intolerance. pain. Body Image Disturbance.

(4) Body Image Disturbance is the only nursing diagnosis listed that includes all the signs and symptoms the scenario. Limping, loss of joint motion, and swelling over large joints are manifestations of impaired physical mobility. Activity intolerance is a typical diagnosis for children with JRA. In this scenario, activity intolerance is evidenced by a limp, loss of joint motion, and perhaps swelling over large joints. The child might be limping because of pain, but without more information this cannot be confirmed. 116. Which nursing action best prevents Body Image Disturbance related to changes in appearance secondary to scarring of chickenpox lesions? 1. 2. 3. 4.

Administer varicella vaccine prior to exposure. Administer varicella-zoster immune globulin upon exposure. Administer oral antihistamines to prevent itching. Administer aspirin for pain and inflammation.

(1) The administration of vaccine to prevent disease is the best nursing action. If a child is protected by the varicella vaccine before exposure to chickenpox, the illness is not contracted, eliminating lesions and any resulting scars that might cause Body Image Disturbance. Varicella-zoster immune globulin can prevent or significantly modify chickenpox, helping to reduce the chance of scarring lesions. However, varicella-zoster immune globulin is given to immunocompromised children to prevent a more life-threatening condition such as encephalitis. Administering oral antihistamines is an example of tertiary prevention and is appropriate for treating the itching associated with chickenpox. Aspirin has no effect on the scarring of the lesions and should never be given to children (unless ordered by a physician) due to the risk for Reye’s Syndrome. 117. When a client using the basal body temperature method to prevent conception says to the nurse, “My partner and I have sex right after my temperature goes up,” the best response by the nurse is: 1. 2. 3. 4.

“To avoid pregnancy you should avoid intercourse the day your temperature rises and for three days after.” “That is the best time to avoid a pregnancy because it means ovulation has passed.” “You should abstain from intercourse the day before your temperature rises to avoid becoming pregnant.” “You are always at risk for becoming pregnant when using the basal body temperature method of contraception.”

(1) The rise in temperature occurs because of a rise in progesterone levels during the second half of a woman’s menstrual cycle and means that ovulation has occurred. The temperature drops just before ovulation. To avoid conception, a couple should refrain from intercourse on the day of the temperature rise and for the next three days because it is the most likely time for pregnancy to occur. Because of the life span of the sperm, the woman is also at risk for becoming pregnant if she has intercourse just before the temperature rise. Many couples have utilized the basal body temperature method successfully to prevent pregnancy. The cycle can be interrupted, and ovulation can occur earlier or later than expected, resulting in pregnancy. Choice 4 is not the best response by the nurse; when a couple has committed to a method of contraception, the best response is teaching them how to be successful.

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118. The teaching plan for a client who is using the basal body temperature method to plan a pregnancy should include which of the following instructions? 1. 2. 3. 4.

Take your temperature before going to sleep at night. Record your temperature one–two months before using the charts to predict ovulation. Utilize a basal body thermometer or a tympanic thermometer. A rise in temperature means ovulation is about to happen.

(3) When recording basal body temperature, a basal body thermometer or tympanic thermometer should be utilized. The basal body thermometer measures temperature within 1⁄10 of a degree; digital thermometers only measure temperature within 2⁄10 of a degree. Basal body temperature should be taken and recorded upon awakening in the morning and before getting out of bed. When a woman becomes active, the basal metabolism rate rises, resulting in an elevated temperature and making the graph inaccurate for ovulation. Basal body temperature should be recorded for three–four months to predict ovulation effectively. A rise in temperature means that ovulation has already occurred and reflects the rise in progesterone. 119. When a woman is using the calendar or rhythm method of contraception, the nurse should include which of the following instructions in the teaching plan? 1. 2. 3. 4.

The fertile phase is calculated using the shortest cycle the woman has experienced. Ovulation occurs 14 days before the next period, plus or minus 2 days. The woman should refrain from having intercourse the second week of her cycle. A basic assumption of the rhythm method is that the ovum is viable for 48 hours.

(2) The rhythm method is based on the assumption that ovulation occurs 14 days before the start of the next menstrual period, plus or minus 2 days. The fertile phase is calculated as 18 days before the end of the shortest cycle the woman has recorded for the past 6–8 months and 11 days from the end of the longest recorded cycle. The woman should refrain from having intercourse during the calculated fertile phase, which usually includes the second week of the cycle, plus or minus a few days. The basic assumption of the rhythm method is that the ovum is viable for 24 hours and the sperm is viable for 48–72 hours. 120. Which of the following statements, if made by a client using the Billings method of birth control, indicates that the client is most likely to become pregnant? 1. 2. 3. 4.

“My partner and I have intercourse when the cervical mucus is thick and sticky.” “My partner and I have intercourse when the cervical mucus is clear.” “My partner and I refrain from having intercourse when the cervical mucus is clear.” “My partner and I refrain from having intercourse when the cervical mucus is thick and sticky.”

(2) The Billings method (or cervical mucus method) of birth control is based on assessment of cervical mucus changes related to ovulation. When the cervical mucus is clear, it is stretchy and permeable to sperm, which is consistent with ovulation. This is the time a woman is most likely to become pregnant if she has unprotected intercourse. When the cervical mucus is thick and sticky, progesterone is the dominant hormone and the physical characteristics of the mucus form a network that traps sperm, making it more difficult for them to progress up the reproductive tract. Choices 3 and 4 both refer to abstaining from intercourse. Pregnancy is not likely when abstaining, regardless of the cervical mucus characteristics. 121. When teaching clients about the use of situational contraceptives, the nurse should include all the following except: 1. 2. 3. 4.

Douching after intercourse might actually facilitate conception. Coitus interruptus requires ejaculation away from the external genitalia of the woman. Spermicides that effervesce offer the most rapid protection. Spermicides provide no protection from gonorrhea and chlamydia.

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(4) One of the advantages of spermicides is that they provide significant protection from gonorrhea and chlamydia. Douching after intercourse might facilitate conception as it pushes sperm farther up the birth canal. Coitus interruptus requires the male to withdraw from the vagina and ejaculate away from the woman’s external genitalia. Any cervical mucus on the external genitalia can facilitate the movement of sperm up the reproductive tract. Spermicides that effervesce offer rapid protection, and coitus can take place immediately after they are inserted. 122. When teaching a client about using spermicides, which of the following pieces of information should the nurse include? 1. 2. 3. 4.

Suppositories are effective immediately upon insertion. Insert the spermicide low in the vagina. Maintain a supine position after the spermicide is inserted. Spermicides require a prescription.

(3) After the spermicide is inserted, the woman should maintain a supine position to prevent leakage of the spermicide. Suppositories are not effective until they have dissolved, which can take as long as 30 minutes. Spermicides are widely available over the counter without a prescription. 123. Which of the following directions should the nurse give a client who uses condoms for contraception? 1. 2. 3. 4.

Use Vaseline jelly as a lubricant. Use natural skin condoms for protection against STDs. Apply the condom to a flaccid penis. Withdraw the penis from the vagina while it is still erect.

(4) For optimal protection, the penis should be withdrawn from the vagina while still erect, and the rim of the condom should be held to prevent spillage. “Natural skin” condoms are not recommended because they contain small pores that can allow passage of viruses such as Hepatitis B, herpes simplex, and HIV. Vaseline jelly deteriorates the latex in latex condoms, allowing sperm penetration; a water-soluble lubricant such as K-Y jelly should be used instead. Note: Condoms are increasingly made of polyurethane rather than latex. Polyurethane condoms are thinner and stronger than latex and can be used with oil-based (petroleum jelly) lubricants. A condom should be applied to an erect penis with a small space left at the end of the condom to allow for ejaculation. 124. When instructing a client on the use of a female condom, the nurse should include which of the following pieces of information? 1. 2. 3. 4.

The greatest protection is obtained when a female condom is used in conjunction with a male condom. The female condom is designed for repeated use. The female condom can be inserted up to eight hours prior to intercourse. The inner sheath of a female condom is lubricated with a spermicide.

(3) The female condom can be inserted up to eight hours prior to intercourse. The female condom is not designed to be used with a male condom. Female condoms are designed for a single use. The inner sheath of a female condom is lubricated but does not contain spermicide. 125. When obtaining a health history from a client who wishes to be fitted for a diaphragm, which piece of information should the nurse recognize as most critical? 1. 2. 3. 4.

smoker over the age of 35 history of toxic shock syndrome lactating client history of noncompliance with oral contraceptives

(2) Women who have a history of toxic shock syndrome should not use diaphragms or any other barrier method of birth control that is left in place for prolonged periods of time. The diaphragm is a good contraceptive choice for women over the age of 35 who smoke because oral contraceptives are contraindicated for smokers. The diaphragm is a

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good contraceptive choice for lactating women who cannot take medications, such as oral contraceptives, because of interference with lactation. When a woman cannot take or is not interested in taking oral contraceptives, the diaphragm is a good alternative. Compliance is an issue with any contraceptive method, but a diaphragm only requires compliance immediately prior to intercourse. 126. When teaching a client about the use of a diaphragm, the nurse should include which of the following pieces of information? 1. 2. 3. 4.

The diaphragm should be used without a spermicide. Use a spermicide if it has been more than two hours since insertion. Leave the diaphragm in place for six hours after intercourse. Minor discomfort might be experienced during intercourse.

(3) The diaphragm should be left in place for six hours after intercourse. If intercourse takes place again within six hours, additional spermicide must be used with the aid of an applicator. The diaphragm should not be disturbed. The diaphragm should be used with a spermicide. The client should place about 1 teaspoon of spermicide around the rim and in the middle of the diaphragm before insertion. If the diaphragm has been inserted more than four hours prior to intercourse, additional spermicide should be inserted. If inserted correctly, no discomfort should be experienced with the use of a diaphragm. 127. When obtaining a health history from a client who used a diaphragm for two years, discontinued use to become pregnant and now wants to go back to the diaphragm, which piece of information should a nurse recognize as the most pertinent? 1. 2. 3. 4.

The client has a history of 10-pound weight loss. The client is six-weeks postpartum. The client occasionally checks diaphragm placement during use. The client reports a popping sensation during insertion.

(2) The size must be checked after the birth of a child and with a weight gain or loss of 15 pounds. Because the client in the question has been using her diaphragm for two years and has recently experienced the birth of a child, she therefore needs to have the fit checked by a trained professional. Choice 1 is incorrect because the weight loss only 10 pounds. Checking for correct placement with each use is recommended, but Choice 2 is more pertinent. An experienced diaphragm user should be able to do occasional placement checks. The final step of inserting a diaphragm is placing the edge under the symphysis pubis; some women report a popping sensation when this occurs. Choice 4 is normal and not a cause for concern. 128. When teaching clients about the active mechanism of intrauterine devices (IUDs), which of the following pieces of information should the nurse include? 1. 2. 3. 4.

They prevent ovulation. They prevent implantation. They promote ovum migration. They alter or inhibit sperm migration.

(4) The current generation of IUDs is thought to prevent conception by inhibiting or altering sperm migration and ovum migration. IUDs do not prevent ovulation. (Oral contraceptives prevent ovulation.) The active mechanism of the original IUDs was not clearly understood, but they were thought to prevent implantation of a fertilized ovum. IUDs might alter or inhibit ovum migration, but they do not promote it.

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129. Which of the following assessment findings, if identified in a client who had an intrauterine device (IUD) implanted four weeks ago, should the nurse report to the physician immediately? 1. 2. 3. 4.

intermittent bleeding palpable string from the cervix cramping fever, chills, and malaise

(4) Fever, chills, and malaise are signs of infection and should be reported to the physician immediately. For the first two–six weeks after the insertion of an IUD, a woman might experience intermittent bleeding and cramping. Being able to feel the string from the IUD through the cervix is a sign that the IUD is in place and is an expected finding. 130. When obtaining a health history from a client who wants an intrauterine device (IUD) inserted, which piece of information should the nurse recognize as a contraindication for an IUD? 1. 2. 3. 4.

history of a monogamous relationship Gravida 2, Para 1 history of multiple sex partners prior use of oral contraceptives

(3) The IUD is not recommended for women with multiple sex partners because they are at higher risk for sexually transmitted diseases (STDs). IUDs are only recommended for women in monogamous relationships who have had at least one child. Choice 2 indicates at least one live birth. A woman who has not had a live birth is more likely to expel the IUD. Prior use of oral contraceptives is not a contraindication to IUD use. 131. Which of the following assessment findings, if identified in a client who has a levonorgestrel-releasing intrauterine device (IUD) in place, should the nurse report to the physician first? 1. 2. 3. 4.

The device has been in place for four years. The client has a known exposure to a sexually transmitted infection (STI). The client has amenorrhea. The client has intermenstrual bleeding.

(2) The nurse should report to the physician that a women with an IUD has been exposed to an STI so that the woman can obtain treatment and prevent pelvic inflammatory disease (PID). The levonorgestrel-releasing IUDs can remain in place for up to five years, so Choice 1 is within normal limits. The IUD releases a hormone (progestin) that can diminish periods and even cause amenorrhea, which is an expected finding with the use of this device. Intermenstrual bleeding is an adverse effect of IUDs but is not of the same urgency as exposure to an STI, and it might improve over time. 132. Which of the following symptoms should the nurse expect to identify in a client who is taking oral contraceptives and experiencing side effects of estrogen? 1. 2. 3. 4.

pruritis decreased libido headache hirsutism

(3) Headache is the only symptom listed that is a side effect of estrogen. Choices 1, 2, and 4 are side effects of progestin. Oral contraceptives contain either estrogen and progesterone or progesterone only.

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133. Which of the following symptoms should the nurse expect to identify if a client is experiencing side effects of progesterone in oral contraceptives? 1. 2. 3. 4.

increased appetite cholasma hypertension nausea

(1) Increased appetite and weight gain are side effects of progesterone. The side effects listed in Choices 2, 3, and 4 are all side effects of estrogen. Oral contraceptives contain either estrogen and progesterone or progesterone only. 134. When obtaining a health history from a client who wishes to start taking oral contraceptives, which piece of information should the nurse recognize as a contraindication? 1. 2. 3. 4.

adolescent smoker hyperlipidemia oligomenorrhea

(3) Clients with known hyperlipidemia should not be prescribed oral contraceptives. One of the side effects of estrogen is alterations in lipid metabolism, and one of the side effects of progesterone is increased low-density lipoprotein levels and decreased high-density lipoprotein levels. Oral contraceptives contain either estrogen and progesterone or progesterone only. These hormones increase the risk of an adverse outcome, such as stroke, in clients taking oral contraceptives. Adolescents can be very good candidates for oral contraceptives. They should be given 28-day packs to perpetuate the habit of taking a pill every day and so that they do not have to keep a record of when they need to start the next pack or where they are in the cycle. Smoking is a contraindication if the client is over the age of 35 or is a heavy smoker. Smoking increases the cardiac and thromboembolic complications of oral contraceptives. Clients with oligomenorrhea might find some improvement in their condition on oral contraceptives, but they should be monitored every three months, rather than once a year. 135. Which of the following strategies should the nurse include when teaching a client how to take oral contraceptives? 1. 2. 3. 4.

“Wait until the onset of menses, and then count five days before starting oral contraceptive.” “If you miss two or more pills, additional contraceptive measures should be taken until the next cycle.” “If progestin-only or low-dose oral contraceptives are used, additional contraception is not necessary for the first seven days.” “If you start taking your pills on Sunday, a backup method of contraception should be used for the first seven days.”

(4) Prevention of ovulation might not occur if oral contraceptives are started after the fifth menstrual cycle day. The first Sunday after the client receives the oral contraceptive pills might be more than five days after the onset of menses, so a backup method of contraception should be used for the first seven days of the first cycle of pills to prevent pregnancy. Choice 1 describes old guidelines for starting contraceptives and is no longer in use because it can result in pregnancy. Whenever a pill (even one) is missed, additional contraceptive measures should be taken for at least seven days. Some physicians recommend that additional contraceptive measures be used until the next cycle begins. Choice 3 is not true. To prevent possible pregnancy as a result of early ovulation, use of backup contraception is recommended for the first seven days of the first cycle of oral contraceptives regardless of the type of oral contraceptive used.

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136. When a postpartum woman is started on oral contraceptives, which of the following pieces of information should be included in the plan of care? 1. 2. 3. 4.

Oral contraceptives should be started within the first two weeks after delivery for a lactating woman. If a woman is taking prolactin-suppressing drugs, oral contraceptives should be started by the 14th postpartum day. Progestin-only pills should not be started until the third postpartum week. Combination oral contraceptives should be started immediately for a nonlactating postpartum woman.

(2) If prolactin-suppressing drugs are being used, ovulation might occur earlier and oral contraceptives should be started by the 14th postpartum day. Because there is an increased risk of spontaneous thromboembolism following delivery, it is recommended that oral contraceptives not be started in postpartum women until the third postpartum week. Because progestin-only pills are not associated with an increased risk of thromboembolism, they can be started immediately postpartum in a nonlactating woman. If a postpartum woman is not nursing, she can begin combination oral contraceptives three to four weeks postpartum without waiting for her first menstrual cycle. Oral contraceptives are contraindicated in lactating women; however, progestin-only products do not appear to have any adverse effects on breast-feeding or on the infant. 137. Which assessment finding, if identified in a client who is taking oral contraceptives, requires immediate followup by the nurse? 1. 2. 3. 4.

new onset headache occurring unilaterally with nausea occasional headache occurring bilaterally at the temples headaches associated with edema of the legs headaches gradually increasing in intensity, occurring bilaterally

(1) There are two types of headaches associated with oral contraceptive use: fluid retention and vascular spasm (migraine). Headaches of the migraine type can be associated with cerebral thrombosis and should be evaluated. Oral contraceptives should be used with caution in women with migraine headaches. Headaches can be present in the weeks or months preceding a stroke. Migraine or vascular headaches usually occur unilaterally and might be accompanied by nausea. They can be new in onset or exacerbated with use of oral contraceptives. Occasional headache occurring bilaterally at the temples is characteristic of tension headache and is not associated with oral contraceptive use. Headaches associated with edema of the legs might be associated with fluid retention related to oral contraceptive use; a lower dose of estrogen might decrease these headaches. A gradual increase in intensity of bilateral headache is typical of tension headaches and is likely not related to oral contraceptive use. 138. When a client taking oral contraceptives complains of nausea or vomiting several hours after meals, the care plan should include which of the following measures? 1. 2. 3. 4.

Take the medication upon waking but before rising. Increase the amount of carbohydrates in the diet. Switch to an oral contraceptive with more estrogen. Consider an oral contraceptive with less progestin.

(4) When a client taking oral contraceptives experiences nausea and/or vomiting several hours after meals, it is most likely caused by hypoglycemia related to the progestin in the oral contraceptive. The client could consider switching to a pill with less progestin. Nausea associated with oral contraceptives can sometimes be relieved by taking the pill at night or with food. If the nausea is caused by estrogen, a diet lower in carbohydrates might be helpful. If the nausea caused by the estrogen component of the oral contraceptive persists, the client could consider switching to a pill with less estrogen.

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139. The nurse should recognize which of the following conditions as the most common cause of absence of menses while taking oral contraceptives? 1. 2. 3. 4.

too little estrogen pregnancy menopause post-pill amenorrhea

(1) The most common cause of absence of menses while taking oral contraceptives is too little estrogenic activity. It is often accompanied by spotting or breakthrough bleeding. It is not harmful and usually occurs during the first few months of oral contraceptive therapy. Pregnancy should be ruled out if two consecutive periods have been missed or if pills have been missed. Choice 3 refers to absence of menses. Choice 4 refers to the lack of resumption of menses after oral contraceptives have been stopped, the causes of which include pregnancy, menopause, and post-pill amenorrhea. When menses do not resume within three months of discontinuing oral contraceptives the woman is said to have postpill amenorrhea with or without galactorrhea. Post-pill amenorrhea without galactoria may be a result of pregnancy or pre-mature menopause or other causes. The question asks about absence of menses while taking oral contraceptives, not resumption of menses after stopping oral contraceptives. 140. Which of the following statements, if made by a client who is using a contraceptive patch, indicates a need for further teaching? 1. 2. 3. 4.

“I wear the patch on my inner thigh.” “I am working hard to keep my weight under 200 pounds.” “I understand the patch is as effective as taking birth control pills.” “I switch patches every week for three weeks, then I don’t wear a patch during the fourth week.”

(1) The patch should be applied to the lower abdomen, buttocks, back, or upper outer arm. Placement on the inner thigh can result in incorrect absorption. If a woman weighs more than 200 pounds, the patch might be less effective in preventing pregnancy. The patch is comparable to oral contraceptives in effectiveness and side effects. The patch is worn continuously for one week, and then changed to a new patch. At the end of three weeks of wearing patches, a woman does not wear a patch during the fourth week. Menstruation occurs during the fourth week. 141. Which of the following statements, if made by a client who has Norplant (subdermal implants), indicates that the client understands how Norplant prevents pregnancy? 1. 2. 3. 4.

“I have to replace the implants in five years.” “I can’t get pregnant because Norplant prevents ovulation.” “Norplant makes my cervical mucus thinner.” “I shouldn’t have any side effects.”

(2) Choice 2 is the only choice that directly answers the question of how Norplant works to prevent pregnancy. It is believed to prevent ovulation in most women. Choice 1 is true. The implants are effective for five years at which time they have to be removed and new ones inserted if continued contraception is desired. Norplant makes the cervical mucus thicker and more difficult for sperm to migrate through up the reproductive tract. 142. Which of the following symptoms should the nurse recognize as a side effect of Norplant (subdermal implants)? 1. 2. 3. 4.

weight loss increased vaginal bleeding euphoria headaches

(4) Headaches are a possible side effect of Norplant. Other side effects of Norplant include spotting, irregular bleeding, amenorrhea, increased incidence of ovarian cysts, weight gain, headaches, fluid retention, acne, mood changes, and depression.

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143. A client has been given instructions about Depot-Medroxy progesterone acetate (Depo-Provera). Which of the following statements, if made by the client, indicates that the client understands the instructions? 1. 2. 3. 4.

“I will be back in one month for my next shot.” “I might not tolerate the estrogen effects of Depo-Provera.” “I need to find another method of birth control because I’m nursing.” “It might take 10 months or so to become fertile again when I stop taking Depo-Provera.”

(4) When the client discontinues Depo-Provera it can take 10–18 months for fertility to return. Fifty percent of women regain fertility within 10 months. When prescribed as a long-acting contraceptive, Depo-Provera is a single injection given every three months. Depo-Provera does not contain estrogen. Because Depo-Provera is a progestin-only form of contraception, nursing mothers might find it to be an acceptable means of birth control. 144. Which of the following nursing actions is most effective when administering Depot-Medroxy progesterone acetate (Depo-Provera) to a client as a long-acting contraceptive? 1. 2. 3. 4.

Administer 400 mg/ml. Administer Depo-Provera into the deltoid muscle. Shake the medication vigorously before use. Administer between days 25 and 28 of the menstrual cycle.

(3) Depo-Provera, prescribed as a suspension, must be shaken vigorously immediately before each use. The dose of Depo-Provera is 150 mg/ml every three months for long-acting contraception. A higher dose of 400 mg/ml might be used in the treatment of endometrial or renal carcinoma. Depo-Provera should be injected deep into the gluteal muscle. Depo-Provera should be administered within the first five days of the menstrual cycle to ensure the client is not pregnant. 145. Which of the following behaviors is most likely to be associated with a 9-year-old child whose parents have divorced? 1. 2. 3. 4.

increased aggression somatic complaints extreme sadness anger

(2) A 9–12-year old is likely to respond to divorce with somatic complaints. The pre-adolescent might also respond with intense anger and confused identity. Increased aggression is characteristic of a 3–5-year old whose parents have divorced. Extreme sadness is mostly likely to be experienced by 6–8-year olds whose parents have divorced. Adolescents experience anger, though less than pre-adolescents, when parents divorce. 146. Which of the following essential features should the nurse expect to identify in a family experiencing partner relational problems? 1. 2. 3. 4.

overprotection or inadequate discipline negative or distorted communication development of symptoms in siblings difficulty with others, such as co-workers

(2) According to the DSM-IV-TR, the essential features of a family experiencing partner relational problems include a pattern of interaction characterized by negative or distorted communication or noncommunication associated with clinically significant impairment in one or both partners. Choice 1 is an essential feature of parent-child relational problems. Choice 3 is an essential feature of sibling relational problems. Choice 4 is an essential feature of relational problems not otherwise specified.

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147. Which of the following characteristics is most significant when assessing a family for structure? 1. 2. 3. 4.

process of resolving differences of opinion consideration of alternative lines of action amount and clarity of information exchange leadership and distribution of function

(4) To determine a family’s structure, the nurse must assess the leadership and distribution of function. When assessing for conflict resolution, the nurse should look at the family processes for resolving differences of opinion. Problemsolving abilities can be assessed by how a family considers alternative lines of action. The amount and clarity of information exchange helps the nurse assess the family’s communication. 148. When completing a family APGAR, the nurse should assess the degree of satisfaction in all the following categories except: 1. 2. 3. 4.

shared resources communication and problem-solving social support systems emotional interaction

(3) The family APGAR is a system to assess the degree of satisfaction that exists within a family. Social support systems might be important to how a family functions, but is not included in the APGAR because it doesn’t assess the interactions within the family. Besides the categories listed in Choices 1, 2, and 4, the APGAR assesses nurturing; freedom to explore new roles; and how space, time, and money are shared. 149. When assessing a client from a functional family, a nurse should expect to identify which of the following characteristics? 1. 2. 3. 4.

Children are responsible for activities advanced for their age. Differences between family members are discouraged. Emotional contact is maintained across generations. Third parties are commonly used to resolve problems.

(3) Healthy, functioning families maintain emotional contact across the generations and between family members while maintaining the necessary lines of authority. Children in functioning families are responsible for age-appropriate activities and have age-appropriate privileges. Functioning families encourage differences between family members so that each member can enjoy personal growth and creativity. In functioning families, differences are resolved between the two members who are having the problem without the involvement of a third party. 150. All the following characteristics, if identified in a client’s family, indicate to the nurse that pathology exists within the family except: 1. 2. 3. 4.

presence of a “super spouse” and a dependent, compliant spouse. positive emotional climate that is valued more than what “should” be done. excessive closeness between grandparents and grandchildren in which lines of authority are blurred. child who has poor peer relations while parenting younger siblings.

(2) All the choices, except 2, are characteristics of families that have a level of pathology within them. Functioning families actually value a positive emotional climate more than what should be done or doing what is “right.” The imbalance between the spouses in Choice 1 indicates a level of pathology. In Choice 3, it is a blurring of the lines of authority that makes the closeness between the and grandchildren pathologic. In this situation, the children act out because they lack a definitive parental figure, and clear limits have not been set. Children who have to parent younger siblings often have poor peer relationships because they have nothing in common with their peers.

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151. When the nurse is documenting a family history by using a genogram, which of the following should not be included? 1. 2. 3. 4.

living first- and second-degree relatives health status of index patient and ill relatives current household configurations four generations of family members

(4) Establishing the current household configurations and relationships between members is an important purpose of the genogram and is always included. All first- and second-degree relatives are included, dead or alive. If the relative is dead, a designation is made to show that. The health status of each person is listed, including the client, and the cause of death for deceased family member is documented. Three generations of family members are included in the genogram. 152. When family members use emotional isolation or geographic distance to deal with intense family conflict, the nurse should document this behavior as: 1. 2. 3. 4.

differentiation Family Projection Process triangulation Emotional Cutoff

(4) Emotional Cutoff is the concept in Family Systems Therapy that describes how dysfunctional families respond to intense crisis through emotional isolation or geographic distance. Differentiation is a concept that describes the separation between thinking and feeling so that an individual in the family is not dominated by the family’s emotional system. Family Projection Processes occur when spouses project their problems onto one or more of their children to avoid emotional conflict with the other spouse. Triangulation, or family triangles, can be described as predictable emotional processes that involve a third party. 153. When a family member has very low self-differentiation, which of the following behaviors should the nurse expect to identify? 1. 2. 3. 4.

personal autonomy ability to retain objectivity when stressed ability to distinguish between thoughts and feelings emotional reaction when stressed

(4) When a family member has low self-differentiation, they are emotionally reactive when stressed. The family member is less adaptable, less flexible and more emotionally dependent on those around them. Those family members having a high degree of self-differentiation have all the characteristics listed in Choices 1, 2, and 3. In times of stress they are able to engage in intellectual thinking, and are more flexible, more adaptive, and not as affected by the emotions of those around them. 154. Which of the following concepts must the nurse understand when working therapeutically with a family triangle? 1. 2. 3. 4.

There is always a victim. All members of a triangle participate equally in maintaining the triangle. Triangles can exist without the active cooperation of all members. A person’s position in a triangle remains constant.

(2) Triangles are not necessarily negative arrangements; they are the basis for emotional systems. A triangle consists of three people, two people and a group, two people and an object, or two people and an issue. It is a myth that one member of a triangle is a victim. By playing a victim role, a person eliminates his or her own responsibility. All members of a triangle participate equally in maintaining the triangle. It cannot exist without the active cooperation of all members. A person’s position in a triangle can change depending on the issue.

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155. Which of the following behaviors by the nurse indicates that the nurse is no longer therapeutic and has become part of a family triangle? 1. 2. 3. 4.

feeling sorry for a member of the triangle maintaining emotional contact with each family member identifying triangles in the nurse’s own family aligning with specific family members in a planned strategy

(1) When working with a family, the nurse can recognize when he or she has stopped being therapeutic and has become a member of the triangle by objectively monitoring his or her own behavior. The following behaviors indicate that the nurse has become part of a triangle: feeling sorry for or pitying a member of the triangle, feeling angry at a member or how the triangle functions, being overly positive about how the triangle functions, wanting to correct the behaviors of the triangle members, and discovering that the nurse no longer has responses to or questions for the triangle members when they meet together. The nurse remains therapeutic when the nurse is able to maintain emotional contact with each family member. Taking sides usually stops any progress in therapy, but, as a planned strategy, it can be helpful to align with specific family members. To be therapeutic, the nurse must be willing to examine his or her own family of origin and recognize the triangles that exist in it. The nurse might take on the same roles/positions within the client family if this is not done. 156. During work with a family, the husband becomes critical and intrusive. The best response by the nurse is: 1. 2. 3. 4.

[to the husband]: “It makes me irritated when you are this critical.” [to the wife]: “How do you feel when your husband interrupts with criticism?” [to both the husband and wife]: “We’ll talk about this more when you calm down.” [to the husband]: “If this is how you behave at home, I understand why your wife feels the way she does.”

(2) The nurse must avoid becoming part of the family triangle, and should elicit the other family member’s responses, as in Choice 2, rather than expressing his or her own emotions. This intervention feeds into the system and keeps the process between the spouses. Choice 1 is a true statement, but it brings the nurse’s emotional response into the situation, making the nurse part of the triangle. Choice 3 delays working through the situation and represents a missed opportunity; it does not teach the members of the triangle how to respond appropriately. Choice 4 is very judgmental and indicates that the nurse has taken the side of the wife. Choice 4 is not therapeutic. 157. When a family has been identified as a cohesive, nuclear family, which of the following characteristics should the nurse expect to observe? 1. 2. 3. 4.

geographic distance frequent contact and communication detachment from family of origin increased emotional dependence between spouses

(2) There are two main emotional systems in nuclear families: cohesive and explosive. Of the characteristics listed, only Choice 2 is identified with a cohesive family. Cohesive families are geographically close and have frequent contact and communication. Sometimes family members put geographic distance between themselves and the family because of conflict. When this happens and there are unresolved issues of detachment from the family of origin, the family member tends to marry someone from a cohesive family. Choices 1, 3, and 4 describe an explosive family, particularly if these characteristics are true of both spouses. They become much more dependent on each other and have intense relationships. 158. When a couple is experiencing marital conflict, which of the following characteristics is the nurse most likely to identify? 1. 2. 3. 4.

spouses highly invested in the happiness of the other productive marital counseling when both spouses are present unpredictable cycles of intense closeness, distancing conflict, and making up decrease in anger-provoking behaviors as therapy progresses

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(1) When marital conflict exists, it can be a result of spouses being highly invested in the happiness of the other (possibly to the point that self-worth is defined by the success of one’s spouse). The spouses continually struggle to have their individual needs met. Both sides are unwilling to compromise. Some spouses say they have invested so much in the success of the other spouse that they are unwilling to leave the marriage because they want to enjoy the results of their hard work. Marital counseling is most productive when begun with the spouse who is most motivated. If the couple attends together, the sessions are much less productive and many times progress is not made at all. When spouses in therapy begin changing the way they view themselves and working on conflicts with their family of origin, they begin making some positive changes; at this point, spouses not in therapy might wish to join the therapy. As old behaviors change, spouses not in therapy might increase the anger-provoking behaviors in an attempt to get things back the way they were. Cycles of intense closeness, distancing conflict, and making up in marital conflict are predictable. 159. When a marriage relationship has a dysfunctional spouse, the nurse should expect to observe all the following conditions except: 1. 2. 3. 4.

an emotionally, socially or physically disabled spouse. a mutually dependent relationship. one overfunctioning spouse and one underfunctioning spouse. a lack of emotional distance.

(4) The dysfunction of one spouse is actually the driving force that maintains emotional distance within a marriage relationship. The dysfunctional spouse has some degree of emotional, social, or physical disability. The dysfunctional spouse underperforms in the marriage, and the other spouse overfunctions to maintain equilibrium. In the process, a mutually dependent relationship emerges. When the dysfunctional spouse begins to improve, a disturbance is created in the balance of the relationship and the once-overfunctioning spouse might compensate less. 160. Which of the following children is most at risk for having parental conflict projected onto them? 1. 2. 3. 4.

a middle child a child entering school for the first time a child who has always lived in the same house a nine-year-old child

(2) Choice 2 is a normative event. This event might create enough anxiety and stress that parental conflict is projected onto the child. Normative events in a family are those events that occur in all families but that also generate anxiety when they occur; examples of normative events include entering school for the first time, entering adolescence, divorce, illness, and so on. The amount of stress an event creates makes a child vulnerable to having parental conflict projected onto him or her. Choice 1 is incorrect because the first and last child in a family are the most likely to experience the projection of parental conflict. The child described in Choice 3 does not reflect any change, so (from this limited description) the child is not considered at risk for the projection of parental conflict. A nine-year-old has already entered school for the first time, is in the school-age years when things remain fairly constant, and is not yet entering adolescence. This child is not at risk for projection of parental conflict. 161. When parents are in a triangle with a child who is acting out, which of the following interventions should be included in the plan of care? 1. 2. 3. 4.

Decide which consequences to apply when the child acts out. Always reassure the child that they are loved unconditionally. Both parents are responsible for all areas of discipline. Parents should not change personal plans to implement a consequence.

(2) It is always important to reassure a child that they are loved unconditionally. All actions are based on that premise. When a child is acting out and the parents are in a triangle with the child, one parent usually takes on the role of the “heavy” and the other parent is “the nice one.” In many cases, parents have given up their authority to the child. When intervening, it is important that consequences have been decided in advance and that they have already been communicated to the child. When the offense or acting out occurs, the consequences should be carried out, without yelling or

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other fanfare. It might mean that the parents have to change their personal plans to implement a consequence. In fact, a child might time an outburst to interfere with parental plans, prevent a consequence, or show that the child is still in control. Responsibilities should be divided between the parents so that the child knows with whom he or she must negotiate certain issues. For example, one parent might make and enforce the rules related to bedtime and allowance, while the other parent takes responsibility for nights out and household chores. This prevents the child from playing one parent against the other in a given area of responsibility. 162. Which of the following emotional responses is the nurse most likely to identify by analyzing the families of origin within a current nuclear family relationship? 1. 2. 3. 4.

a person’s predictable position in family triangles flexibility of thought freedom to choose emotional response proactive and fluid emotional responses

(1) By studying or analyzing the families of origin represented in a nuclear family, the nurse can identify several emotional responses. It is possible to predict what position a family member takes within family triangles related to certain issues. Over many generations, families develop a group think or “party” line about emotionally charged issues relating to money, sex, alcohol, politics, work, and so on. There is a loss of freedom and flexibility of thought. Families tend to polarize around these issues and develop very rigid and inflexible ways of thinking about them. When traditional ways of emotional response have been identified, the nurse can assist family members in creating strategies that free them from predictable ways of thinking, thus removing them from the triangle. 163. Which type of family is one composed of a mother, a father, and children living in one home with other relatives of the mother living near by? 1. 2. 3. 4.

nuclear extended stepfamily single-parent

(2) An extended family is one in which a nuclear family exists along with other relatives of one or both spouses. The other relatives do not have to live with the nuclear family to be considered an extended family. A nuclear family consists of a mother, a father, and one or more children. A stepfamily includes one divorced or widowed adult with all or some of their children and a new spouse with some or all of their children. The new spouses often have additional children together. Single-parent families are composed of a mother or father living with their biological or adopted children without a legal tie to a partner. 164. When methods of handling routine activities of daily living in a family are identified, the nurse documents the findings as: 1. 2. 3. 4.

Internal Structures. External Structures. Instrumental Functions. Expressive Functions.

(3) Instrumental Functions in families are ways of handling the routine activities of daily living. Internal Structures include family composition, rank, subsystems, and boundaries. External Structures include culture, religion, social class, mobility, environment, and extended family. Expressive Functions refer to nonverbal and verbal communication, problem-solving abilities, control issues, beliefs, alliances, and coalitions.

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165. Which of the following statements or questions by the nurse best assesses the External Structure that exists within a family? 1. 2. 3. 4.

“Tell me about how your family communicates.” “Tell me who the members of your family are.” “Who is responsible for deciding which responsibilities everyone has?” “Which culture or ethnicity best describes your family?”

(4) Choice 4 asks a question about culture or ethnicity; the External Structure of a family includes culture, religion, social class, mobility, environment, and the extended family. Choice 1 assesses how information is communicated within the family; communication is one component of Expressive Function within a family. Choice 2 assesses how the composition of the family composition is a component of Internal Structure. Choice 3 assesses how ordinary activities of daily living are accomplished; the ways in which families handle routine activities of daily living reveal the Instrumental Function of the family. 166. If the nurse defines a family in terms of each individual member’s ability to unify his or her personality with assigned positions, roles, family expectations, and norms of behavior, the nurse is using which of the following family theories? 1. 2. 3. 4.

Developmental Theory Interactional Theory Structural-Functional Theory Role Theory

(2) The Interactional Theory defines a family in terms of individual members, a unity of interacting personalities with assigned positions, roles, expectations, and norms of behavior. This theory sees families as closed units with little relationship to outside institutions, associations, or cultures. The Developmental Theory defines families as a group of interacting personalities, intricately organized into paired positions with norms for reciprocal relations and a prescribed role behavior for each position. According to this theory, families have a predictable natural history designated by stages. The Structural-Functional Theory sees families as a social system open to outside influences and transactions that maintains boundaries by responding to the demands of the system. According to Structural-Functional Theory, families passively adapt to external forces rather than act as agents of change themselves. Role Theory defines families in terms of each member’s role and how that role interacts with the other roles in the family unit. Roles include circumscribed behaviors, social positions, influencing group associations, defining the purpose of interactions, and providing norms for the family. 167. Which of the following strategies should the nurse use when utilizing the Developmental Theory for therapeutic interaction with a family? 1. 2. 3. 4.

Determine how family patterns are related to other institutions and overall society. Analyze role reciprocity, complementarity, and strain. Analyze developmental needs and tasks of each family life-cycle stage. Analyze roles, interstatus relations, authority, communication processes, and decision-making.

(3) Choice 3 describes a strategy that is appropriate for Developmental Theory. In addition to what is described, Developmental Theory strategies include analyzing family behaviors and changing developmental tasks and considering cultural influences for each stage of family life. Choice 1 describes a strategy that is appropriate for StructuralFunctional Theory. Choice 2 describes a strategy that is appropriate for Role Theory. Choice 4 describes a strategy that is appropriate for Interactional Theory.

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168. A nurse approaches family assessment by analyzing the family’s adaptive process, decision-making, exchanges between members, and cooperative and coercive processes. Which of the following theories is the nurse using? 1. 2. 3. 4.

Crisis Theory Family Systems Theory Developmental Theory Role Theory

(2) The approach described is consistent with Family Systems Theory. Crisis Theory includes analyzing the present situation and coping skills as well as identifying tasks to be mastered so that plans to cope can be established. In Developmental Theory, the tasks and developmental needs of each family life-cycle stage are assessed. Role Theory approaches include analyzing roles, relations, authority, communication, and decision-making abilities. 169. Which of the following measures, if included in the care plan for a family, is most effective in establishing the social functions of the family? 1. 2. 3. 4.

making a referral to social services for assistance with food and shelter providing parents with strategies for meeting the emotional needs of their children working with the community center on establishing a neighborhood watch arranging for a Big Brother or Big Sister relationship for the children in the family

(4) Social functions of the modern family include providing opportunities for observing and learning social and sexual roles. The Big Brother and Big Sister programs help provide mentoring for these roles. Assuring that families have basic food and shelter needs met helps establish the physical functions of the family. Affectional functions within a family are met when the emotional needs of family members are met. This is done by meeting emotional needs and promoting adaptation and adjustment. Neighborhood watches help protect families against danger, which is a physical function of families. 170. A family in which everybody smiles, no one admits to having any difficulty, and the presence of a superficial harmony is identified indicates to the nurse that the family is most likely using which of the following adaptive mechanisms? 1. 2. 3. 4.

coalitions resignation reaction formation withdrawal of emotional ties

(3) When families develop a reaction formation as an adaptive mechanism, the family can exhibit superficial harmony in which everybody appears to experience togetherness and everyone smiles, but no one offers expressions of love. When asked, family members deny conflict or difficulty. Great tension exists in these families because emotions and feelings are not expressed. If families develop coalitions or alliances as adaptive mechanisms, some family members side against other family members causing anger and antagonism. In time, the family member outside the coalition might move to get control. Resignation is an adaptive mechanism that creates temporary harmony because someone has suppressed his or her need for affection or emotional expression. The harmony is eventually broken when the capacity to suppress can no longer be maintained. When families use withdrawal of emotional ties, communication is reduced to handle the conflict. The family functions in a rigid and mechanical fashion. 171. Which of the following characteristics is a nurse most likely to identify in a client who is a middle child? 1. 2. 3. 4.

less stimulated toward achievement dominant with siblings and peers more dependent in relationships demonstrates superior use of language

(1) A middle child is less stimulated toward achievement. A firstborn child is more achievement oriented. Firstborn children are more dominant with siblings and peers than middle children. The youngest child in a family is more dependent in relationships. An only child is most likely to demonstrate superior use of language.

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172. A child demonstrates the following characteristics: He is assertive, responsible, independent, adept at various roles, not skilled at coping with jealousy, has difficulty sharing adult attention, and is able to entertain himself. A nurse should recognize these characteristics as indicative of which ordinal position in a family? 1. 2. 3. 4.

firstborn child middle child youngest child only child

(4) The characteristics described are that of an only child. Firstborn children have some similar attributes: They might identify more readily with their parents than with their peers, have a high level of self-discipline, and be goal directed. Middle children are similar in that they are prepared in a variety of roles. The youngest child in a family is much more dependent in his or her relationships and identifies more with peers than parents. 173. When assessing a client for positive adaptive sexual responses, a nurse should expect to obtain which of the following findings? 1. 2. 3. 4.

satisfying sexual behavior that respects the rights of others sexual behavior impaired by anxiety resulting from personal or societal judgment dysfunction in sexual performance sexual behavior that is harmful, forceful, nonprivate, or not between consenting adults

(1) A continuum of sexual responses has been developed that is free of moral judgment for the purpose of helping nurses understand the range of sexual responses. The most adaptive sexual response is Choice 1. Adaptive sexual responses include sexual behavior between two consenting adults, mutually satisfying to both but not psychologically or physically harmful to either, lacking in force or coercion and conducted in private. Choice 4 is at the opposite end of the continuum and represents the most maladaptive sexual responses. The choices in order from most adaptive to most maladaptive on the continuum are 1, 2, 3, and 4. 174. Which of the following phases represents the nurse’s first step in developing self-awareness and clarification of values regarding human sexuality? 1. 2. 3. 4.

anxiety anger cognitive dissonance action

(3) To help clients, it is vital for the nurse to possess knowledge and awareness of his or her feelings and values regarding sexuality. The first step in developing awareness is cognitive dissonance, which occurs when a situation arises that causes two opposing beliefs to exist. For example, the nurse might have been raised not to discuss sexual matters but recognize that, as a professional nurse, the nurse must be able to discuss sexual concerns with patients. Anxiety is the second step in which the nurse recognizes that uncertainty, insecurity, questions, and sometimes problems regarding sexuality are normal. The third step in the process is anger, which generally arises after anxiety, fear, and shock subside. The nurse begins to recognize that issues associated with sexual behavior are sometimes emotional and volatile. The final step in the process of self-awareness is action. The action phase progresses from data inquiry to choosing values to prizing values. The nurse finds healthy ways to explore and decide what to believe. 175. When a client says to the nurse, “I don’t feel like a man; I feel like a woman inside a man’s body, and as a woman I am attracted to men,” the nurse should recognize this as indicative of: 1. 2. 3. 4.

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bisexuality. transvestism. transsexualism. homosexuality.

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(3) Transsexualism is a term applied to individuals who experience a mismatch between their biological gender and their gender identity. Transsexuality is different from homosexuality in that homosexuals are comfortable with their biological gender and do not want to change their gender. Homosexuals are sexually attracted to members of the same gender. Many transsexuals are heterosexual but believe they belong to the opposite gender. Bisexuals are individuals who are sexually attracted to both men and women. Transvestites are usually males who dress in female clothing, but are married and practice heterosexual behavior. Transvestites do not seek hormonal or surgical treatment. 176. When a male client has premature or retarded ejaculation, which of the stages of the sexual response cycle is disrupted? 1. 2. 3. 4.

desire excitement orgasm resolution

(3) When the orgasm stage of the sexual response cycle is disrupted in males, they might experience premature or retarded ejaculation. Absence of the desire stage is characterized by hypoactive sexual desire disorder or sexual arousal disorder. When the excitement stage is inhibited, there might be erectile dysfunction. Interruption or inhibition of the resolution stage rarely results in any specific sexual dysfunctions. 177. When assessing a male client’s sexual genetic identity using the biological factors, the nurse should expect to obtain which of the following findings? 1. 2. 3. 4.

XX chromosomes XY chromosomes XXY chromosomes XXX chromosomes

(2) A biologic male typically has XY chromosomes. Males with Klinefelter’s syndrome have triple chromosomes with an additional X or Y chromosome, yielding an XXY or XYY pattern. A biologic female has XX chromosomes. Females with Turner’s syndrome have triple chromosomes with an additional X chromosome or a single chromosome (XO). 178. When assessing a 4-year-old female child according to Freud’s Psychosexual Theory, which of the following findings should the nurse expect to identify? 1. 2. 3. 4.

repressed sexual impulses Oedipus complex child’s focus is on genitals sense of pleasure derived from oral stimulation

(3) Children ages 3–5 are in the Phallic stage of Freud’s Psychosexual Theory. According to Freud’s Psychosexual Theory, children at this stage focus on the genitals. Male children in the phallic stage experience the Oedipus complex in which they fear their father might cut off their penis for being attracted to their mother. Female children in the phallic stage experience the Electra complex, characterized by a belief that they had a penis at one time, but it was cut off. Female children in this stage blame their mothers for the loss of their penis. Repressed sexual impulses are characteristic of the latency stage, which follows the phallic stage. The first stage of sexual development, according to Freud, is the oral stage. Children experience the oral stage between birth and 12–18 months of age. During the oral stage, pleasure is derived from oral stimulation such as sucking. The anal stage is from 1–3 years of age and is characterized by a focus on elimination functions and gaining control over urinary and fecal sphincter muscles.

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179. Using behavioral theories of sexual development, which of the following factors should the nurse expect to impact a child’s sexual development the most? 1. 2. 3. 4.

sexual abuse physiological responses to learned stimuli psychological responses to a reinforcement event measurable sexual behavior

(1) To some extent, all the choices are addressed in behavioral theories of sexual development. Behaviorists believe that sexual behavior is measurable and that it includes both physiological and psychological responses to learned stimuli and a reinforcement event. However, behaviorists also consider the sexual behavior of adults who care for children as very important. Further, they believe that sexual abuse in childhood leads to sexual difficulties in adulthood. Women who were sexually abused as children might experience depression, self-destructive behavior, suicide attempts, anxiety, and panic attacks. Men who were abused as children might experience erectile dysfunction, premature ejaculation, and low sexual desire. 180. A client who is receiving an selective serotonin reuptake inhibitor (SSRI) is at risk for developing which of the following sexual side effects? 1. 2. 3. 4.

anorgasmia increased libido premature ejaculation priapism

(1) Sexual dysfunction is a common side effect of SSRIs. While the medications have the capability of causing problems in any phase of the sexual response cycle, one side effect common to both genders is anorgasmia, or the inability to experience an orgasm. Clients on SSRIs are more likely to have decreased libido, delayed ejaculation, and erectile dysfunction. Priapism is the term used to describe a prolonged erection lasting four hours or more and is an unlikely occurrence while taking SSRIs. 181. When obtaining a health history from a female client who is concerned about contracting HIV/AIDS, which of the following sexual practices should a nurse recognize as having the greatest risk for infection? 1. 2. 3. 4.

unprotected heterosexual sexual contact intravenous drug use homosexual (lesbian) sexual contact protected heterosexual sexual contact with five lifetime partners

(1) Heterosexual sexual contact is the leading mode of HIV/AIDS transmission in women. The difference between Choices 1 and 4 is protection. Having five lifetime partners does not put a person in a high-risk category for transmission, particularly if the sexual contact is protected. Intravenous drug use causes fewer women to be infected with HIV/AIDS than does heterosexual sexual contact; further, the question asks about sexual practices. Lesbian sexual contact has a low risk of HIV/AIDS transmission because there is limited exchange of body fluids. 182. When assessing the sexual functioning of a postmenopausal woman, the nurse should expect to obtain which of the following findings? 1. 2. 3. 4.

increased elasticity of the vaginal walls decreased vaginal lubrication no change in sensitivity of the breasts increased blood flow to the vagina

(2) After menopause there are two main vaginal changes: decreased lubrication and decreased blood flow to the vagina. Decreased estrogen levels contribute to decreased lubrication. Additionally, there is decreased elasticity of the vaginal walls and decreased sensation in the breasts.

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183. When assessing the sexual function of aging men, the nurse should expect to obtain which of the following findings? 1. 2. 3. 4.

decreased refractory period increased physical need to ejaculate no change in amount of semen released increased time needed to obtain an erection

(4) As men age, more time and more direct stimulation are needed to achieve an erection. The refractory period is increased, there is a decreased physical need to ejaculate and the amount of released semen is reduced. Erections tend to be less firm, and ejaculations become less intense. 184. When an elderly client with a chronic illness says to the nurse, “I don’t seem to be able to have an erection anymore,” the best response by the nurse is: 1. 2. 3. 4.

“It is not uncommon for aging men to have difficulty having an erection.” “Tell me what medicines you are taking for your illness.” “Illness usually doesn’t cause difficulties with sexual functioning.” “I’ll let the doctor know you’d like to talk about this.”

(2) Chronic illnesses experienced by many elderly clients impact sexual functioning in several ways: physiologic process related to the illness, medications taken for the illness, and psychological issues surrounding the illness. The nurse should not assume sexual dysfunction is related to the aging process and should seek more information. Choice 2 is an example of the nurse seeking more information. Many medications interfere with sexual functioning. Aging male clients might require more time and more direct stimulation to attain an erection, but normal aging should not prevent them from having an erection. Illnesses that affect mobility, endurance, and blood or nerve supply can alter sexual functioning. Choice 4 closes communication with the client and suggests it is not appropriate to talk about this with the nurse. It is well within the practical nurse’s scope of practice to contribute to the assessment of client sexual functioning. 185. Which of the following measures, if included in the plan of care for an elderly client in a nursing home, is most effective to promote the client’s sexual expression? 1. 2. 3. 4.

Discourage physical contact between nursing home residents. Discourage discussion of sexual concerns. Insist on having patient room doors open at all times. Allow socialization with sexual partners.

(4) Older adults in a nursing home setting find it difficult to express their sexuality. By recognizing the sexual needs and privacy rights of elder clients, nurses can help nursing home residents with sexual expression. Nurses should facilitate sexual expression by encouraging socialization with sexual partners, discussion of sexual concerns, and closing doors to ensure client privacy. 186. When an elderly client reports to the nurse that her sexual activity is less than desired because she fears pain when positioning herself for intercourse, the nurse should expect to identify which of the following conditions in her medical history? 1. 2. 3. 4.

Chronic Obstructive Pulmonary Disease (COPD) stroke arthritis diabetes

(3) Persons with arthritis can experience limited range of motion and might experience pain when trying to position themselves for intercourse. COPD clients might experience dyspnea when having intercourse. Clients who have had a stroke might have damage to the nerve pathways, which might lead to erectile dysfunction. Diabetic clients might be impotent related to impaired blood circulation.

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187. When a client tells the nurse that he is really thinking about someone else while having sex with his partner, the nurse should recognize this as indicative of which of the following coping mechanisms? 1. 2. 3. 4.

projection rationalization fantasy denial

(3) Use of fantasy can be a normal coping mechanism used to enhance sexual experiences. Fantasies often create a way to increase sexual pleasure without indicating dissatisfaction with a current partner. Fantasy becomes maladaptive when it is used as a replacement for actual sexual expression. Projection is a coping mechanism that blames the partner for sexual dysfunction. Rationalization is another common coping mechanism related to sexual health that is maladaptive in nature; it allows the person to avoid dealing with sexual issues and attempts to rationalize or explain difficulty with sexual functioning. When clients use denial as a coping mechanism for sexual dysfunction, it is characterized by a refusal to admit a sexual problem exists and is considered maladaptive. 188. When a client says to the nurse, “I’ve never had any sexual problems with any of my previous lovers. I think my current partner is the problem,” the best response by the nurse is: 1. 2. 3. 4.

“I think you are using fantasy to keep from dealing with your sexual performance problem.” “Denying that you have a sexual problem only prolongs my ability to help you.” “When you rationalize your problem, it keeps you from finding out how to fix it.” “It sounds as if you blame your partner for the sexual problems you are having.”

(4) Projection is the blaming of the sexual partner for any sexual dysfunction the couple is experiencing, absolving the person doing the blaming from any responsibility. Projection is a maladaptive coping mechanism. Choice 4 indicates that the nurse has correctly identified the coping strategy the client is using and is creating an atmosphere where intervention can be successful. Choice 1 misidentifies the coping mechanism as fantasy. Fantasy can be a normal, adaptive coping mechanism. Choice 2 incorrectly identifies the coping mechanism as denial. Denial is maladaptive. Choice 3 incorrectly identifies rationalization, another maladaptive coping mechanism, as the manner in which the client is framing the problem. Before a plan can be developed for care, the correct assessment must be made. 189. When a client has a nursing diagnosis of Altered Sexuality Patterns, the nurse should expect to identify which of the following symptoms? 1. 2. 3. 4.

limitations in sexual behaviors lack of sexual satisfaction alterations in perceived sex role conflicts involving values

(1) When a nursing diagnosis of Altered Sexuality Patterns has been made, the nurse has identified difficulties, limitations, or changes in sexual behaviors or activities. Choices 2, 3, and 4 are all findings for the nursing diagnosis of Sexual Dysfunction. 190. When a client has persistent or recurrent delays in, or absence of, an orgasm following a normal sexual excitement phase (during sexual activity that is judged by the clinician to be adequate in focus, intensity, and duration considering the person’s age), the nurse should recognize this as indicative of: 1. 2. 3. 4.

sexual arousal disorder. hypoactive sexual desire disorder. sexual aversion disorder. orgasmic disorder.

(4) The description contained in the question matches the DSM-IV essential features of orgasmic disorder. Sexual arousal disorder is the persistent or recurrent, partial, or complete failure to attain or maintain the physiological response of sexual activity (or persistent or recurrent lack of a subjective sense of sexual excitement and pleasure during sexual

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activity). Hypoactive sexual desire disorder is the persistent or recurrent, deficit or absence of sexual fantasies and desire for sexual activity. Sexual aversion disorder is the persistent or recurrent, extreme aversion to and avoidance of genital sexual contact with a sexual partner. 191. When a client has a persistent association, lasting at least six months, between intense sexual arousal, desire, acts or fantasies, and nonliving objects (such as female undergarments), the nurse should recognize this as indicative of: 1. 2. 3. 4.

fetishism. frotteurism. exhibitionism. sexual masochism.

(1) Fetishism is characterized by the description contained in the question. Frotteurism is the persistent association, lasting at least six months, between intense sexual arousal, desire, acts, or fantasies, and rubbing against a nonconsenting person (usually done in crowded places by young men). Exhibitionism is the persistent association, lasting at least six months, between intense sexual arousal, desire, acts or fantasies, and exposing one’s genitals to an unsuspecting stranger. Sexual masochism is the persistent association, lasting at least six months, between intense sexual arousal, desire, acts, or fantasies and being humiliated, beaten, bound, or otherwise made to suffer (real or imagined). 192. When a nurse says to another nurse, “Homosexuals are sick and cannot control their sexual behavior,” the best response by the second nurse is: 1. 2. 3. 4.

“I agree and so must the courts because they take their children away from them.” “I think they should all be put in jail.” “It has been proven that homosexuals have a harder time adjusting socially.” “The fact is that heterosexual men are more likely to make objectionable sexual advances.”

(4) There are a lot of common myths about homosexuality. The comment made by the first nurse is one of those myths. The fact is that objectionable sexual advances are more likely to be made by heterosexual men. Most homosexuals experience the same social and psychological adjustments that heterosexuals do. When the myth described in the question is believed by authorities, homosexuals can become involved in the criminal justice system (even when innocent), and homosexual parents might have problems gaining or maintaining custody of their children. 193. While a nurse is teaching young adults about sexual expression, a student asks whether it is true that excessive masturbation is harmful. Teaching by the nurse should include all the following except: 1. 2. 3. 4.

There is evidence that masturbation causes physical problems. If it leads to pleasure and satisfaction, masturbation is unlikely to be a problem. Masturbation is a way to discharge sexual tension. Many people feel shame or guilt when they masturbate.

(1) There is no evidence that masturbation causes physical problems. The statements in Choices 2, 3, and 4 are all true and can be included in teaching. It can also be noted that some people do not masturbate because of feeling uncomfortable with how society views this practice. 194. If a nurse experiences sexual attraction to a client, all the following strategies preserve the nurse’s professional and ethical integrity except: 1. 2. 3. 4.

ignoring or denying the feelings. avoiding flirtatious gestures. avoiding sharing personal information. seeking consultation from a more-experienced nurse.

(1) To ignore or deny the feelings of attraction prevents the nurse from dealing with them and interferes with the nurse’s ability to provide quality care. If the nurse admits to the feelings without judging them, they can be dealt with.

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One of the best strategies is to seek consultation from a more-experienced nurse. The nurse should not tell the client about the feelings of attraction. The nurse should avoid flirtatious gestures and the temptation to share personal information. The nurse should never engage in sexual behavior with a client. To do so is not only harmful to the patient but puts the nurse’s license at risk and invites malpractice suits. 195. When a client expresses sexual attraction to the nurse, which of the following measures is the most effective first step in maintaining a professional nurse-patient relationship? 1. 2. 3. 4.

Redirect the client’s energies toward appropriate health-care issues. Explore the meaning of the client’s feelings and behaviors. Express nonsexual caring and concern for the client. Set limits on the client’s sexual behavior.

(4) The first step in maintaining a professional nurse-patient relationship in this case is to set clear limits on the client’s sexual behavior. The nurse might say, “Mr. Smith, when you ask me to get into bed with you it makes me uncomfortable and I’m asking you to stop saying that.” The measures listed in Choices 1, 2, and 3 might be appropriate after limits have been set. Redirecting the client’s energies to health-care issues helps focus the client on the reason he has a nurse and might contribute to exploring how nursing care makes the client feel. Many times it is being cared for that the client is responding to. Clients might confuse the feeling of being cared for with sexual attraction. Exploring the client’s feelings and behaviors is another way to help the client see that he is expressing sexual feelings to the wrong person and redirect them. The nurse can express nonsexual caring and concern by being a responsive listener and reinforcing the purpose of the therapeutic relationship. 196. A client has been given instructions about the relationship between diabetes and the client’s level of sexual functioning. Which of the following statements, if made by the client, indicates that the client correctly understands the teaching? 1. 2. 3. 4.

“Diabetes can cause impotence.” “I know I have diabetes, which means there is too much sugar in my blood.” “I have always had sex two to three times a week.” “Now that I know what to expect, I’m not nearly as anxious about how my illness might impact my sex life.”

(1) Choice 1 is straightforward and is the only choice that demonstrates the connection between illness and sexual function. The client is accurately describing the impact of diabetes on sexual functioning. There are at least four different content areas that must be covered when teaching clients about sexual responses and an organic illness such as diabetes. The first is to be sure they understand the variety of sexual responses. Choice 3 indicates that the client can describe his or her typical level of sexual functioning, which is another component in this topic. The nurse needs to be sure the client understands the physiologic component of his or her illness. Choice 2 shows that the client understands at least some of the physiologic component. The fourth topic of discussion is identifying ways the client’s sexual functioning can be enhanced and communicating about how sexual functioning can be improved. Choice 4 reflects that the client is more relaxed and has reduced anxiety about sexual functioning related to the illness. 197. Which of the following criteria must be met for a transsexual client’s request for surgical reassignment to be granted? 1. 2. 3. 4.

The client must be at least 21 years old. The client must live in the role of the preferred gender for at least two years. At least three therapists must agree that surgical reassignment is appropriate. Follow-up care must be provided.

(4) There are professional standards of care for surgical gender-reassignment clients. Because the surgical procedure is not reversible, the assessment phase is extremely important and follow-up care must be available. Clients must be at least 18 years of age, live in the role of the preferred gender for at least one year, and have a minimum of two therapists agree that surgical reassignment is appropriate.

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198. When a client has a nursing diagnosis of Altered Sexuality Patterns, which of the following nursing interventions assists the client to relate accurate information about sexual concerns? 1. 2. 3. 4.

Encourage relaxation techniques and alternative means of sexual expression. Explore sexual beliefs, values, and questions. Provide specific education about sexual health practices. Focus on behaviors that enhance role functioning and sexuality.

(3) If the goal for the client is to relate accurate information about sexual concerns, specific education needs to be provided. Otherwise, the client will continue to relate personal beliefs that might or might not be accurate. Other nursing interventions that assist the client in relating accurate information about sexual concerns include clarifying sexual misinformation, dispelling myths, giving professional permission to continue sexual behaviors that are not harmful, and reinforcing positive attitudes. Choices 1 and 4 are nursing interventions that assist the client in implementing a new behavior to enhance sexual response. Choice 2 is a nursing intervention to assist the client in describing values, beliefs, questions, and problems regarding sexuality. 199. The teaching plan for a comprehensive school sex education program should include all the following goals except: 1. 2. 3. 4.

Teach appropriate values, beliefs, and attitudes about sexuality. Communicate accurate information about sexuality. Help students develop relationships and interpersonal skills. Encourage the exercise of responsibility in sexual relationships.

(1) The nurse should provide opportunities for the students to develop their own values, beliefs, and attitudes about sexuality but should not determine for the students what appropriate values are. Choices 2, 3, and 4 are all goals of a comprehensive sex education program. Many times students have not gotten accurate information about sexuality because too few parents discuss sexual issues with their children, and many school sex education programs focus only on biological facts to avoid controversy. A comprehensive program helps students develop positive views about sexuality, gain factual information about sexual health, develop the skills to maintain sexual health, and provides students with the opportunity to acquire decision-making abilities related to sexual issues. 200. When reviewing the results of an adolescent risk survey about sexual behavior, which of the following findings should receive the highest priority in planning sex education programs? 1. 2. 3. 4.

Sixteen percent of students have had sexual intercourse with four or more partners. Fifty-seven percent of currently sexually active students used a condom during their last sexual intercourse. Twenty-eight percent of currently sexually active students used drugs or alcohol during their last sexual intercourse. Seven percent of students have had sexual intercourse before the age of thirteen.

(2) All the choices represent real findings of a recent CDC youth risk behavior surveillance. While the surveillance included other behaviors, of the ones provided in the question, Choice 2 represents the highest priority for education. Fifty-seven percent of students using a condom during their last sexual intercourse puts 43% of students at risk for sexually transmitted infections and unwanted pregnancy. Increasing the use of condoms becomes the number one priority in view of these findings. The second priority is Choice 3, to decrease alcohol and drug use because nearly one-third of the students used drugs or alcohol during their last sexual intercourse. Alcohol and drug use increase the risk potential of adolescents because they are more likely to have unprotected sex and not use condoms while under the influence of drugs or alcohol. Choice 1 describes a high-risk behavior, but, because it involves a smaller percent of students, it doesn’t carry the same priority for intervention. Choice 4 is the lowest priority of the findings listed, even though it is an ominous finding for the students it represents. All these issues can be addressed in a comprehensive sex education program, but the question asked for the highest-priority finding. The findings in order of priority are Choice 2, 3, 1, and 4.

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201. The manager of a pediatric health care clinic notices many staff absences due to illness and decides to present an in-service on illness prevention. What is the most important method of illness prevention that should be highlighted in the presentation? 1. 2. 3. 4.

wearing gloves while taking vital signs wearing a mask while caring for ill children frequent hand washing using antiseptic hand cleanser

(3) Frequent and effective hand washing removes most organisms from the skin. Contaminated hands are the primary cause of disease transmission. Using soap and water, or an antiseptic hand cleanser, has been shown to be effective in removing infectious agents. The Centers for Disease Control and Prevention (CDC), the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) and individual health care facilities establish guidelines and policies regarding preferred methods of hand washing before and after performing specific types of care. Wearing gloves while taking vital signs is only necessary when encountering blood or body fluids and is not the most important method of preventing illness. Wearing a mask while caring for ill children is only necessary when encountering highly contagious illnesses such as measles and varicella. 202. Which type of precautionary measures should the nurse use while caring for a client with an HIV-related illness? 1. 2. 3. 4.

standard precautions gloves and gown gloves, gown, and mask no precautions

(1) Standard precautions allow the nurse to choose the appropriate protective gear based on potential contact with blood or body fluids. Gloves, gown, and/or mask are only necessary if the nurse is coming in contact with blood or body fluids. Personal protective gear is not necessary for every interaction with the client described in the question. Using no precautions could put the nurse at risk for contracting HIV. 203. While taking a medical history, the nurse notes that a 35-year-old client has a history of hypertension in her family. The client’s mother and father have both been diagnosed with the illness. Although the client has not shown any symptoms of this illness, which piece of information should be included in the nurse’s teaching regarding prevention of this disease? 1. 2. 3. 4.

Increase sodium intake. Monitor blood pressure twice a day. Eliminate stress. Participate in a low-to-moderate intensity exercise program.

(4) Participating in a low-to-moderate intensity exercise program is the best prevention at this point in the client’s life. Increasing sodium intake could put the client at higher risk for developing hypertension. Monitoring blood pressure twice a day is an unnecessary measure if the client has shown no symptoms of hypertension. Limiting stress is important, but eliminating all stress from a client’s life is not realistic. 204. What is the nurse’s primary responsibility when following standard precautions in the care of a client? 1. 2. 3. 4.

Wear gloves and a mask when caring for a client who has diabetes mellitus. Place a sign on the door stating Body Substance Isolation Precautions. Consider all blood or body fluid a potential source of infectious agents. Wear gloves whenever in contact with the client.

(3) All blood or body fluids should be considered a potential source of infectious agents. Wearing gloves and a mask when caring for a client with diabetes mellitus is unnecessary unless contact with blood or body fluids is possible. Placing a sign on the door stating Body Substance Isolation Precautions is not necessary when caring for clients.

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Wearing gloves whenever in contact with the client is not necessary unless the nurse assesses a possibility for contact with blood or body fluids. If working in a facility that uses latex gloves, continued exposure can increase the potential for the nurse to develop a latex allergy. 205. Which of the following infectious agents is responsible for the most nosocomial infections? 1. 2. 3. 4.

fungi viruses protozoa bacteria

(4) Bacteria are the number one cause of nosocomial or health care–associated infections (HAIs). Prevention of the transmission of bacteria and other infectious agents can be accomplished through frequent hand washing, disinfection, cleaning, and the appropriate disposal of trash and linens. Infection control processes are essential in preventing the spread of disease in a health care facility. 206. The nurse has just completed a teaching session regarding the risk factors for coronary artery disease for a 45year-old male client. The nurse asks the client to verbalize the modifiable risk factors for the disease. Which of the following is the correct response? 1. 2. 3. 4.

cholesterol, menopause, and obesity heredity, smoking, and diabetes cholesterol, obesity, and smoking hypertension, gender, and obesity

(3) Cholesterol, obesity, and smoking are all considered modifiable risk factors. Other modifiable risk factors include hypertension and diabetes. Modifiable risk factors are those factors that can be monitored and changed by a client to decrease the client’s risk of developing coronary artery disease. Other factors such as age, race, menopause, heredity, and gender are considered nonmodifiable risk factors, or those that cannot be changed. 207. A 40-year-old female client has been admitted to the medical-surgical floor with acute bronchitis. During the nursing assessment, it is noted that the client’s mother and father have both died of COPD (Chronic Obstructive Pulmonary Disease), and the client admits to smoking a pack of cigarettes a day. What is the most important step in preventing the client from developing COPD? 1. 2. 3. 4.

Determine the client’s level of interest in smoking-cessation programs. Prevent the client from smoking while in the hospital. Teach the client to breathe deeply and cough frequently. Administer supplemental oxygen at 4L/min. via nasal cannula per the physician’s order.

(1) Determining the client’s level of interest in smoking-cessation programs is the most important first step in preventing chronic respiratory illnesses such as COPD. Smoking is associated with many pulmonary illnesses; however, the client must be ready and willing to participate in a cessation program to aid in prevention of these illnesses. Although preventing the client from smoking while in the hospital for bronchitis can help in the healing process, the client must stop smoking to prevent further pulmonary disease. Teaching the client to breathe deeply and cough frequently might help with oxygenation and healing from the present pulmonary illness but does not prevent the development of COPD. Administering supplemental oxygen might aid in the healing process but does not prevent the development of COPD. 208. Which test is important in the prevention of colon cancer and should be administered yearly starting at the age of 50? 1. 2. 3. 4.

barium enema upper GI series flexible sigmoidoscopy esophagogastroduodenoscopy (EGD)

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(3) A flexible sigmoidoscopy is important in the prevention of colon cancer and should be administered yearly starting at the age of 50. This test (or a colonoscopy) and a fecal occult blood test are recommended for all clients over the age of 50 for the detection of abnormal growths or polyps in the colon. An upper GI series and an EGD are radiological tests for detecting abnormalities of the esophagus, stomach, and duodenum but are not recommended for detecting colon cancer. A barium enema can show lesions in the colon but is not the test of choice for clients with no previous symptoms or history of GI problems. 209. A client with hepatitis B is being discharged in three days. What should the nurse include in the discharge planning? 1. 2. 3. 4.

Eat large meals three times a day. Avoid alcohol for one week. Family members do not need to receive an immunoglobulin shot. Use a condom during sexual intercourse.

(4) Hepatitis B is spread through blood and body fluids, so it is very important that the nurse discuss the use of barrier protection (such as a condom for sexual intercourse) with the client to prevent the transmission of this disease. Eating large meals three times a day might actually cause the client to have nausea. It is recommended that the client eat small meals throughout the day to avoid this complication. Alcohol is broken down in the liver; therefore, the client must avoid alcohol for one year to allow for recovery. The CDC does recommend immunoglobulin for post exposure of hepatitis B. It is also recommended that close friends and family members be vaccinated with the hepatitis B vaccine. 210. Most states require the administration of erythromycin (0.5%) or silver nitrate into the eyes of newborns to prevent which sexually transmitted disease? 1. 2. 3. 4.

HIV or AIDS gonorrhea syphilis herpes

(2) Untreated gonorrheal eye infections in newborns can cause permanent blindness; therefore, the laws in many states require the administration of this medication. HIV, AIDS, herpes, and syphilis do not cause blindness, but other preventive measures can be taken to prevent the transmission of these diseases from mothers to infants. 211. Which of the following is an example of a disease-prevention program? 1. 2. 3. 4.

prostate exam clinic breast exam clinic immunization clinic all the above

(4) All these programs are disease-prevention programs. The prostate and breast exam clinics aid in the prevention and early detection of cancer. The immunization clinic provides immunity from life-threatening illnesses. 212. A 45-year-old client has a history of celiac sprue (or gluten-sensitive enteropathy) with three hospitalizations over the past 10 years. The client’s last hospitalization was more than a year ago. The client is able to suppress his symptoms by eating a well-balanced, gluten-free diet. Dietary management of this disease corresponds with which level of prevention? 1. 2. 3. 4.

primary prevention secondary prevention tertiary prevention health promotion

(3) Tertiary prevention is the ability of the client to maintain wellness through adaptation. This client is able to change his diet to eliminate the GI symptoms associated with the illness and maintain wellness through this adaptation.

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Primary prevention involves activities that are utilized to prevent illness or injury. Secondary prevention involves early detection of a disease or illness and quick intervention to aid the client in maintenance of the disease or injury. Health promotion is any activity that increases a client’s health and wellness and prevents disease. The client already has the disease and cannot prevent it through health promotion. 213. While working in a university health care clinic, the nurse encounters an 18-year-old female student requesting birth control pills. The nurse teaches the student about contraceptives and sexually transmitted diseases (STDs). Which statement from the student indicates an understanding of the information? 1. 2. 3. 4.

“I don’t need to worry about getting pregnant even if I miss a pill.” “You can only get an STD if you have vaginal intercourse.” “I must use a condom or other barrier method to keep from getting an STD.” “Birth control pills are effective in preventing pregnancy and STDs.”

(3) Condoms or other barrier methods are the only mechanism for the prevention of STDs in the sexually active. If the client misses a pill, she is at an increased risk for getting pregnant. STDs can be contracted by any type of sexual encounter, including oral and anal sex, and are only prevented with the use of condoms or a barrier method. Birth control pills are not effective against STDs. 214. A 55-year-old female client recently had a bone scan. She was found to have a decrease in bone mass. What should the nurse recommend the client do to slow the development of osteoporosis? 1. 2. 3. 4.

Increase calcium intake. Decrease activity to prevent bone loss. Stop exercising to prevent bone fractures. Decrease sodium intake.

(1) Increasing calcium intake, along with vitamin D, might limit the rate of bone loss. This is an example of a treatment that might decrease progressive bone loss in postmenopausal women by decreasing the rate at which osteoclasts reabsorb bone. It is not classified as a bone-forming treatment. Exercise can help reduce bone loss. A sedentary lifestyle and a decrease in activity can increase the risk for bone loss. Sodium intake has no direct effect on bone loss. 215. A nurse is teaching a nutrition course at the local retirement center. Due to decreased peristalsis in some inactive elder adults, constipation is a concern. What recommendation can the nurse make to help prevent this problem? 1. 2. 3. 4.

Increase vitamin E. Increase fiber intake. Decrease water intake. Take aspirin once a day.

(2) An increase in fiber helps to increase the motility of the GI tract. This can help those with a tendency toward constipation. Increasing vitamin E and taking an aspirin once a day do not have a direct effect on the motility of the GI tract. Decreasing water intake can worsen an existing problem. Increasing water intake can help prevent constipation. 216. A 60-year-old client is scheduled for a colon resection at 7 a.m. tomorrow morning. What is the most important preoperative education the nurse can provide the client to decrease the client’s risk of developing pneumonia postoperatively? 1. 2. 3. 4.

incentive spirometry eating soft food supplemental oxygen splinting the abdomen

(1) Incentive spirometry is an important intervention in the prevention of pneumonia postoperatively. This activity increases lung capacity and helps mobilize the secretions that might settle in the client’s lungs during and after surgery.

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Eating soft food after surgery might be ordered when the client has progressed from clear to full liquids. This diet does not affect the development of pneumonia postoperatively. Supplemental oxygen might be ordered but does not decrease the risk of developing pneumonia. Splinting the abdomen helps the client decrease pain when coughing or turning but is not related to the prevention of pneumonia. 217. While at a health fair, a client indicates to the nurse that she has a mammogram yearly, conducts self-breast exams monthly, and has her cholesterol checked yearly. This conversation indicates to the nurse that the client believes which of the following? 1. 2. 3. 4.

She is at high risk for breast cancer. She is at high risk for heart disease. She understands the need for health promotion activities. She understands the need for disease prevention activities.

(4) The statement from the client indicates that she understands the importance of activities associated with disease prevention. There is no indication that she is at high risk for either breast cancer or heart disease. The client did not indicate participation in health-promotion activities, such as adhering to a heart-healthy diet or attending aerobic exercise classes three to five times a week. 218. A 47-year-old client with active tuberculosis is to be transported to receive a chest X-ray. Which precaution should the nurse implement to prevent transmission of the disease? 1. 2. 3. 4.

Provide the transport aid with gloves and a mask. Place a mask on the infected client. Provide a gown and gloves for the transport aid. Provide no isolation equipment during the transport.

(2) The client should wear a mask during the transport to X-ray. The X-ray personnel should wear an N-95 mask to protect themselves from tuberculosis. A gown and gloves are not necessary unless personnel anticipate coming into direct contact with blood or body fluids. Providing isolation equipment during client transport is an important nursing responsibility to prevent the potential transmission of infection. 219. The diabetes educator at the hospital has been providing diabetes education to a newly diagnosed elderly client. Why should the diabetes educator provide the client with information regarding foot care? 1. 2. 3. 4.

The client does not have good hygiene. The client is obese, and it is hard for him to see his feet. The client is at risk for increased neuropathy related to diabetes. The client is at risk for skin breakdown due to his age.

(3) The client is at increased risk for neuropathy due to diabetes. Neuropathy results in decreased sensation and circulation. The result can be skin breakdown, especially of the lower extremities (which are difficult to heal), and can require amputation if untreated. Good hygiene is important to remove microorganisms and prevent infection, but there is no indication the client needs this instruction. There is also no indication that the client is obese. Although the client is at risk for skin breakdown due to the aging process, it is not as great a risk as the diabetic neuropathy. 220. To prevent the postoperative complications of thrombophlebitis, the nurse should educate clients regarding which activities? 1. 2. 3. 4.

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Teach clients range-of-motion exercises. Teach clients ROM exercises Encourage early ambulation. All the above.

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(4) All these activities can aid in the prevention of clot formation and thrombophlebitis in postoperative clients. Ambulation and range-of-motion exercises are the best methods to prevent pooling of blood in the client’s legs and promote circulation. 221. A 71-year-old client has been admitted for Vancomycin-resistant enterococcus (VRE). Which of the following practices should be implemented with this client? 1. 2. 3. 4.

Equipment that is used often on the client should be kept in the room. The client should be kept in a negative-pressure room. Visitors should wear a mask. The client should not be transported without a mask.

(1) Equipment that is used often on the client should be kept in the room. Contact precautions should be in place for this client. When a client is placed on contact precautions, equipment (such as blood pressure cuff, thermometer, and stethoscope) is isolated with the client. This aids in prevention of nosocomial transmission of the disease. Gloves should be worn when coming in contact with the client, but sterile gloves are not necessary. A gown should be worn if the nurse determines that there is potential for contact with an infectious source. Visitors should also wear gloves when coming in contact with the client and should be instructed to do so by the nurse. Airborne precautions, such as a mask and negative-pressure room), are not required. 222. While providing home care for an immobile client with multiple sclerosis, the nurse should do which of the following to help prevent renal calculi? 1. 2. 3. 4.

Monitor the client’s intake and output. Strain the client’s urine for stones. Increase the client’s sodium intake. Educate the client to perform Kegel exercises.

(1) Monitoring intake and output can help the nurse to determine whether the client has urinary stasis. Urinary stasis can lead to the formation of renal calculi. This can also indicate whether the client has adequate fluid intake to prevent renal calculi. Straining the urine for stones is not necessary at this stage. Increasing sodium intake does not decrease the risk of developing renal calculi. Kegel exercises are effective in preventing urinary incontinence, not renal calculi. 223. A 44-year-old client has a family history of non-insulin-dependent diabetes mellitus (NIDDM). The client wishes to avoid the illness and requests information from the nurse regarding steps to lessen his risk for development of this disease. Which step(s) can the client take to aid in the prevention of this disease? 1. 2. 3. 4.

exercising weekly and maintaining weight within an acceptable range according to height eliminating sugar and fat from the diet decreasing fiber and water intake decreasing alcohol consumption

(1) Studies support teaching that moderate exercise and maintaining a healthy weight are steps that clients can take to reduce the risk of developing NIDDM. Excess weight and a sedentary lifestyle are added risk factors for this client. Clients who are of African-American or Hispanic descent are at a higher risk for developing this illness. Monitoring sugar intake and eating a healthy, low-fat diet can help in the overall health of the individual client; however, eliminating these items from the diet is not necessary and has not been shown to eliminate the risk of developing this illness. Decreasing fiber, water, and alcohol intake have not been associated with reducing the risk for NIDDM.

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224. A 36-year-old Latin-American client waits several months before seeking care for a cough and hemoptysis. The client is diagnosed with active tuberculosis. When the client is asked why she delayed seeking treatment, she replied, “I was still able to care for my family and go to work.” Which of the following factors contributed to the client’s delay in illness prevention? 1. 2. 3. 4.

lifestyle cultural beliefs religious beliefs fear

(2) Some clients in Latin-American cultures might believe that they do not require medical attention unless they are unable to perform daily activities such as work. Because the client is able to participate in her normal activities, she does not feel medical treatment is necessary. No information is given about the client’s lifestyle choices or religious beliefs. The client does not mention being afraid to seek medical advice or having a fear of disease. Based on the client’s statement, her cultural beliefs are the contributing factor. 225. An 85-year-old client at a nursing home has a 5 cm reddened area on her sacrum. What intervention can the nurse provide to prevent further breakdown of the sacrum? 1. 2. 3. 4.

Monitor white blood cell (WBC) count. Monitor nutritional intake to determine whether the client has an altered nutritional status. Place sheepskin booties on the client’s feet. Place the client on her back to prevent further breakdown from friction with the sheets.

(2) Altered nutritional status can be the cause of skin breakdown. If the client has not had adequate intake of protein and other nutritional components, the client is at risk for developing pressure ulcers. A serum protein is also recommended to assess the client’s nutritional status. Increasing the intake of water also prevents dehydration and dry skin. Monitoring WBC count indicates the presence of infection but does not prevent further breakdown. The breakdown is on the sacrum and not on the client’s heels, so the booties are not effective in preventing further breakdown of the sacrum. However, interventions focusing on prevention of breakdown on other areas that are prone to pressure is a prudent nursing action. The client should be turned at least every two hours. Immobility and lying in one position can increase the risk of skin breakdown. 226. A 58-year-old client has a family history of stroke. The client also has been diagnosed with Diabetes Mellitus and Hypertension. Which of the following is the highest-priority intervention for the prevention of a stroke? 1. 2. 3. 4.

controlling hypertension exercising moderately smoking cessation decreasing fat intake

(1) Controlling hypertension is the highest-priority intervention for the prevention of a stroke. Maintaining a blood pressure within normal limits decreases the risk of a stroke and is considered a modifiable risk factor. The client should carefully monitor blood pressure and take all blood pressure medications as prescribed by the physician. Any significant increases in blood pressure should be reported to the physician. Exercising moderately, stopping smoking, and decreasing fat intake can aid in disease prevention but are not the most significant interventions for a client that has been diagnosed with hypertension and is already at high risk for a stroke. 227. A pregnant client asks the nurse, “Because I am HIV positive, what can I do to prevent transmitting the virus to my baby?” Which of the following is the correct response? 1. 2. 3. 4.

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“There is nothing that can be done to prevent the transmission of the disease.” “Delivery through cesarean section can prevent the transmission of HIV.” “One preventive measure that can be taken is to bottle feed the baby.” “Breast-feeding can help prevent the spread of the disease.”

Health Promotion and Maintenance

(3) Although there is no way to know whether the child will acquire HIV after birth, one measure that can be taken to prevent further exposure to HIV is bottle feeding the infant because HIV can be transmitted through breast milk. The method of delivery does not decrease the risk of transmission. 228. Which of the following clients is at higher risk for stroke? 1. 2. 3. 4.

a 28-year-old Asian-American woman taking birth control pills a 36-year-old Native-American client with a history of diabetes mellitus a 45-year-old Caucasian man with a history of kidney failure a 56-year-old African-American woman with a history of hypertension

(4) African Americans, men, and clients with a history of hypertension, have been shown to have the highest risk for developing transient ischemic attacks and stroke. Although clients with a history of diabetes mellitus and those taking birth control pills are at risk, they are not at as high a risk as the client in Choice 4. The 45-year-old male Caucasian client with a history of kidney failure is not at a high risk. 229. Health care workers are at an increased risk for developing hepatitis B from exposure through client contact. How can health care workers decrease their risk of developing this illness? 1. 2. 3. 4.

Use standard precautions with every client. Be vaccinated with the hepatitis B series. Dispose of sharps in proper containers. All the above.

(4) All the methods are effective in decreasing the risk of developing hepatitis B by health care workers. Using standard precautions (including gloves, mask, gown, and goggles when there is potential for exposure to blood and body fluids) is the most important intervention health care workers can use to protect both themselves and the clients they care for. The hepatitis B vaccination is useful in providing antibodies to this virus that can provide acquired immunity. Using the proper container to dispose of sharps aids in the prevention of accidental needle sticks by safely isolating sharps. 230. A client asks for information on dietary requirements, including the best sources of carbohydrates, fats, and protein. Which of the following dietary considerations should the nurse encourage? 1. 2. 3. 4.

all low-carbohydrate foods good sources of protein only adequate intake of essential nutrients all minerals and vitamins

(3) Experts recommend that 15% to 20% of a person’s daily caloric intake come from protein, about 30% from fat, and 50% to 55% from carbohydrates. Protein-rich foods include poultry, fish, meat, eggs, milk and cheese (complete proteins), as well as some vegetables and grains (incomplete proteins). Fats are found in vegetable oils and animal fats both are needed for good health. Carbohydrates, which are ingested as starches (complex carbohydrates) and sugars (simple carbohydrates), are the chief protein-sparing ingredients in a nutritionally sound diet. In general, the diet should include more calories from complex carbohydrates, such as rice, bread, and legumes, than from simple carbohydrates, such as sugar, cookies, and candy. Excessive carbohydrate intake—especially of simple carbohydrates—can cause obesity, predisposing a person to many disorders. 231. Which of the following factors contributes to malnutrition in elderly clients? 1. 2. 3. 4.

lack of water supply and social stimulation poorly fitting dentures and limited mobility critical issues in family affairs smoking

(2) Poorly fitting dentures can decrease nutritional intake and limit variety in diet. Physical disabilities that limit mobility affect the ability to obtain, prepare, or eat food.

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232. Karen McNulty, age 18, is pregnant and comes to the prenatal clinic for a checkup. Because of her age and condition, Ms. McNulty is at nutritional risk. Which health history question should the nurse ask Ms McNulty to assess her nutritional status? 1. 2. 3. 4.

“Are you unhappy?” “Do you have a support person to cook for you?” “Have your eating patterns changed?” “Are you married?”

(3) Choice 3 is the best question. Other questions to ask in assessing Ms. McNulty include: “In what way have your eating patterns changed since you became pregnant?” “Are you taking any nutritional supplements, such as vitamins?” “How has your weight changed since you became pregnant?” “Are you currently breast-feeding another baby?” “What do you eat in a typical day (24 hours)?” “What snacks and fluids do you consume?” “Do you use any alcohol, drugs, tobacco, caffeine (coffee, tea, cola or cocoa), or salt?” “If so, what effects do they produce?” “Do you follow any special diets?” 233. Which assessment techniques are used to determine a client’s nutritional status? 1. 2. 3. 4.

inspection and palpation palpation and percussion laboratory and percussion auscultation and ballottement

(1) Inspection and palpation are the assessment techniques used to assess a client’s nutritional status. The nurse inspects the client’s skin, hair, and nails (integumentary system) as well as posture, musculature, and extremities (musculoskeletal system). The nurse also inspects the oral structures, eyes, and thyroid gland and palpates to detect enlarged glands, such as the thyroid (endocrine system), liver (gastrointestinal system), and spleen (immune system). 234. Susan Hammer, age 75, is admitted to the orthopedic unit for fractured hip repair. Because of the stress and immobility associated with this injury, Ms. Hammer is at increased risk for developing which metabolic disorder? 1. 2. 3. 4.

negative nitrogen balance hyperlipidemia hypoglycemia anabolism

(1) Negative nitrogen balance can result from inadequate dietary protein intake, inadequate quality of ingested dietary protein, or excessive tissue breakdown following stress, injury, immobility, or disease. 235. When obtaining a health history, the nurse asks basic questions that assess nutritional health. Based on Ms. Hammer’s developmental status, which question is the most important? 1. 2. 3. 4.

“Do you eat three times a day?” “What are your food preferences?” “Do you have any food allergies?” “Who prepares your meals?”

(4) Some elderly clients are unable to prepare their own meals and have no influence on what they eat, so this situation might influence their overall nutritional status.

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236. Which assessment technique helps determine protein and fat reserves? 1. 2. 3. 4.

height and weight measurements anthropometric arm measurements chest circumference measurements head circumference measurements

(2) Midarm circumference, triceps skin fold thickness, and midarm muscle circumference measurements help to determine the amount of skeletal muscle and adipose tissue, which can indicate protein and fat reserves. 237. One of the components of antepartal nursing care is childbirth education classes (health promotion). What is the main objective of most childbirth education programs in the United States? 1. 2. 3. 4.

a painless childbirth experience the participation of both parents in the birth process the elimination of medication in labor and delivery an emotionally satisfying birth experience

(4) The main objective of most childbirth education programs is an emotionally satisfying birth experience. Childbirth classes are designed to increase clients’ understanding of pregnancy and birth and to promote the optimum health of mother and baby. Through use of relaxation and other techniques, pregnant women are helped to better cope with labor and achieve an emotionally satisfying experience. The father of the baby is not always available to participate in the birth experience; successful childbirth is not solely dependent on this participation. Pain-free birth and avoidance of analgesia or anesthesia are not main objectives of childbirth education. 238. Ms. Blackburn brings her daughter, Becky, age 4, for her annual checkup. The nurse plots Becky’s height and weight on a pediatric growth grid. Normal growth is represented by which range of percentage? 1. 2. 3. 4.

50th to 100th percentile 25th to 75th percentile 10th to 100th percentile 5th to 95th percentile

(4) Measurements that fall between the 5th and 95th percentiles represent normal growth for most clients. The weight and height chart is completed for each child to help determine growth patterns. 239. The nurse should use which assessment tool to evaluate Mr. Greenspan’s nutritional patterns? 1. 2. 3. 4.

anthropometric measurements height and weight measurements 24-hour diet recall lipid profile

(3) To assess nutritional patterns, the nurse obtains a dietary history (using a 24-hour diet recall, 3-day or 7- to 14-day dietary inventory, food frequency form, or similar tool). Using this tool, the client writes down all foods consumed; this provides an opportunity for the nurse to analyze the client’s intake and make plans to teach a healthy diet, if indicated. 240. Vitamins are essential for: 1. 2. 3. 4.

transmission. psychosocial development. catabolism. metabolism.

(4) Vitamins are essential to support metabolism and are necessary for body maintenance. Vitamins are water soluble (B complex and C) or fat soluble (A, D, E, and K).

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241. A client has several laboratory tests to determine her level of wellness and nutrition status. A female adult who has iron-deficiency anemia falls below which of the following laboratory values: 1. 2. 3. 4.

10%–20% (HCT). 20%–30% (HCT). 17%–18% (HCT). 37%–47% (HCT).

(4) The normal hematocrit (HCT) range for a female adult is 37%–47%. The World Health Organization (WHO) considers an HCT less than 30 to be anemia. 242. During a preventive health care visit, an elderly client states that she is getting shorter. As part of the assessment, the nurse should ask for the client’s: 1. 2. 3. 4.

parents’ heights. usual water retention. calcium intake. previous weight and height.

(4) The nurse can use previous weight and height and current weight and height measurements in plotting the trend for this client. Additional assessment data that should be gathered includes the client’s eating patterns and general health status, as well as a psychosocial assessment. 243. Milestone achievements are data that most likely begin to appear in: 1. 2. 3. 4.

infants. children. adolescents. young adults.

(1) Plotting growth and development begins at birth and continues into childhood. Other milestone parameters of growth and development are also used to determine wellness and health. 244. Skin fold measurements are most likely performed on: 1. 2. 3. 4.

newborn infants who are small for their gestational age. children who have frequent sore throats. adolescents who plot within the 50th percentile. elderly adults who complain of weight loss.

(4) Skin fold (tricep-thickness) measurement is an advanced assessment skill. This measurement, along with midarm circumference, height, and weight, is used to determine the elderly client’s amount of skeletal muscle and adipose tissue. This helps determine the amount of dehydration, an issue of the utmost important to the elderly. 245. A weight of 60 kilograms (kg) in a 60-year-old female whose height is 5' 4" with a small frame is considered: 1. 2. 3. 4.

normal. slightly low. unusually low. very high.

(1) The weight in kg can be converted to pounds by multiplying it by 2.2. The client’s weight of 134.4 lbs. is a normal weight for the client’s height and age.

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246. How do sleep patterns change with age? 1. 2. 3. 4.

Total sleep time increases at age 4. During adolescence, total sleep time increases. The need for sleep increases with advanced age Sleep patterns change over an individual’s life span.

(4) Sleep patterns change over an individual’s life span. A newborn infant sleeps 16 to 20 hours a day and shifts into different sleep stages every 20 to 35 minutes. A 6-month-old infant sleeps about 13 hours a day and begins with NREM sleep rather than REM sleep. Total sleep time decreases from age 4 (10 to 12 hours) to age 10 (9 to 10 hours). During adolescence, total sleep time decreases to about 7.5 hours and remains at that level until about age 50. However, the amount of sleep in each stage shifts. After age 35, the amount of Stage 3 and 4 sleep decreases. Adults younger than 60 might have difficulty falling asleep, but—when asleep—have no difficulty staying asleep. The need for sleep does not decrease with age. After age 60, an individual has more Stage 1 and 2 sleep and less deep sleep. After age 70, sleep patterns can include daytime naps. 247. Which question should the nurse ask when assessing a client with a sleep pattern disturbance? 1. 2. 3. 4.

“Do you have any difficulty sleeping or falling asleep?” “Do you have any sight difficulties?” “Do you have any difficulty hearing?” “Do you have any problems with friends?”

(1) The nurse should ask the client whether the client has difficulty falling asleep and staying asleep. It is important to find out whether the client is excessively sleepy during the day, sleeps normally but at inappropriate times, sleepwalks, experiences night terrors or enuresis, or makes unexplained movements or noises at night. It is also important to ask about factors that influence sleep: age, exercise, smoking, caffeine, alcohol, diet, environment, and emotions. 248. Kate Jackson, age 50, presents for a follow-up evaluation of her hypertension. The nurse assesses Ms. Jackson’s health promotion and prevention patterns, including activities of daily living (ADLs) and sleep patterns. Which factor most influences Ms. Jackson’s ADLs? 1. 2. 3. 4.

occupation environment culture diet

(3) The following factors affect a person’s interest in and ability to perform ADLs: age and developmental status, culture, physiologic health, cognitive function, stress level, and biological rhythms. 249. To improve her cardiovascular status, Ms. Jackson has begun an exercise program. What should the nurse tell Ms. Jackson about exercise and sleep? 1. 2. 3. 4.

Vigorous exercise within two hours before retiring might inhibit sleep. Sporadic exercise before retiring induces sleep. Regular exercise inhibits sleep. Sporadic exercise induces sleep.

(1) Regular or sporadic exercise tends to have little effect on sleep. However, vigorous exercise within two hours before retiring might inhibit sleep by increasing metabolism, stimulating the client, and enhancing wakefulness.

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250. Ms. Jackson is beginning a weight-reduction program. Which effect does diet have on sleep? 1. 2. 3. 4.

A person gaining weight tends to sleep for shorter periods but more deeply than normal. A person losing weight might sleep for shorter periods and might have more-fragmented sleep. A person losing weight tends to sleep longer and deeper than normal. Diet has little or no effect on sleep-wake patterns.

(2) A person losing weight might sleep for shorter periods and might have more-fragmented sleep. An effective intervention is to plan to eat a snack, which includes a carbohydrate and a protein, before retiring to enhance the stability of blood sugar during the night. A person gaining weight might sleep longer and deeper than normal. 251. Jamie Sharp, age 22, is a nurse who works one night shift every three weeks. A work pattern that includes changing hours can disrupt the circadian rhythm. How long is the usual circadian rhythm cycle? 1. 2. 3. 4.

8 hours 10 hours 12 hours 24 hours

(4) The circadian rhythm, a type of biological rhythm, operates on a cycle of approximately 24 hours. The nurse should adjust his or her schedule during these times to alleviate the situation. 252. Margaret Cliff, age 25, has just given birth to a girl. What should the nurse tell Ms. Cliff about her infant’s sleeping patterns? 1. 2. 3. 4.

Infants normally have 10 to 14 hours of consolidated sleep daily. Infants normally have 16 to 20 hours of consolidated sleep daily. Infants normally have 10 to 14 hours of fragmented sleep daily. Infants normally have 16 to 20 hours of fragmented sleep daily.

(4) Neonates usually sleep 16 to 20 hours daily; the sleep is not confined to one period but is fragmented with frequent awakenings. 253. Mr. Jarvis’s health history reveals that he smokes. How can cigarette smoking affect sleep? 1. 2. 3. 4.

It should have no effect on sleep. It can reduce the amount of time needed to fall asleep. It can produce a deeper sleep for longer periods. It can cause lighter sleep with more frequent arousals.

(4) Smoking increases the amount of time needed to fall asleep and causes lighter sleep with more-frequent arousals Nicotine is a stimulant. 254. Mr. Jarvis has a high caffeine intake. How might this affect his sleep? 1. 2. 3. 4.

It should have no effect on sleep. It might increase sleep latency and reduce total sleep time. It might increase sleep latency and total sleep time. It might decrease sleep latency and total sleep time.

(2) Caffeine intake can increase sleep latency and reduce total sleep time. Caffeine is a stimulant.

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255. Jessie Clemon, age 73, is a recent widow who has been having difficulty sleeping. What is the normal sleep pattern of a 73-year-old person? 1. 2. 3. 4.

Sleep is consolidated and the percentage of REM sleep is reduced. Sleep is fragmented and might include a daytime nap. Sleep is consolidated but characterized by sleep latency. Sleep is fragmented but characterized by fewer arousals.

(2) Usually elders experience sleep latency, more arousals, fragmented sleep, and less deep sleep. By age 70, a person’s sleep is less consolidated and might include a daytime nap.

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Psychosocial Integrity This chapter contains questions and answers from the following topic areas: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Abuse or Neglect Behavioral Interventions Behavioral Management Coping Mechanisms Crisis Intervention Cultural Awareness End-of-Life Concepts Grief and Loss Mental Health Concepts Mental Illness Concepts

■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Religious or Spiritual Influences on Health Sensory/Perceptual Alterations Situational Role Changes Stress Management Substance-Related Disorders Suicide/Violence Precautions Support Systems Therapeutic Communication Therapeutic Environment Unexpected Body Image Changes

1. Which of the following nursing approaches is most therapeutic in assisting a client to cope with stressful life events? 1. 2. 3. 4.

encouraging the client to complain about the stresses experienced helping the client to refocus only on the positive aspects of stress encouraging the client to avoid thinking about future life changes helping the client to develop patience and skills to deal with life changes

(4) It takes both patience and skills to adjust to life changes. The more effective one’s coping skills, the more effectively one can deal with life stresses. Choices 1, 2, and 3 are incorrect; the client needs to look at both positive and negative aspects of change and to anticipate future changes. 2. Which of the following strategies is effective for a client who is coping with stress and anxiety? 1. 2. 3. 4.

expressing feelings, developing problem-solving skills, and exercising seeking a support system, developing problem-solving skills, and striving for independence and retribution encouraging family to intervene and solve the client’s problems role-playing all feelings and emotions, and gaining independence from stressors

(1) Coping strategies for stress reduction include expressing feelings, developing problem-solving skills, exercising, seeking a support system, striving for self-discipline, and participating in activities that induce relaxation. 3. A nurse is teaching a stress-management program. Which of the following beliefs should the nurse advocate as a method of coping with stressful life events? 1. 2. 3. 4.

Avoidance of stress is an important goal for living. Control over one’s response to stress is possible. Most people have no control over their level of stress. Significant others are important to provide care and concern.

(2) When learning to manage stress, it is helpful to believe that one has the ability to control one’s response to stress. It is impossible to avoid stress, which is a normal experience. Stress can be positive and growth-enhancing, as well as a negative force. The belief that one has some control can minimize the stress response.

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4. A client becomes angry and belligerent toward the nurse after speaking on the phone with his mother. The nurse recognizes this as which coping mechanism? 1. 2. 3. 4.

compensation introjection displacement projection

(3) Displacement is a coping mechanism in which a person transfers his feelings for one person to another person who is less threatening. 5. Several long-term clients have died at the same facility recently. Which of the following actions is most likely to represent ineffective coping? 1. 2. 3. 4.

The nurse talks at length to her partner about the deaths. The nurse keeps busy with other actions and doesn’t think about the deaths for several days. The nurse offers to work extra shifts for several weeks. Several nurses schedule a group session with agency clergy to discuss the deaths.

(3) Effective coping might include verbalizing feelings (one-on-one or in groups) and distraction. However, taking on extra work can serve as an additional stressor. Nurses who have not begun to resolve their own stress are unlikely to be able to meet the emotional needs of clients. 6. A 50-year-old male client is beginning to take insulin for diabetes. The nurse wishes to help him identify successful coping strategies that he might have used in the past during a similar stressful situation. Which of the following situations should she ask about? 1. 2. 3. 4.

interviewing for a new job death of a pet while the client was a teenager the person’s partner filing for a divorce starting to wear eyeglasses at age 30

(4) Wearing eyeglasses is an example of beginning a new strategy to assist with a lifelong health need. Interviewing for a job is a very short-lived situational stressor. Coping strategies effective during teenage years might not be relevant at age 50. Experiencing the stress of divorce is a social/role stressor unlike that of a health problem. 7. Two people have been in a car accident and have similar injuries. According to the Transaction Model, their degree of stress from the accident is: 1. 2. 3. 4.

completely individual based on previous experience. extremely similar because they had the same stimulus. an identical physiologic alarm reaction. different, depending on their external resources and support levels.

(1) In the Transaction Model, stress is seen as a personal experience that varies widely among individuals. Choice 2 represents the Stimulus Model, and Choice 3 represents the Response Model of stress. External resources and support are factors in determining stress levels, but the key aspects are internal, personal influences. 8. Although clients exhibit calm behavior, physical evidence of stress might still be manifested by: 1. 2. 3. 4.

constricted pupils. dilated peripheral blood vessels (flush). hyperventilation. decreased heart rate.

(3) With stress, respirations increase, pupils dilate, peripheral blood vessels constrict, and heart rate increases.

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9. The parents of a hospitalized young child have just been informed that the child has leukemia. The father responds by continuing his usual work schedule, rarely visiting, and asking when the child can return to school. Of the following, which is the most likely to be an appropriate nursing diagnosis at this time? 1. 2. 3. 4.

ineffective denial caregiver role strain rear compromised family coping

(4) The father demonstrates compromised family coping by his difficulty in being supportive. It is too soon for caregiver role strain to appear, especially because the child is not at home. Ineffective denial and fear are common reactions to this type of threat. 10. Mr. Jones, a 40-year-old businessman, is admitted to the hospital for diagnostic tests. He insists there is nothing wrong with him except a chest cold that he’s having difficulty shaking off. His wife says he coughs a lot, has lost 15 pounds, and seems easily fatigued. What defense mechanism is Mr. Jones using? 1. 2. 3. 4.

regression displacement denial projection

(3) Denial is an unconscious blocking out of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of development. Displacement shifts feelings to a more neutral person or object. Projection attributes one’s own unacceptable thoughts or feelings to another. 11. Mr. Jones (from the previous question) is diagnosed with a mass in the left upper lobe of his lung. He is scheduled to undergo a biopsy. When the nurse explains the procedure to him, he seems to have difficulty grasping what she is saying and asks questions such as, “What do you mean I’m going to have surgery? What are they going to do?” His voice is tremulous. His respirations are noticeably rapid at 28, and his pulse is 110. The nurse should assess Mr. Jones’s level of anxiety as: 1. 2. 3. 4.

mild. moderate. severe. panic.

(2) Moderate anxiety prevents the individual from grasping information, reduces problem-solving ability to less-thanoptimum levels, and is characterized by an increase in vital signs. Mild anxiety can heighten attention and enhances problem-solving. Severe anxiety causes great reduction of the perceptual field, while panic-level anxiety results in disorganized behavior. 12. Mr. Jones can be assessed as having a cognitive problem called: 1. 2. 3. 4.

rationalization. conversion. introjection. selective inattention.

(4) Selective inattention means that only certain things are understood or grasped. Choices 1, 2, and 3 are defense mechanisms, not cognitive problems.

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13. The nursing diagnosis formulated for Mr. Jones is Anxiety Related to Impending Biopsy. This anxiety is evidenced by voice tremors, elevated pulse and respirations, and by the client asking repeated questions such as, “What do you mean I’m going to have surgery? What are they going to do?” Choose an appropriate short-term goal related to this nursing diagnosis. 1. 2. 3. 4.

Before the biopsy, Mr. Jones accurately describes the procedure. Before the biopsy, Mr. Jones admits to the nurse that he might have lung cancer. Before the biopsy, Mr. Jones admits to the nurse that he has been denying his symptoms. Before the biopsy, Mr. Jones reports to the nurse that he will cooperate with the procedure.

(1) When Mr. Jones’s anxiety is under control, he is better able to attend to the nurse’s teaching and to comprehend the information he is given. Describing the procedure in his own words verifies his comprehension. None of the behaviors mentioned in the other choices directly relate to the behaviors that support the nursing diagnosis. 14. Which nursing intervention effectively addresses the short-term goal for Mr. Jones? 1. 2. 3. 4.

Reassure Mr. Jones that there are many treatments for a lung neoplasm. Use a calm manner and simple language to describe the procedure to him again. Tell Mr. Jones that the staff is prepared to help him in any way they can. Explain to Mr. Jones that he should not keep his feelings to himself.

(2) Giving information in a calm, clear manner helps the client grasp the important facts. Introducing extraneous topics, as in Choices 1, 3, and 4, can further scatter a client’s attention. 15. While working with Mr. Jones, the nurse begins to feel tense and jittery and notices that she is having some difficulty concentrating on what Mr. Jones is telling her. The nurse is experiencing: 1. 2. 3. 4.

introjected anxiety. secondary anxiety. empathized anxiety. maturational anxiety.

(3) Anxiety is transmissible from one person to another via empathy (the ability to experience another’s feelings). Introjected anxiety is an illogical choice because introjection is a defense mechanism. Secondary anxiety is associated with a physical disorder. Maturational anxiety arises from a situation in which there is a threat to the achievement of a developmental task. 16. The nurse encourages Mr. Jones to talk about his feelings and concerns. What is the rationale for this intervention? 1. 2. 3. 4.

Concerns stated aloud become less overwhelming and can serve as the basis for later problem-solving. Offering hope allays the client’s anxiety. Anxiety can be reduced by focusing on and validating what is occurring in the environment. Encouraging clients to explore alternatives increases a sense of control and lessens anxiety.

(1) All principles listed are valid, but the only principle directly related to the intervention of assisting the client to talk about his feelings and concerns is Choice 1. 17. As the nurse works with Mr. Jones, he begins to share his feelings and concerns. Which response by the nurse facilitates the development of the nurse-client relationship? 1. 2. 3. 4.

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“I’m willing to explain anything you need to know to make you more comfortable.” “Please don’t worry. I believe everything is going to be all right.” “I understand what you’re experiencing. My father had a tumor in his lung too.” “It must be very difficult for you to be going through this.”

Psychosocial Integrity

(4) Choice 4 displays empathy and acknowledges the client’s feelings. Knowing that someone understands and cares can lessen feelings of alienation and anxiety. Choice 1 avoids discussion of feelings; Choice 2 offers false reassurance; Choice 3 focuses on the nurse rather than the client. 18. A college student, who usually scores an A on his tests, scores a C on a difficult examination. When he received the grade, he experienced feelings of nausea, clamminess, and had difficulty comprehending what was written. When touched on the shoulder, he jumped, looked dazed, and walked away. The student is experiencing: 1. 2. 3. 4.

panic. mild to moderate anxiety. severe anxiety. reaction formation.

(3) The symptoms described are those of severe anxiety. The student seems to have a poor grasp of what is happening in the environment but is not totally disorganized, as he would be with panic-level anxiety. His symptoms, however, are more severe than those found with mild to moderate anxiety. Reaction formation is a defense mechanism unrelated to what is described in the situation. 19. A school-age client has just been diagnosed with juvenile diabetes. The client is very angry about her new disease. Which of the following statements is most appropriate for the nurse counselor to make when working with this client? 1. 2. 3. 4.

“Try not to be angry because you are receiving the best care possible.” “It is all right to be angry with your friends, but try not to be angry with your parents.” “Tell me what you do when you get angry.” “You learn quickly and will probably handle the treatment very well.”

(3) Therapeutic communication requires the nurse to choose the most effective approach to individual client situations. Words, or silence, can be used along with consistent nonverbal behaviors. If a client is angry and upset, the nurse should begin by accepting the client’s feelings, and then assess the meaning of the client’s communication. (first, listening to the client’s verbal and nonverbal messages, clarifying when needed, and then interpreting meanings). A defensive or argumentative approach to anger blocks further communication. The next step should be to define the desired client outcome. The nurse should focus on the client’s feelings (rather than the accusations) and reflect understanding of the client’s feelings. 20. Which of the following actions negates the principle of genuineness on the part of the nurse? 1. 2. 3. 4.

The nurse smiles at a joke the client tells. The nurse shows unconditional positive regard. The nurse’s behavior is inconsistent with her words. The nurse self-discloses.

(3) Genuineness and sincerity are demonstrated by consistency in words and actions. The nurse receives information from the client with open, nonjudgmental acceptance, clarifies as needed, and communicates understanding of information and feelings so that the client feels understood. 21. When a nurse is assigned to care for a client who speaks a language the nurse does not understand, an important intervention to facilitate communication with the client is: 1. 2. 3. 4.

relying on gestures and other forms of nonverbal communication. using validation as a therapeutic tool. using an interpreter. using simple pictures.

(3) When a client speaks a language the nurse does not understand, an interpreter can help facilitate communication. Nonverbal communication is important, but the client needs to provide information and verbalize thoughts and feelings to the nurse. Validation is an important therapeutic technique when relating to a client from a different culture, but it requires some verbal communication. Pictures can only aid in the communication of basic needs.

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22. A nurse and client are talking comfortably about the client’s progress and feelings about the therapeutic relationship. This is typical of which phase in the therapeutic relationship? 1. 2. 3. 4.

Assessment Orientation Working Termination

(4) Termination is an important phase in the therapeutic relationship, during which the nurse and client reassess the client’s progress, evaluate goal attainment and explore how the therapeutic relationship was experienced. It is also important to deal with feelings about termination during this phase. Assessment is an ongoing part of the therapeutic relationship and occurs in all phases. The Orientation and Working phases of the relationship are characterized by establishing trust (Orientation) and planning outcomes/interventions to assist the client in meeting goals (Working). 23. The nurse says to a client, “I’m here to help you.” The client states, “I don’t want to talk,” and turns away from the nurse. Basing your choice on knowledge about the Structural Model of Communication, which of the following statements about the situation is correct? 1. 2. 3. 4.

No feedback loop exists because the client did not respond. The client’s verbal and nonverbal behavior constitutes a feedback loop. The nurse’s message is the feedback loop. A feedback loop is not illustrated in the situation.

(2) A feedback loop is demonstrated in this situation. The Structural Model of Communication consists of a sender, receiver, message, context, and feedback loop. The receiver’s verbal and/or behavioral response constitutes feedback. Choices 1 and 4 are incorrect because the client’s verbal and nonverbal behavior does constitute a response to the message. Choice 3 is incorrect because the nurse is the sender of the message. 24. During an interaction with the nurse, a client with bipolar disease states that she doesn’t have anything to contribute to the art therapy group. Upon exploration of the client’s concerns, the nurse recognizes a pattern of withdrawal and nonparticipation in situations requiring communication with others. Which nursing diagnosis is appropriate for this client? 1. 2. 3. 4.

Impaired Social Interaction Impaired Trusting Relationship Impaired Nurse-Client Relationship Impaired Personal/Artistic Feelings

(1) The assessment data supports the nursing diagnosis of Impaired Social Interaction. Some defining characteristics of this diagnosis include limited communication with others and verbalization of negative feelings of insecurity around other people. Choice 3 is incorrect because no information is given about the nurse-client relationship. Choice 4 is incorrect because personal or artistic feelings are not necessary for participation. 25. An accurate statement about transference is: 1. 2. 3. 4.

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Transference occurs when a client attributes thoughts and feelings about a person in the client’s past to the therapist. Transference occurs when the therapist attributes thoughts and feelings toward the client that belong to a person in the client’s past. Transference occurs when the therapist understands and builds a value system consistent with the client’s value system. Transference occurs when the therapist recalls circumstances in his or her own life similar to those the client is experiencing and shares this with the client.

Psychosocial Integrity

(1) Transference occurs when a client attributes thoughts and feelings to a person (often the therapist) that belong to a significant person in the client’s past. Transference is a valuable tool used by therapists in psychotherapy. The therapist assists the client in exploring emotion-loaded areas by pointing out and interpreting the transference, in an effort to weaken the client’s defenses and bring repressed conflicts to the surface. This can enable the client to work through the situation toward a more-satisfactory conclusion. Finally, the therapist assists the client in converting new insights into positive choices in the client’s everyday life. 26. A behavior by a nurse that is not considered a boundary violation of the nurse-client relationship is: 1. 2. 3. 4.

narcissism. controlling. genuineness. keeping secrets about the nurse-client relationship.

(3) In a therapeutic nurse-client relationship, the focus is on the client’s needs, thoughts, feelings, and goals. The nurse is expected to meet his or her own personal needs outside the professional setting. Genuineness, positive regard, and empathy are personal strengths in a helping person that foster growth and change in others. 27. Paraphrasing, restating, reflecting, and exploring are techniques used for the purpose of: 1. 2. 3. 4.

clarifying. summarizing. encouraging comparison. placing events in time and sequence.

(1) Clarification includes the use of paraphrasing, which means to restate the basic content of a client’s message in different (often fewer) words. As a result, the client is made aware that the interviewer is actively involved in the search for understanding. Restating is described as the nurse mirroring the client’s overt and covert messages and can be used to echo feelings as well as content. Reflection models the thinking process and is used to help clients better understand their own thoughts and feelings. Exploring is a technique the nurse uses to examine important ideas, experiences, or relationships more fully. 28. When a client makes the statement, “I get all balled up when I try to talk to him,” and the nurse responds, “Give me an example of getting all balled up,” the nurse is using a technique called: 1. 2. 3. 4.

exploring. reflecting. interpreting. paraphrasing.

(1) A technique that enables the nurse to examine important ideas, experiences, or relationships more fully is called exploring. The nurse can clarify a vague or generic statement made by a client by exploring. 29. Which statement, made by the nurse to a client, is considered nontherapeutic? 1. 2. 3. 4.

“I know exactly how you feel.” “I’m not sure I understand what you mean.” “Tell me more about what happened when you resigned.” “I see that you are wringing your hands as we talk about the job interview.”

(1) Effective communication is a skill that develops over time and is a crucial tool for all nurses. Feedback is a vital component in the communication process for validating the accuracy of a sender’s message. The message in Choice 1 is that the nurse has experienced the same feelings the client is experiencing. Whether the nurse has had the same experience is not relevant to the client’s therapy because each person perceives experiences differently.

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30. The nurse tells a client, “While I’m here with you, I will focus on the content and process of our communication as a participant/observer.” The client looks blankly at the nurse. The communication is misunderstood due to: 1. 2. 3. 4.

a personal factor, that is, use of terms not understood by the client. a social factor, that is, the socioeconomic difference between the client and the nurse. an environmental factor, that is, the lack of privacy afforded the client. incongruent verbal and nonverbal communication.

(1) Various personal, environmental, and social factors can be responsible for effective (or ineffective) communication. In this case, a personal factor is involved: The nurse used a highly intellectual explanation of his purpose for talking with the client. 31. Which statement underrates a client’s feelings and belittles their concerns? 1. 2. 3. 4.

“You appear tense.” “Everything will be all right.” “I notice you are biting your lip.” “I’m not sure I follow you.”

(2) Choice 2 offers the client false reassurance. This is a nontherapeutic technique that suggests to a client that his or her views and feelings are not being taken seriously. The other choices illustrate the use of therapeutic techniques. Choices 1 and 3 seek clarification. Choice 4 makes an observation. 32. Which behavior indicates that the nurse is entering into a therapeutic relationship with a client? 1. 2. 3. 4.

Engaging in self-reevaluation regarding a personal experience similar to the client’s. Offering the client advice on how to deal with problems. Assisting the client by interpreting what the client’s statements really mean. Focusing the clinical interview on significant personal issues introduced by the client.

(4) During the Working Phase of a therapeutic relationship, the client (with the assistance of the nurse) identifies issues and dysfunctional behaviors that become the focus of the therapeutic work. Choice 4 points out the client-centeredness of a nurse-client relationship. Choice 1 is a nurse-centered behavior. Choice 2 gives advice and is a nontherapeutic technique. Choice 3 is a nontherapeutic technique. Choices 1, 2, and 3 are not specific to the Working Phase. 33. Which statement shows that the nurse has empathy for the client? 1. 2. 3. 4.

“It makes me sad to see you going through such anguish.” “I am glad to speak to the doctor on your behalf.” “You must have been very upset to do what you did today.” “This is an example of how none of us get by with anything.”

(3) Empathy illustrates that the nurse sees an event from the client’s perspective, understands the client’s feelings, and communicates this understanding to the client. Choice 1 focuses on the nurse’s feelings, rather than the client’s. Choice 2 is not empathetic; it’s a nontherapeutic action that promotes client dependence. Choice 4 is a punishing statement. 34. Which awareness helps the nurse identify possible countertransference? 1. 2. 3. 4.

The client’s reaction toward the nurse seems realistic and appropriate. The client states that her boyfriend is just like her father. The nurse feels exceptionally happy when the client has a good day. The nurse develops a trusting relationship with the client.

(3) Strong positive or negative reactions, to or overidentification with, a client signal possible countertransference. Nurses must monitor their own feelings and reactions carefully to detect countertransference and seek guidance if it is detected. Choice 1 describes a desirable outcome. Choice 2 suggests transference. Choice 4 describes a desirable outcome.

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35. How should the nurse respond if a client asks that information about their therapy not be shared with others? 1.

2. 3. 4.

“I will not share information with your family or friends without your permission. However, I need to share information that relates to your reason for being here and your safety, or the safety of others, with appropriate staff.” “The nice thing about a therapeutic relationship is that it is just between the nurse and the client. You have to tell others whatever you want them to know about you and the problems that led to your hospitalization.” “It really depends on what you choose to tell me. I am glad to disclose at the end of each session what I plan to report to other staff.” “I really cannot tell anyone about you. It is like talking about my own problems; we can help each other by keeping it between us.”

(1) A client has the right to know with whom the nurse shares information and that confidentiality is protected whenever possible. Choice 2 is untrue. While a therapeutic relationship is primarily between the nurse and client, other staff have a need to know pertinent data. Choice 3 is inappropriate. It promotes incomplete disclosure on the part of the client and requires daily renegotiation of an issue that should be resolved when the nurse-client contract is established. Choice 4 presents an inappropriate picture of the nurse-client relationship, suggesting that it is used for mutual problemsolving. The relationship must be client centered. 36. In which phase of the nurse-client relationship are client issues identified, explored, and resolved? 1. 2. 3. 4.

the Working Phase the Identifying Phase the Dysfunctional Phase the Termination Phase

(1) Providing support, guidance—including the client’s thoughts, feelings, behavior, and perceptions—is the major role of the nurse. Emphasize that there is no one right way of doing things. Assist significant others in helping the client work through the process. 37. Children respond differently to loss according to their: 1. 2. 3. 4.

developmental level. attachments to the loss. stressors at the time of the loss. psychopathology.

(1) Children respond to loss according to their developmental level, though individual differences affect response. Children, like adults, tend to grieve in stages. 38. The nurse has an important role in caring for a dying client. The nurse’s most effective approach to communication with a dying client is: 1. 2. 3. 4.

telling the client what death will be like. confronting the client with unwanted information. respecting the client’s dignity and autonomy. leading the client with future plans.

(3) The client should be respected and have autonomy. The client should take the lead in addressing what is important to him or her.

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39. The most important task of the nurse in helping a client in acute grief is to: 1. 2. 3. 4.

Use patience; express condolences. Talk to the bereaved person about thoughts on religion. Support the client and family. Tell the client to assume all routine activities.

(3) The most important task of the nurse in helping a client in acute grief is to first support the client and family. In addition, the nurse should employ methods that can facilitate the grieving process; show understanding and patience with the bereaved; and encourage the support of family, friends, ministerial staff, and others, as necessary. 40. Since a client’s diagnosis of terminal liver cancer, the nurse observes that the client’s family assists with all the activities of daily living. Which of the following rationales for self-care is most important for the nurse to communicate to the family? 1. 2. 3. 4.

Strengthening muscles might encourage healing of the cancer. The client needs time alone to reason through his diagnosis. Sense of loss can be lessened by retaining control in certain areas of life. Increased mental activity required for self-care enhances mood.

(3) It is important that independence be maintained in the dying client as long as possible to allow the client to feel some control and maintain personal dignity. Choices 2 and 4 might or might not be true; the question does not provide sufficient information to determine this. Choice 1 is a false statement. 41. A client confides to the nurse his distress regarding his mother’s remarriage two months following the death of his father. Which of the following outcomes is most therapeutic for the client? 1. 2. 3. 4.

expressing his emotions freely to his mother accepting the marriage without causing added stress to the relationship avoiding revealing his feelings to his mother having a friend discuss his feelings with his mother

(1) Healing of the relationship requires honesty and expression of concerns. This must occur between the parties involved in the relationship. The actions in Choices 2 and 3 do not help resolve feelings. Choice 4 does not encourage honesty and expression of concerns. 42. The nurse evaluates the outcome criteria of the nursing care plan of a dying client and discerns that the goal has not been met. Which of the following should the nurse do first? 1. 2. 3. 4.

Talk with the client’s family to determine whether it has intervened inappropriately. Notify the physician immediately. Reassess to determine whether the nursing diagnosis is appropriate. Ask that another nurse take over care of the client.

(3) The first action of the nurse is to reassess to determine why the plan was unsuccessful.. The nurse should also look at his or her own actions to determine appropriateness. Choice 4 is incorrect because it is important for the dying client to have continuity of care. Passing the client on to another nurse does not help the client to work through the grieving process and move to a resolution level. There are usually enough stressors for the client that changing the role of the nurse could add more problems to this situation. 43. Grief is best described as: 1. 2. 3. 4.

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a normal response to a significant loss. a mild to moderately severe mood disorder. the abnormal display of feelings associated with death. denial of the reality of the loss of a significant person, object, or state.

Psychosocial Integrity

(1) Grief is described as a normal response to a significant loss. The subjective feelings and effects that are precipitated by a loss are recognized as grief. 44. Which of the following statements indicates that functional grieving has taken place? 1. 2. 3. 4.

“She was so strong after her husband died. She never cried the whole time. She kept a stiff upper lip.” “She was a wreck when her sister died. She cried and cried. It took her about a year before she resumed her usual activities with any zest.” “He still talks about his mother as if she were alive today, and she’s been dead for four years.” “He never talked about his wife after she died. He just picked up and went on life’s way.”

(2) Functional grieving consists of a Task-Based Model that attempts to describe tasks that are involved in the process of grieving. The stages of grieving are accepting the reality of the loss, sharing in the process of working through the pain of grief, adjusting to an environment in which the deceased is missing, restructuring the family’s relationship with the deceased, and reinvesting in other relationships and life pursuits. The other choices describe situations of dysfunctional grieving. 45. A single male with very few close friends and relatives was very dependent on his mother before her death, although he often complained about her intrusiveness. Which of the following statements best describes his risk for problems in resolving his grief? 1. 2. 3. 4.

He is at no particular risk because the death of parents is an expected event in one’s life. He is at low risk because the task of young adulthood is to develop independence from the family of origin. He is at moderate risk. He is at high risk because he was dependent on his mother, demonstrated ambivalence toward her, and has a limited support system.

(4) Acute grief can be a time of exacerbation of a preexisting medical or psychiatric problem. A history of depression, substance abuse, or post-traumatic stress disorder can also complicate grief and might need special treatment. 46. Which statement about palliative care could serve as a basis for the introduction a nurse gives to a client? 1. 2. 3. 4.

Palliation focuses on aggressive comfort care when a cure might not be the goal. Clients receiving palliative care can realistically expect discomfort at life’s end. Palliation addresses emotional and spiritual pain more than physical pain. Clients receiving palliative care are relieved of the responsibility of most care decisions.

(1) Palliative care is a medical specialty that has grown out of the Hospice movement and the increasing awareness nationally of the need for better care for the dying. It focuses on aggressive comfort care when the goal might not be a cure. 47. Which nursing strategy is disruptive to the provision of nursing care for dying clients? 1. 2. 3. 4.

seeing a dichotomy between living and dying understanding that there is no right way to die learning to follow the client’s lead maintaining one’s emotional health

(1) The nurse needs to understand as much as possible about end-of-life issues to help protect dying individuals and give support where necessary. Palliative care focuses on aggressive comfort care (holistic care) when the goal might no longer be a cure.

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48. According to Engel, three phases are involved in the grieving process. By experiencing these steps, a person is believed to: 1. 2. 3. 4.

die with dignity. develop self-awareness. accept the inevitable. help family members.

(2) The phases of grieving have significance for the individual working through the loss. If the individual works through the stages, the outcome for the client might include resumption of more usual activities, feeling better, and placing loss in perspective. 49. Anticipatory grieving can be beneficial to a client or family because it can: 1. 2. 3. 4.

be done in private. draw a family closer and help them care for each other better. be discussed with others. help a person progress to a healthier emotional state.

(4) Anticipatory grieving is an intellectual and emotional response and a behavior by which individuals and families work through the process of modifying their self-concept based on the perception of the potential loss. Grief processes need to be recognized by the client. The nurse should develop a plan, help the client get to a resolution stage, and work through the grief stages. 50. The daughter of a hospitalized client who is dying has been crying outside the client’s room. The nurse determines that the daughter is experiencing: 1. 2. 3. 4.

an actual loss. a perceived loss. a personal loss. anticipatory grieving.

(4) The nursing diagnosis of Anticipatory Grieving is grieving based on the perception of potential loss. The characteristics of loss, personal resources and stressors, and sociocultural resources and stressors affect the grief process. Loss is defined as the experience of parting with an object, person, belief, or relationship that one values; the loss requires a reorganization of one or more aspects of the person’s life. 51. A newly graduated nurse is assigned to her first dying client. Nurses are best prepared to care for this client if they: 1. 2. 3. 4.

have completed a course dealing with death and dying. are able to control their own emotions about death. have developed a personal understanding of their own feelings about death. have experienced the death of a loved one.

(3) The reaction to a client’s impending or actual death, or to the potential reality of the nurse’s own death, depends on the nurse’s understanding of his or her own feelings about death. 52. When caring for a dying client who is in pain, the nurse should provide: 1. 2. 3. 4.

pain medication on a regular basis. frequent bathing and skin care. an environment that is quiet and limits visitors. a focus on the client’s needs.

(4) Nurses should focus on the client’s needs and assist the client in determining his or her own physical, psychological, and social priorities.

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53. The nurse is assigned to a client who was recently diagnosed with a terminal illness. During morning care, the client asks about organ donation. The nurse should: 1. 2. 3. 4.

have the client first discuss the subject with the family. suggest that the client delay making a decision at this time. assist the client in obtaining the information necessary to make this decision. contact the client’s physician to obtain consent from the family.

(3) The nurse should assist the client in obtaining information on organ donation so that the client can make the decision. This is a legally sensitive area for the nurse. It is difficult to work with a client at the end of life in this matter, as it requires specific policies and procedures of the health care facility. The Uniform Anatomical Gift Act is in effect in all 50 states and the District of Columbia, with some variations. State law governs the procurement process while safeguarding donor intentions, and designates procedures for use and distribution of organs. 54. A 78-year-old client tells the nurse that she hasn’t been eating very well since the loss of her spouse two months ago. The nurse determines that the client is in a state of: 1. 2. 3. 4.

shock. mourning. bereavement. acceptance.

(3) Bereavement is the subjective response experienced by surviving loved ones after the death of a person with whom they have shared a significant relationship. In shock, the survivor either refuses to accept the loss or shows intellectual acceptance of the loss but denies its emotional impact. Mourning encompasses the socially prescribed behaviors after the death of a significant person in the client’s life. Acceptance is reaching the point in the grief process where the client has worked through several stages to reach this point of accepting the loss. 55. The nurse’s role in health promotion regarding mental health is: 1. 2. 3. 4.

to foster support of the client and family, in helping them to learn from their experiences and renew their efforts to change. to help solve problems and make decisions for the client and family. to increase the lifestyle changes necessary for the client to live longer. to help the client modify behavior and change his or her environmental causes.

(1) The goal of health promotion activities within the mental health framework is to utilize the nursing process to identify the risk factors that are inherent in a client’s life in order to motivate the client to reduce specific risks and develop more positive health habits. 56. The concept of holistic health within the mental health framework includes: 1. 2. 3. 4.

proper clothing, nutrition, and exercise. herbal teas, special foods, and acupuncture. concentration, relaxation, and social systems. moxibustion, special foods, and relaxation

(3) The interrelated facets of mental health include concentration, relaxation, social systems, hobbies, and family activities. 57. Developmental stressors that can increase anxiety in middle-aged adults are: 1. 2. 3. 4.

menopause, climacteric, and aging. retirement, alcoholism, and drug addiction. menopause, birth, and alcoholism. aging, birth, and obesity.

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(1) Developmental stressors, such as menopause, the climacteric, aging, and impending retirement and situational stressors (such as divorce, unemployment, and death of a spouse), can cause increased anxiety and depression in middle-age adults. 58. Mental health factors that can affect levels of activity of in a client are: 1. 2. 3. 4.

temperature, safety, and values about health and exercise. depression, chronic stress, and fatigue. depression, osteoporosis, and congenital heart disease. stress, temperature, and availability of a gym.

(2) Mental and affective disorders such as depression, or chronic stress and fatigue may affect a person’s desire to be active. 59. Nursing intervention(s) for clients with mental health disorders include: 1. 2. 3. 4.

identifying long-term goals. encouraging expression of total life experiences. focusing on the symptoms of the client. encouraging greater self-understanding.

(4) Nursing intervention(s) for clients with mental health disorders include: promoting the client’s self-actualization by encouraging greater self-understanding, assessing, readiness for growth, identifying realistic short-term goals, encouraging the exploration of feelings, and focusing on the client (rather than on symptoms). 60. The major components of self-concept include: 1. 2. 3. 4.

depression, confusion, growth, and development. body image, identity, roles, and self-esteem. body image, self-esteem, and ideals of the world. self-esteem, roles, growth, and development.

(2) The person’s self-concept includes body image, identity, roles, and self-esteem. 61. A psychiatric nurse generalist differs from a psychiatric nurse specialist in that the generalist: 1. 2. 3. 4.

has an Associate degree. has a Master’s degree. has family certification. has a baccalaureate degree in nursing.

(4) Psychiatric nurse generalists have a baccalaureate degree in nursing. They and meet the profession’s standards of knowledge, experience, and quality of care. Specialists have graduate education, supervised clinical psychiatric nursing experiences, and a depth of knowledge, competence, and skill in psychiatric nursing. 62. What are the psychiatric nursing functions in primary prevention? 1. 2. 3. 4.

health education, referral, and support health education, symptom analysis, and development of disease plans support of client/social contacts, and improvement of environmental conditions improvement of environment; i.e. ( housing), and improvement of self-worth

(1) In primary prevention, the psychiatric nursing functions include health education, referral, and support.

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63. The Behavioral Model that nurses use with clients is: 1. 2. 3. 4.

the nurse and the client are equal, with the nurse acting as a guide. the nurse focuses on the client’s “whole” system. that “mothering” behaviors are learned, not instinctual. the client initiates therapy and defines the problem.

(3) The Behavioral Model is based on the concept that all behavior is learned. 64. Conceptual models of psychiatric nursing care include a nursing focus. What is the focus of nursing models? 1. 2. 3. 4.

Nursing models focus on the client’s biological, psychological, and sociocultural needs, and on the nurse’s caring function. Nursing models focus on the client’s interpersonal development, utilizing six phases of development along with nursing diagnoses and nursing interventions. Nursing models focus on the “here and now” of the client’s problems with appropriate intervention. Nursing models focus on the nurse’s role as a knowledgeable and positive influence on the client.

(1) Nursing models have a holistic approach to client’s needs. The client is seen as a whole and more than the sum of individual parts. 65. Which one of the following statements about a therapeutic nurse-client relationship is not true? 1. 2. 3. 4.

The social needs of both participants are considered. The relationship is focused on the client’s needs and problems. The relationship is directed toward specific goals. The relationship has clearly defined parameters.

(1) Therapeutic relationships differ from a social relationships because they are based on the needs of the client, are goal-oriented, and have clear parameters. Therapeutic relationships are professional relationships, with the nurse functioning as a therapeutic agent. Choices 2, 3, and 4 are true regarding a therapeutic relationship. 66. After having one conversation with a female nurse, a young male client asks the nurse for her phone number, stating that he would like to date her. Which of the following responses by the nurse is the most appropriate? 1. 2. 3. 4.

“I’m sorry, but I’m married and not interested in dating.” “It’s against hospital policy for me to date clients.” “This is a professional relationship, and we need to stay clear on that.” “I might consider dating you after you have fully recovered.”

(3) At the beginning of a professional relationship, it might be necessary to clarify the parameters of the therapeutic relationship. Choices 1 and 2 avoid the issue of dealing with the nurse-client relationship. Choice 4 is an unprofessional response. Because it is likely that the client is testing the nurse, this response may be very frightening to him. Promising to date a client is also unethical and unprofessional. 67. A client hospitalized under a voluntary admission wants to call his lawyer about a personal matter involving a lawsuit with his neighbor. Which of the following nursing actions is be appropriate in this case? 1. 2. 3. 4.

Allow the phone call without seeking further information. Ask the client detailed questions about the lawsuit. Allow the phone call only after the client explains what the matter is about. Call the lawyer to tell him that his client is hospitalized.

(1) One of the client’s rights is to manage his or her personal affairs, including communicating with others as necessary— to make phone calls, send letters, and so forth. Choices 2 and 3 indicate that the nurse is being too intrusive into the client’s personal affairs. Choice 4 represents a clear violation of the client’s right to privacy.

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68. The ANA’s Standards of Practice for the nurses who do not have a master’s or doctoral degree include: 1. 2. 3. 4.

basing actions on theoretical foundations. being accountable to a psychiatrist for client care. conduction clinical research. conduction psychotherapy.

(1) The ANA’s Standards clearly state that practice is to be guided by the use of theory. Choice 2 is incorrect, because the ANA’s Standards are focused on independent nursing functions. Choices 3 and 4 are incorrect because conduction of research and doing psychotherapy require the minimum of a master’s degree preparation. 69. Based on Maslow’s Hierarchy of Needs, which human need must be met after the need for food and water is satisfied? 1. 2. 3. 4.

security and safety love and acceptance beauty and philosophy recognition and competence

(1) After the need for food and water is satisfied, security and safety are necessary before a person can strive to meet higher needs. Physiologic needs take precedence over psychological and spiritual needs. Choices 2, 3, and 4 are all higher needs on Maslow’s Hierarchy of Needs. 70. The staff of a facility meets weekly to discuss the diagnoses and treatment protocols of newly admitted clients. Which framework for psychiatric care does this approach represent? 1. 2. 3. 4.

biomedical psychodynamic behavioral cognitive

(1) The biomedical framework is based on the disease model. Syndromes are diagnosed, and treatment plans are based on what is currently known about the condition and its treatment. Choices 2, 3, and 4 refer to other frameworks for psychiatric practice. 71. The coping mechanism that allows a person to get into a car and drive to work under dangerous conditions without fear of injury or trauma is: 1. 2. 3. 4.

repression. regression. projection. denial.

(4) Denial generally operates as a healthy mechanism that protects a person from the immediate shock of reality. Repression is the process by which thoughts and feelings are forced into the unconscious. Regression is a process by which a person avoids anxiety by returning to an earlier, more-comfortable time. Projection is the displacement of feelings perceived as negative onto another individual. 72. A child, age 21⁄2, begins to wet her pants when her newborn sister is brought home from the hospital. This behavior represents which of the following defense coping mechanisms? 1. 2. 3. 4.

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regression denial repression displacement

Psychosocial Integrity

(1) Regression is a process by which a person avoids anxiety by returning to an earlier, more secure time in life when needs were met more readily. Denial is an avoidance concept, protecting the person from the immediate shock of reality. Repression is a process by which certain thoughts and feelings are forced into the unconsciousness. Displacement is the transfer of an emotion from its original object to a substitute object. 73. After learning her diagnosis of Deep Vein Thrombosis, a client states, “If it is God’s will, I will get better.” Which of the following is the nurse’s highest-priority intervention to provide culturally competent care? 1. 2. 3. 4.

Notify the physician immediately. Convey respect for the client’s belief. Further assess the client’s knowledge of the disease. Introduce yourself with your title.

(2) To gain a client’s trust, respect for her beliefs must be conveyed even if the nurse personally disagrees with the belief expressed. Introductions and further assessment are important but are not specifically related to culturally competent care. Notifying the physician is not a high priority at this time. 74. A Jewish client confesses to the nurse his fear that he will never walk again following back surgery. The client states that his back problem is punishment for a past sin. What goal has the highest priority for this client? 1. 2. 3. 4.

restoration of spiritual well-being enhanced relationships with support people walking within three days of surgery to facilitate coping praying the rosary for forgiveness

(1) A nursing diagnosis of Spiritual Distress is appropriate for this client. Therefore, the most important goal is to help him restore spiritual well-being. Relationships and walking are not related to this diagnosis. The rosary is a Roman Catholic aid to prayer. 75. To provide culturally competent care, the nurse plans to provide a Chinese client with which of the following as the highest priority? 1. 2. 3. 4.

a visit from a rabbi a choice of diet written discharge instructions rather than oral a teaching video instead of oral and written instructions

(2) Culturally competent care includes providing the client with items from his culture, such as food choices. The nurse must understand the culture to provide this type of care. Unless the nurse knows whether the client is fluent in the English language, it is difficult to make an appropriate decision regarding choices 3 and 4. A rabbi is a spiritual leader in the Jewish religious community. 76. A four-year-old Mexican-American client has recently been diagnosed with leukemia. Which intervention is appropriate when considering the client’s culture? 1. 2. 3. 4.

Limit all visitors, including extended family. Encourage visits from extended as well as immediate family. Ban all visits from alternative healers. Make diet selections for the child and family.

(2) The extended family is usually considered a source of strength, support, and emotional stability for MexicanAmerican families. Alternative healers and specific foods might also be culturally important for the client’s state of health.

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77. Before acting on the perceived nonverbal behavior of a client from Italy, the nurse must do which of the following? 1. 2. 3. 4.

Validate the perception. Use a translator. Get another nurse to assess the client. Form a nursing diagnosis.

(1) Nonverbal behavior can have varied meanings among different cultures; therefore, the nurse must validate his or her perception. The question does not provide sufficient information to determine the need for a translator (as in Choice 2). Choice 3 is unnecessary, and Choice 4 is premature because the nurse has insufficient data. 78. An elderly client states that she is having difficulty sleeping because her spirit is disturbed due to sin in her life. Which of the following nursing interventions has priority? 1. 2. 3. 4.

Call the chaplain and schedule a visit. Ascertain which religious practice comforts the client. Pray immediately with the client. Administer sleep medications as ordered.

(2) Assessment of religious practices that the client finds comforting should be accomplished first to assist the client with spiritual distress. Choice 1 might be indicated as a response to Choice 2. Choice 3 might or might not be appropriate; the question does not provide sufficient data to support it. Choice 4 might be needed as an adjunct therapy for dealing with the client’s spiritual distress. 79. The major factor contributing to the need for culturally competent care is: 1. 2. 3. 4.

an increasing birth rate. limited access to health care services. demographic change. a decreasing rate of immigration.

(3) Census data on demographic changes from 1990–2000 relating to race reveals an increase in the Hispanic population in the United States. 80. The nurse providing culturally competent care to clients should be knowledgeable about: 1. 2. 3. 4.

rituals, customs, and practices. customs, dietary beliefs, and medications. practices such as voodoo. religion, customs, and gender habits.

(1) In providing culturally competent care, the nurse should learn the rituals, customs, and practices of the major cultural groups in the nurse’s practice area so that the nurse can provide high-quality care for clients. Common cues to subcultural or ethnic identities requiring assessments include religion, native language, food preferences, and characteristic body adornments (tattoos, jewelry, etc.). When the individual cues are identified, culturally sensitive nurses adapt care to respect each client’s beliefs. 81. The term culturally sensitive implies that the nurse: 1. 2. 3. 4.

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is prepared to do transcultural nursing. possesses knowledge of the traditions of clients from major cultural groups. applies underlying knowledge to providing nursing care. understands the context of the client’s situation.

Psychosocial Integrity

(2) The term culturally sensitive implies that the nurse possesses some basic knowledge of and constructive attitudes toward clients from the major cultural groups found in the nurse’s practice area. Choice 1 requires an advanced degree and certification. Choices 3 and 4 apply to nursing care in general and are not specific to culture. 82. An individual’s heritage and cultural background can: 1. 2. 3. 4.

disrupt the process of nursing care. lead to conflicts between the nurse and client. influence health beliefs and practices. influence and modify the client’s cultural characteristics.

(3) Health beliefs and practices, family patterns, communication style, space and time orientation, and nutritional patterns are all factors that might influence the health beliefs and practices of the client and the nurse-client relationship. Culture enables a person to behave reasonably in contexts that the person shares with members of the same culture. Culture is an integral component of nursing’s knowledge base and requires nurses to incorporate cultural differences into the client’s plan of care. 83. When initiating care for a client from a different culture than the nurse, which of the following is an appropriate statement? 1. 2. 3. 4.

“Because people in your culture don’t drink ice water, I will being you hot tea.” “Do you have any books I could read about your culture?” “Please let me know if I do anything that is not acceptable in your culture.” “You need to set aside your usual customs and practices while you are in the hospital.”

(3) The nurse should indicate that he or she is open to diverse cultural views and practices. Choice 1 assumes the client follows a particular cultural practice, which might not be the case. Nurses should learn about the major cultural groups in the practice area, but Choice 2 is not the best answer to the question. Choice 4 is an incorrect approach to culturally appropriate care. 84. Culture is the: 1. 2. 3. 4.

classification of human beings into groups based on particular physical characteristics. condition of belonging to a group whose members share a unique heritage. socially inherited characteristics of a human group. learned behavior by a particular person.

(2) Culture is learned behavior defined as the nonphysical traits, values, beliefs, attitudes, and customs of a group sharing a unique heritage. Culture might define how health is perceived. 85. A client states that his religion has placed an evil spell on him, and, unless it is removed, he will not get well. In planning care for this client, the nurse should: 1. 2. 3. 4.

call in the health care team to see what it can do. plan care with the client, setting goals together. call a witch doctor. ignore the client.

(2) Some cultures believe that magic can cause illness. Some people view illness as possession by an evil spirit. If necessary and important to the client in sharing goals for care, the nurse should incorporate religious and cultural beliefs to optimize care. The role of religion in health is very important and should not be overlooked as people usually interpret life-death and health-illness issues in terms of their cultural heritage of religious beliefs.

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86. When caring for a Hispanic client, the nurse notes that the client lowers her eyes when conversing. Culturally, this might be a sign of: 1. 2. 3. 4.

shame. deference. modesty. aggression.

(2) Lowering the eyes might be a sign of deference or showing respect to the caregiver. Many cultures hold those seen as healers in high esteem. Also, the Hispanic client might have difficulty adapting to a new environment and might be particularly vulnerable in a new health care setting. Cultural shock is a disorder that can occur in response to transition from one cultural setting to another. Expressions of culture shock can range from lowering the eyes to silence and immobility. 87. When assessing the pain of a client from another culture, the nurse should: 1. 2. 3. 4.

realize that everyone’s pain is similar. utilize the same criteria for pain assessment for all clients. encourage medically prescribed pain regimens. respect a client’s individuality in pain response.

(4) The nurse should respect a client’s individuality in pain response and discover the meaning of the client’s behavior. Client outcomes are established after assessment by the nurse, which includes cultural diversity. In clients of all ages expressions of pain differ as to type and coping behaviors. Assessments and interventions should be an ongoing process, encompassing the client’s culture and perception of pain. 88. Appropriate nursing interventions for a client experiencing illness using Dunn’s Model of Wellness should include: 1. 2. 3. 4.

providing holistic care as appropriate. discovering the causative agent of the disease. ascertaining the client’s perception of the seriousness of the disease. providing care directed solely to treat the disease.

(1) Dunn’s holistic health model holds that forces of nature (including health and wellness, physical, mental, emotional, and spiritual factors) must be maintained in balance and harmony. 89. A Catholic couple requests that communion be served to them and their hospitalized child prior to surgery. This is an example of which of the following types of client needs? 1. 2. 3. 4.

environmental physical spiritual sociocultural

(3) Spiritual beliefs should be honored when possible, showing respect for the client and their religion. Religion can be an important coping strategy that provides inner strength, as well as a frame of reference with which to organize information. 90. A nurse caring for a Puerto Rican client experiencing extreme anxiety notes agitated movements resembling seizure activity. The nurse should: 1. 2. 3. 4.

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ask for a neurological consult for the abnormal behavior. stay with the client to assess whether the behavior is culturally relevant and to ensure client safety. allow the client to have privacy until the behavior returns to an acceptable level. ask the client to cease the inappropriate behavior immediately.

Psychosocial Integrity

(2) Culture is complex and depends on an underlying social matrix, including knowledge, belief, art, law, morals, and customs. All phases of the nursing process are affected by the client’s and the nurse’s cultural values, beliefs, and behaviors. Client outcomes are influenced by culture and beliefs. 91. Which of the following cells produce myelin and permits rapid nerve conduction? 1. 2. 3. 4.

ependymal microglial oligodendroglial astrocytal

(3) Oligodendroglial cells form or maintain the myelin sheath of neural processes. Ependymal cells make up the membrane lining the cerebral ventricles and central canal of the spinal cord. Microglia are cells of the central nervous system that collect waste products of the body’s nerve tissues. Atrocytes, or spider cells, help maintain the chemical environment of cells. 92. The ability to sit upright in a chair is due in part to which of the following types of sensory perception? 1. 2. 3. 4.

tactile process kinesthetic process tactile nerves visceral process

(2) Kinesthesia refers to the ability to perceive direction, extent, or weight of movement. Tactile describes the perception of touch. Visceral refers to the organs in the body. 93. The purpose of the reticular activating system (RAS) in the sensory experience is to: 1. 2. 3. 4.

alert a person to more aesthetic stimulation. free the body to recognize all stimuli. maintain a sense of balance. remember information not immediately acted upon.

(4) RAS is essential to remembering information not immediately acted upon. The RAS is composed of the reticular formation, subthalamus, hypothalamus, and medial thalamus. The RAS extends from the core of the brain stem to all parts of the cerebral cortex. 94. Which of the following clients should the nurse be concerned about experiencing sensory overload? 1. 2. 3. 4.

a person who is blind and deaf a person with post-operative pain for three weeks a prisoner in solitary confinement a client in ICU for 14 days

(4) Light, machine noise, and multiple caregivers can lead to sensory overload for a client in the ICU. Too much stimuli at one time might be difficult for the client to process. 95. Appropriate assessment data to collect when assessing a client’s need for sensory stimulation includes: 1. 2. 3. 4.

race. age. gender. culture.

(4) Culture can be defined as the unique nonphysical traits (such as values, beliefs, attitudes, and customs) that are shared by a group of people and passed from one generation to the next. Culture can affect how health is perceived.

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96. A client is complaining of tingling and numbness in her hands and wrists. The nurse should conduct which of the following assessments? 1. 2. 3. 4.

general nerve assessment cranial sensory assessment cranial motor assessment peripheral nerve and motor assessment

(4) A peripheral nerve and motor assessment includes the evaluation of muscle movement and sensation. 97. An appropriate nursing diagnosis for a client with a medical diagnosis of Depression Secondary to Blindness might be: 1. 2. 3. 4.

Altered Sensory Perception and Integration (related to blindness). Impaired Communication (related to receiving and perceiving sensory stimuli). Social Isolation (related to sensory perception disturbance due to impaired vision). Anxiety (related to verbal communication and stemming from impaired vision).

(3) An appropriate nursing diagnosis for a client with a medical diagnosis of Depression Secondary to Blindness might be Social Isolation (related to sensory perception disturbance due to impaired vision). 98. Which of the following is not an appropriate nursing strategy to prevent sensory deprivation in an elderly client? 1. 2. 3. 4.

Determine whether the client needs for glasses and/or hearing aids. Note the condition of the client’s feet and dentures. Provide large-print books and magazines. Prescribe eye drops to assist in clearing vision.

(4) Sensory deprivation is described as a decrease in or lack of meaningful stimuli. When a person experiences sensory deprivation, the balance in the reticular activating system is disturbed. The person often experiences alterations in perception. 99. In assessing a client’s response to directing light into the eye, the nurse is assessing: 1. 2. 3. 4.

visual acuity. peripheral vision. pupillary response. extra ocular movements.

(3) Directing light into the client’s eye assesses pupillary response. 100. In assessing a client with Myasthemia Gravis (MG), one of the earliest findings is: 1. 2. 3. 4.

lid lag. opaque lenses. decreased papillary reflex. ectropin.

(1) Muscle weakness is the hallmark of MG. Lid lag, or pitosis, is one of the earliest symptoms of MG. 101. The neurotransmitter responsible for nerve conduction in the CNS is: 1. 2. 3. 4.

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GABA. acetylcholine. dopamine. serotonin.

Psychosocial Integrity

(2) Acetylcholine is the neurotransmitter released at neuromuscular junctions in the parasympathetic nervous system and sympathetic preganglionic fibers, and at some synapses in the CNS. 102. Most clients who have a cardiovascular accident (CVA) have pathology associated with the: 1. 2. 3. 4.

Circle of Willis. middle cerebral artery (MCA). basilar artery. vertibular artery.

(2) The MCA is an artery coming off the carotid artery. MCA pathologies most commonly result in CVAs. 103. In performing a two-point discrimination test, the nurse is assessing the function of which spinal cord column? 1. 2. 3. 4.

posterior column ascending posterior column descending lateral ascending anterior ascending

(1) Two-point discrimination is used to assess the posterior spinal column. The posterior column is also responsible for vibration and passive movement. 104. A touch assessment evaluates the function of which spinal cord tract? 1. 2. 3. 4.

posterior spinothalamic reticulo spinal cortico spinal

(2) Sensation of touch ascends the spinal cord as a tactile stimulation. 105. Vertigo is best described as: 1. 2. 3. 4.

a feeling of light headedness and giddiness. a vomiting episode. an inability to maintain normal balance in a standing or seated position. when the client forgets who he or she is.

(3) Vertigo is the result of a disturbance of the equilibrium and might be caused by a variety of things (including, but not limited to, middle-ear disease, toxic conditions caused by salicylates, alcohol, streptomycin, sunstroke, postural hypotension, food poisoning, or infectious disease). Choices 1, 2, and 4 might be concerned with decreased circulation of blood flow to the brain or other factors. 106. Sensation is integrated and interpreted in which lobe of the brain? 1. 2. 3. 4.

frontal parietal occipital temporal

(2) Sensation is integrated and interpreted in the sensory cortex, especially in the parietal lobe.

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107. A client has suffered a CVA, primarily affecting the Wernicke center in the brain. Which of the following symptoms should the nurse expect to note in this client? 1. 2. 3. 4.

inability to name objects fluent speech without content and meaning nonfluent speech, secondary to organizing and initiating speech inability to understand spoken language

(2) The Wernicke center is found in the temporal lobe of the brain. An injury to the Wernicke center can result in the inability to comprehend spoken or written words. Visual and auditory pathways might be unaffected. The client might be able to speak fluently but has a disordered speech pattern (called paraphasia, in which inappropriate syllables are inserted into words, and inappropriate words are substituted for appropriate ones). 108. When assessing proprioception, the nurse performs which of the following assessment tests? 1. 2. 3. 4.

heel to toe Romberg test Rosig test rebound tenderness test

(2) Proprioception is assessed with the Romberg test. Romberg’s sign is the inability to maintain body balance when the eyes are closed and the feet are close together. The sign is positive if the client sways and falls; this is seen in clients with sensory ataxia. 109. Which of the following statements best describes a crisis? 1. 2. 3. 4.

Crises are precipitated by multiple events. A crisis for one person is a crisis for the next person. Crises are chronic states of coping. Crises last approximately six weeks.

(4) Crises are acute (not chronic) events that are resolved in one way or another within a time period of approximately six weeks. Crises are usually triggered by a specific, identifiable event. A crisis for one person might not be perceived as a crisis by another person. 110. When a person expresses work-related frustration and anger by abusing her spouse at home, the nurse should identify this crisis as which type? 1. 2. 3. 4.

psychiatric emergency developmental anticipated life transition dispositional

(4) A dispositional crisis is a response to an external situation. The external situation, anger at work, is displaced to the spouse through abuse. An anticipated life transition crisis is a crisis that might be anticipated as part of the life cycle, over which the person has no control. A developmental crisis occurs in response to emotions triggered by an unresolved conflict in one’s life and is based on Freudian psychology. A psychiatric emergency crisis can occur when an individual’s general functioning has been severely impaired and the individual has been rendered incompetent. 111. A client who has suicidal intentions is experiencing which type of crisis? 1. 2. 3. 4.

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psychiatric emergency developmental anticipated life transition dispositional

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(1) A psychiatric emergency crisis occurs when an individual’s functioning has become severely impaired. An example is an individual who contemplates suicide. A developmental crisis can occur in response to a situation that triggers emotions related to unresolved conflict in one’s life. An anticipated life transition crisis might be anticipated as a part of a life-cycle transition over which the individual has no control. A dispositional crisis is an acute response to an external situation or stressor. 112. A client and his significant other have an argument. Which behavior by the client indicates that he is learning adaptability to solve problems related to situational frustrations? 1. 2. 3. 4.

The client says to the nurse, “Give me some of that medication before I end up in restraints.” When the significant other leaves, the client goes to the exercise room and punches on a punching bag. The client says to the nurse, “I am going to leave this relationship.” The client says to the significant other, “You had better leave before I do something I’m sorry for.”

(2) Choice 2 describes a client who is learning to adapt by channeling frustrations into acceptable behaviors. Choices 1, 3, and 4 demonstrate avoidance behavior, which does not help the client solve problems effectively. 113. A crisis occurs when an individual: 1. 2. 3. 4.

perceives a stressor to be threatening. has no support system. is exposed to a precipitating stressor. experiences a stressor and perceives coping strategies to be ineffective.

(4) A crisis is a reaction to a stressor that the individual perceives as unmanageable with his or her current coping strategies. The client has inadequate or ineffective problem-solving skills, resulting in an unresolved problem that might lead to a crisis. Choices 1, 2, and 3 are incomplete descriptors of a stressor. 114. A client’s home is destroyed in a fire. The client receives no major injuries but experiences disabling anxiety soon after the event. This type of crisis is: 1. 2. 3. 4.

dispositional. anticipated life transition. developmental. the result of an unexpected traumatic stressor.

(4) A home destroyed in a fire is an event caused by an unexpected traumatic stressor over which a person has no control and can result in the person experiencing disabling anxiety. 115. A recently divorced client comes to the clinic. The client is an established lawyer and has custody of two teenagers. The client states, “I can’t keep working so hard and raise my children the way I want.” This is an example of: 1. 2. 3. 4.

role ambiguity. role strain. role conflict. gender role stereotype.

(3) Role conflict reflects a situational role change that might be due to divorce. Role ambiguity occurs when the person lacks knowledge of role expectations, which fosters anxiety and confusion. Role strain occurs when the person perceives him- or herself as inadequate for a role. Gender role stereotype is a role assignment of what is expected of that particular gender.

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116. Which of the following techniques is appropriate for crisis intervention? 1. 2. 3. 4.

Role-Modeling Information-Giving Counseling Improvement of Functioning

(4.) In crisis intervention, the nurse’s therapeutic goal is of psychological resolution of the patient’s immediate crisis and restoration to at least the level of function that existed before the crisis period. 117. A major goal of crisis intervention is: 1. 2. 3. 4.

including family support in the crisis events. withdrawing direct nursing intervention to allow the client to exercise problem-solving skills. identifying client strengths, weaknesses, and healthy coping mechanisms. recognizing that rehospitalization is necessary in crisis events.

(3) With potential crisis situations, identifying a client’s strengths, weaknesses, and healthy coping mechanisms helps the client deal with self-esteem issues and achieve successful coping. Choice 1 does not build on the client’s strengths or skills. Choices 2 and 4 do not help the client in problem-solving and coping. 118. A nurse working with clients who suffer from chronic mental illnesses should be alert for high risk factors which could lead to a crisis. Possible “high risks” are: 1. 2. 3. 4.

demonstration of self-esteem based on success in college courses. a stable relationship with a mature therapist. a supportive spouse. a low-paying job and poor budgeting skills.

(4) A client with chronic mental illness who has a low-paying job and poor budgeting skills is at the highest risk for a crisis. 119. Which of the following health care workers is likely to have the most difficulty terminating a relationship with a client who required crisis intervention? 1. 2. 3. 4.

one who has highly developed empathy one who believes clients must participate in goal-setting one who needs to be needed by all one who identifies highly creative alternatives for clients

(3) The health care worker who needs to be needed is most likely to have difficulty terminating a client relationship because the worker is getting his or her own needs met by continuing the relationship. This health care worker cannot serve the client’s best interest, has poor professional boundaries, and needs intervention. 120. The crisis that might occur when an individual moves from one developmental level to another is called: 1. 2. 3. 4.

situational. maturational. reactive. adventitious.

(2) A maturational crisis can occur when an individual arrives at a new stage of development, finds that his or her old coping styles are ineffective, and has to develop new strategies. Situational crisis can arise from external sources, such as job loss or divorce. Adventitious crisis can occur when disasters (such as floods or hurricanes) disrupt coping. Reactive is not a classification of crisis.

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121. Which of the following should be considered an adventitious crisis? 1. 2. 3. 4.

death of a child due to SIDS being fired from a job retirement a riot at a newspaper office

(4) The riot at the newspaper office is unplanned, might be violent, and is not a part of everyday life. Choices 1 and 2 might cause situational crises, and Choice 3 might cause a maturational crisis. 122. The role of the nurse in a crisis intervention clinic might be described by all the following adjectives except 1. 2. 3. 4.

inflexible. active. supportive. goal-directed.

(1) Inflexibility is not a desirable attribute in a crisis-intervention nurse. Flexibility is a personal quality that enhances nursing effectiveness. 123. A client is being interviewed on her first crisis visit. The client states, “I am here because I need help.” The nurse can help this client focus on the reason(s) for her crisis event by asking any of the following questions except: 1. 2. 3. 4.

“Can we do anything for you?” “What has happened recently in your life that is different?” “What was happening to you just before you decided you needed help?” “What is happening that you have come for help today?”

(1) Choice 1 is a closed question that allows the client to say, “ No.” This blocks communication. Choices 2, 3, and 4 are open-ended questions that help the client identify the precipitating crisis event. 124. A client reveals that he is so anxious he cannot think straight because his spouse left him. To assess the client’s coping skills, the nurse should say: 1. 2. 3. 4.

“I can see that you are upset. You can rely on us to help you feel better.” “Do you think you deserve to have this happen to you?” “In the past, how have you handled difficult situations?” “What can we do to help you feel better?”

(3) This question can help the nurse assess the crisis situation. Choice 1 is an example of false reassurance because the nurse is guaranteeing that the client will feel better. Choice 2 is a closed, nontherapeutic question asking the client to respond in the negative. Choice 4 is incorrect because if the client knew what he needed to feel better, he would likely not be seeking help. 125. A client tells the nurse he finds playing his horn relaxing. The client has given up playing the horn because he moved into an apartment. He took Valium for a short time, but did not like the side effects. The nurse can appropriately suggest any of the following tension-relieving strategies except: 1. 2. 3. 4.

taking Valium four times per day. returning to the clinic in 24 hours for reevaluation. playing the horn in the park. visiting with his sister.

(1) Only a physician or nurse practitioner can prescribe drugs. Increasing the Valium might not be advisable, and the side effects might be increased. Valium is a drug used for anxiety but, like all anti-anxiety drugs, has many side effects.

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The client should speak with the physician regarding alternative drugs that might be more effective. Choice 2 can provide additional support for the client, as well as giving the nurse a chance to reassess the client. Choices 3 and 4 are coping mechanisms that might be tension relieving for the client. 126. A client who has been given a narcotic analgesic wants to go home from the Emergency Department alone. Which is the best intervention for the nurse when responding to the client’s wishes? 1. 2. 3. 4.

Drive the client home. Let the client do as she wishes. Ask the client how she will get home. Call a family member or significant other for the client.

(4) The best intervention for the nurse is to find a support person to transport and supervise the client. 127. The adjustment that takes place in human beings in response to a stressor is termed: 1. 2. 3. 4.

homeostasis. reaction. adaptation. reorganization.

(3) Adaptation is the process of adjusting to internal or external conditions or circumstances. A stressor is any condition or circumstance capable of producing stress. 128. A nurse employed in the intensive care unit of a hospital finds the job very stressful. An appropriate stress management activity for the nurse to engage in is to: 1. 2. 3. 4.

become involved in constructive change. sleep 4 to 6 hours every night. exercise for 20 minutes once a week. eat high-carbohydrate foods daily.

(1) An appropriate stress-management activity for the nurse is getting involved in constructive-change efforts. Development of a collegial support group to deal with feelings of stress generated in the work setting is another example of an appropriate stress-management activity for the nurse. 129. Which of the following interventions might a nurse recommend for management of lifestyle stress? 1. 2. 3. 4.

regular physical exercise. attendance at a support group. self-awareness skill development. time management.

(1) Regular exercise has been shown to be an effective intervention for the management of lifestyle stress. Nurses can teach a variety of relaxation techniques to their clients for use when they encounter stressful situations. 130. The nurse checks on a client before scheduled surgery. The client states that he is nervous, and his respiratory and pulse rates are elevated. The client is experiencing which type of anxiety? 1. 2. 3. 4.

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mild anxiety moderate anxiety severe anxiety panic

Psychosocial Integrity

(2) Moderate anxiety increases a person’s arousal state to a point where he or she express feelings of tension, nervousness, or concern and has changes in vital signs. Perceptual abilities are narrowed and attention is focused on a particular aspect of a situation, rather than on peripheral activities. 131. Even when clients exhibit calm behavior, physical evidence of stress can still be manifested by: 1. 2. 3. 4.

constricted pupils. dilated peripheral blood vessels (flush). hyperventilation. decreased heart rate.

(3) Physical evidence of stress includes rapid respirations, dilation of pupils, constriction of peripheral blood vessels, and an increase in heart rate. 132. A nonspecific response of the body to a demand is: 1. 2. 3. 4.

stress. distress. adaptation. homeostasis.

(1) A nonspecific response of the body to a demand is usually unpredictable and can occur at any time. Stress can be positive or negative. A certain amount of stress is normal and can stimulate an individual to purposeful action. 133. During the intershift report, a nurse notes that a client is reported as having been very nervous and preoccupied during the evening and that no family visited. To determine the amount of anxiety the client is experiencing, the nurse should ask which of the following questions? 1. 2. 3. 4.

“Would you like me to call a family member to come support you?” “Would you like to go down the hall and talk with another client who had the same surgery?” “How serious do you think your illness is?” “You seem worried about something. Would it help to talk about it?”

(4) Stating evidence and asking an open question helps the nurse make an accurate assessment about whether the client has a problem and, if so, formulate an appropriate plan. The overall goals for clients experiencing stress-related responses are to decrease or resolve anxiety, increase ability to manage or cope with stressful events or circumstances, and improve role performance. The nurse who is sensitive to client’s needs and reactions is an appropriate person to help the client choose the most effective intervention. 134. Complete assessment of a client must include identification of the impact of the psychosocial sphere on both the development of illness and the client’s response to illness. All the following choices depict the interaction between stress and the organism except: 1. 2. 3. 4.

biological needs—changes in physiological functions. interpersonal relationships—feelings of punishment. sociocultural—mobilization of social structures. psychological—feelings of hopefulness.

(4) Hopelessness is demonstrated by feelings of deprivation, boredom, grief, or sadness; feelings of anxiety, pressure, or guilt; feelings of danger; or a sense of failure or hopelessness.

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135. What is the basic component in the “bridge” between the mind and the body? 1. 2. 3. 4.

neurotransmitters stimulation of the parasympathetic nervous system biochemical steps of increasing sugar and water mechanisms of stressors with the pathological condition

(1) Neurotransmitters (such as norepinephrine, acetylcholine, and dopamine) are released when the axon terminal of a presynaptic neuron is excited. Neurotransmitters send messages between the mind and the body. Disorders in neurotransmitters are implicated in the development of many psychiatric illnesses. All brain functioning (whether it involves thinking, feeling, or sending messages to the muscles of the limbs or organs) depends on the neurotransmitters. 136. A client has received the following nursing diagnosis: Self-Esteem Disturbance (related to feelings of abandonment as evidenced by stated feelings of worthlessness). Identify an appropriate short-term goal for this client. 1. 2. 3. 4.

The client initiates daily social interactions with another client or staff. The client verbalizes two positive personal traits. The client identifies two personal behaviors that might push others away. The client agrees to take antidepressant medications regularly.

(2) The ability to verbalize something positive about one’s self indicates improvement in self-esteem. 137. The nurse wishes to reinforce a client’s self-esteem by acknowledging an improvement in her personal appearance. The client is wearing new clothes and has combed her hair. The most appropriate remark by the nurse is: 1. 2. 3. 4.

“You look nice this morning.” “I like the clothes you’re wearing.” “What brought about this stylish transformation?” “You’re wearing new clothes.”

(4) Clients with low self-esteem often see the negative side of things. They might perceive the compliments in Choices 1, 2, and 3 to mean they didn’t look nice yesterday, you don’t like their other clothes, or they weren’t stylish before. Neutral comments avoid negative interpretations. 138. To help a client meet the goal of improved self-esteem, the nurse should: 1. 2. 3. 4.

assist the client to identify and develop strengths. encourage the use of PRN (pro re nata; Latin for “whenever necessary”) anxiolytic medications. engage in power struggles as necessary. encourage behavior changes only when the client thinks she is ready.

(1) Assisting the client to identify and develop strengths helps the client improve his or her feelings of self-worth. 139. When caring for a client who has been given the medical diagnosis of Generalized Anxiety Disorder, the nurse experiences feelings of discomfort and anxiety. When the client starts trembling, perspiring, and pacing, the nurse gets cold, clammy hands and her pulse races. In such an interaction, the client most likely experiences: 1. 2. 3. 4.

claustrophobia. increased anxiety. fatigue. improved self-esteem.

(2) Anxiety is transmissible. The client who feels the nurse’s anxiety might experience a heightening of his own anxiety.

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140. A client’s spouse believes the client is going through a midlife crisis. Which of the following behaviors indicates that this is likely to be true? 1. 2. 3. 4.

The client buys a new wardrobe. The client is writing a novel. The client wallpapers her mother’s room. The client bakes bread for a neighbor.

(1) Erickson’s developmental task for middle-aged adulthood is generativity versus stagnation. Behaviors indicating lack of progression are self-centered (as in Choice 1) and demonstrate a lack of commitment. Successful task resolution is demonstrated by creativity and concern for others (as in Choices 2, 3, and 4). 141. A client is admitted to the nursing unit following a work-related injury sustained when the client failed to utilize safety devices available at his work site. The client tells the nurse that no one ever said the safety devices were important. In the report to the next shift, the nurse most appropriately states that the client is experiencing which of the following: 1. 2. 3. 4.

role ambiguity. interpersonal conflict. role mastery. cultural conflict.

(1) Role ambiguity occurs when the client does not know what to do or how to do it. The client’s situation best matches Choice 1. Choice 3 is the opposite of Choice 1. Data in the question does not support Choices 2 or 4. 142. The nursing diagnosis formulated for a client is Ineffective Individual Coping (related to feelings of loneliness and isolation as evidenced by use of overeating as a comfort measure). Which short-term goal is appropriate for this client? 1. 2. 3. 4.

The client verbalizes the importance of eating a balanced diet within two weeks. The client identifies two alternative methods of coping with loneliness and isolation within two weeks. The client verbalizes two positive personal traits within two weeks. The client appropriately expresses angry feelings within two weeks.

(2) The goal of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective Individual Coping. 143. A client is under a great deal of stress at work because she is working long hours to make up for a staff shortage. When the client gets home, she props her feet up in front of the TV and eats until bedtime. The client feels too exhausted to exercise and gains 25 pounds in a month. At 5', the client weighs 175 pounds. What is a possible etiology of the client’s obesity? 1. 2. 3. 4.

developmental obesity obesity related to an underlying medical condition reactive obesity side effects of pharmacotherapy

(3) Reactive obesity occurs when an individual uses excessive eating to cope with stress and anxiety. Developmental obesity results from overfeeding in childhood. No underlying medical condition or medication therapy that might produce weight gain is mentioned in the question.

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144. One of the goals for the client in Question 143 is to resolve compulsive eating problems by recognizing the anxiety that precedes bingeing and reducing it with a constructive strategy. Of the following interventions, which one helps the client operationalize this goal? 1. 2. 3. 4.

teaching stress-reduction techniques such as relaxation and imagery exploring the client’s need to single-handedly make up for a staff shortage exploring ways that the client can feel in control of her environment encouraging the client to attend a support group such as Overeaters Anonymous

(1) Teaching stress-reduction techniques that can be substituted for overeating most directly addresses the goal of replacing compulsive eating with a constructive anxiety-releasing activity. 145. A Native-American client has been hospitalized and requests that the tribal shaman be involved in treatment. The most appropriate nursing intervention in this situation is: 1. 2. 3. 4.

Explain to the client that this is not appropriate in medical treatment. Facilitate the client’s request by reporting to the treatment team. Ignore the client’s request, as it is not possible to do this. Reflect that the client is seeking magical healing rather than relying on science.

(2) Some Native Americans believe in the special healing abilities of a religious shaman. The client’s request is congruent with cultural beliefs and should be honored. The nurse can help facilitate this request by acting as the client’s advocate. Choice 1 is a value judgment and an inappropriate response to the client. Choice 3 is a disrespectful response that does not show acceptance of the client’s beliefs. Choice 4 is an interpretive response based on the nurse’s belief system and does not accurately reflect the client’s culture. 146. A structure that includes the nuclear family as well as other relatives (aunts, uncles, cousins, grandparents) who are committed to maintaining a close family support system is: 1. 2. 3. 4.

intragenerational/extended family. single/foster family. nuclear family. binuclear family.

(1) In some cultures, more than two generations live together. Intragenerational family structures provide support systems for several generations; the relatives of the nuclear family (aunts, uncles, cousins, grandparents) compose the extended family. A single-parent family is headed by a single man or woman. A foster family is an arrangement for temporary placement of children who no longer live with their birthparents. A nuclear family is a family structure composed of parents and their offspring. 147. A health care system that focuses on the health of the family as a unit, as well as the health and growth of each person in the unit is a: 1. 2. 3. 4.

closed system. communal system. open system. family-centered system.

(4) Family-centered nursing focuses on family structures, family roles and functions, physical health status, communication, values, and support and coping resources. Choices 1, 2, and 3 deal with arrangement and types of family units, not health care systems.

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148. Healthy families are __________ systems with complex interactions and supports that can be resources within the family and in the external environment. 1. 2. 3. 4.

family open closed miscellaneous

(2) The answer is “open.” A family with an open system is characterized by a high degree of awareness of each member’s needs, is able to support individual members in crisis, and has open channels of communication between all members. 149. Mutual support and self-help groups evolved because: 1. 2. 3. 4.

Clients like to meet with others who have similar needs. Clients want a lot of support. Clients do not get support at home. Clients’ needs are not met by existing health care systems.

(4) Mutual support and self-help groups focus on nearly every major health problem or life crisis that people experience. These groups evolved primarily because people feel they need support in addition to that provided by existing health care systems. 150. Appropriate client education includes all the following except: 1. 2. 3. 4.

teaching family members and/or friends how to care for the client. providing information about the client’s primary health problem and its implications. understanding the cultural and health beliefs of the client and his or her family members and/or friends. participation of the client’s family in group therapy.

(4) Group therapy might be indicated depending on the client’s needs, problems, and desired goals and outcomes. Choices 1, 2, and 3 are all appropriate for client education. 151. The National Alliance for the Mentally Ill (NAMI) is an important self-help/support group for consumers of mental health services and their supporters. The major goals of NAMI include all the following except: 1. 2. 3. 4.

communicating that mental illness can be a brain disorder. improving access to treatment services for people with mental illness. communicating that mental illness is completely treatable with medication. integrating clients with mental illness into community life.

(3) Mental illness is not completely treatable with medication, but many forms of mental illness can be improved and/or controlled with appropriate drug regimens. NAMI is a self-help/support group for both clients and support people that advocates for people with mental illness and works to achieve the goals described in Choices 1, 2, and 4. 152. Today the setting where most clients with psychiatric disorders live is the: 1. 2. 3. 4.

asylum. state hospital. community. jail.

(3) Before state asylums, people with mental illness in the United States lived on the streets, in homes for the poor or ailing, in jails, or with their families. State hospitals were created in the 1800s to protect vulnerable people from the stress of society and provide the services they needed. Today, clients with mental illness live with their families (or other caregivers) in the community.

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153. The nurse carefully listens to the concerns a family expresses about a family member who suffers from alcoholism. What type of intervention is the nurse using? 1. 2. 3. 4.

helping solve family problems dealing with destructive behaviors changing family behaviors establishing a nurse-family relationship

(4) Nursing interventions used to establish a nurse-family relationship include the use of active listening techniques as part of developing and establishing trust. 154. A client is suffering from alcoholism. The nurse educates family members about alcoholism. This is an example of which type of nursing intervention? 1. 2. 3. 4.

helping families with problem-solving establishing a nurse-family relationship enhancing relationships dealing with destructive behaviors

(3) Nursing interventions often have the goal of enhancing family relationships so there may be some family behavior changes. This can be accomplished through education and therapy. 155. A family is asked to recall all past, concrete events that have caused them worry, concern, or grief related to an alcoholic member of the family. A family session is held to discuss the personal growth and goals of each family member who has been affected by the alcoholic family member. Time is provided for family members to vent their feelings and respect the perspectives of other family members. The supervision of these activities is an example of which type of nursing intervention? 1. 2. 3. 4.

helping solve family problems establishing a nurse-family relationship changing family behaviors dealing with destructive behaviors

(4) Helping family members identify and deal with destructive behaviors is an advanced nursing skill and is essential to goals related to developing positive changes in families. 156. A client’s family provides a high degree of emotional support. This is an example of which of Bloom’s Domains of Learning? 1. 2. 3. 4.

Health Care Socialization Affective Cognitive

(3) The support of the family is an example of the Affective domain, which can be described as the feelings domain within Bloom’s Taxonomy of Learning (1956). The other two domains are Cognitive (mental skills) and Psychomotor (physical skills). Choices 1 and 2 are not examples of learning domains. 157. A married couple cannot agree on whose responsibility it is to clean the house. The husband believes it is the wife’s responsibility, and the wife believes the household duties should be shared. This couple is experiencing which of the following? 1. 2. 3. 4.

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developmental stress economic stress family stress role conflict

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(4) Role conflict is related to expectations concerning the role. Role conflict can be described as intrapersonal (when the role expectation conflicts with the person’s values), interpersonal (when the person’s expectations differ from that of a significant other’s), or interrole (when a person is expected to fill two or more roles simultaneously). All stress factors are or can be results of inadequate coping or self-concept problems, no matter what type the stress is. 158. A client is interested in learning about a low-salt diet. Both the client and the client’s spouse have hypertension and want to change their eating habits. Which of the following nursing diagnoses is most appropriate? 1. 2. 3. 4.

Altered Parenting Family Coping: Potential for Growth Ineffective Family Coping: Compromised Ineffective Family Coping: Disabling

(2) Family Coping: Potential for Growth is the most appropriate choice because the client exhibits desire and readiness for enhanced health and growth. 159. An 80-year-old client has been living with the client’s middle-age son and his wife who have been providing financial and emotional support. The relationship has been mutually satisfying and beneficial. Unfortunately, the client fell and fractured a hip. The family does not know how to manage the client’s new need for personal care. Which nursing diagnosis is most appropriate? 1. 2. 3. 4.

Altered Parenting Family Coping: Potential for Growth Ineffective Family Coping: Compromised Ineffective Family Coping: Disabling

(3) The nursing diagnosis most appropriate for this situation is Ineffective Family Coping: Compromised because the usual level of support has become inadequate due to a new health challenge. 160. A family has decided to confront an alcoholic family member about drinking. The nurse helps the family identify destructive behaviors and arrange a convenient date and private space for the confrontation to occur. Which type of nursing intervention is this? 1. 2. 3. 4.

helping solve family problems establishing a nurse-family relationship changing family behaviors dealing with destructive behaviors

(4) Because alcohol abuse is a destructive behavior, Choice 4 would be correct. 161. When working with a client, the nurse needs to assess the degree of family support. All the following are essential pieces of information to gather in an assessment of family support except: 1. 2. 3. 4.

family interactions to identify the client’s level of support or lack thereof. whether the client has unrealistic perceptions or reality distortions. the client’s perception of their family or friends as a positive support system. the specific strategies used by the support team for the client’s positive outcome.

(2) Skillful use of therapeutic response is essential for accurate assessments and interventions. Assessing perceptions of reality includes determining the person’s orientation to time, place, and person. All are very important to identifying what is contribuing to disorganized thinking.

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162. Of the following choices, which presents a barrier to accessing support systems? 1. 2. 3. 4.

Adequate support systems are available but not utilized. Support systems are used ineffectively. The need for social isolation increases, and self-esteem decreases. Support systems are not available.

(3) An increased need for social isolation and decreased self-esteem greatly reduce the likelihood of a client accessing available support systems. Choices 1 and 2 might be true but are not barriers. 163. The nurse is taking the health history of an adolescent client. The nurse can best facilitate communication with the adolescent client by making which of the following statements? 1. 2. 3. 4.

“If you read the pamphlet, you’ll know all you need to know.” “We can talk about this with your mother.” “Other teenage girls also feel depressed.” “Tell me about the last time you had sexual intercourse.”

(3) Choice 3 indicates that the client is not alone, which can enhance communication by affirming the client’s feelings. Adolescents are more willing to discuss personal issues if parents are not present. Questions should be sensitively worded rather than intrusive (as in Choice 4). Written instructions should supplement teaching rather than being the primary vehicle for teaching. 164. A rationale for implementing group therapy immediately after meals in an eating-disorders treatment unit is to: 1. 2. 3. 4.

promote processing of anxiety and maladaptive behaviors associated with eating. shift the clients’ focus from food to psychotherapy. prevent occurrences of maladaptive behavior such as purging. focus on weight control mechanisms and food preparation.

(1) Eating produces a high level of anxiety for all clients with eating disorders. Anxiety levels must be lowered if the client is to be successful in achieving therapeutic goals. Groups exist to help people achieve goals (outcomes) that might be unattainable by individual effort alone. 165. An 11-year-old child is seeing a nurse-counselor to help deal with his feelings related to the death of his maternal grandmother as the result of a heart attack. The nurse-counselor could expect this child to say which of the following? 1. 2. 3. 4.

“I wonder if Grandma will ever come back?” “I think I’ll start going to church with Mom now.” “I’m not ever going to die; it makes everyone too sad.” “I wonder if I’ll die of a heart attack, too?”

(4) A child, age 11, could imagine dying of a heart attack as the grandmother did. At that developmental age, the child understands death as the inevitable end of life. The child also is beginning to understand his own mortality, expressed as questioning related to his own death someday. Assisting the child with the grief experience includes helping the child regain the normal continuity and pace of emotional development. Children can feel afraid, abandoned, and lonely. Careful work with bereaved children is especially necessary because experiencing a loss in childhood can have serious effects later in life.

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166. The nurse has been working with a family by using crisis intervention techniques. The nurse is concluding her care with the family and asks the family to complete the final step of the process. The nurse should ask the family to: 1. 2. 3. 4.

identify alternatives. choose from available alternatives. accept what they cannot change. evaluate outcomes.

(4) Crisis intervention is a short-term helping process of assisting clients to work through a crisis to its resolution and restore their precrisis level of functioning. It is a process that includes not only the client in crisis but also various members of the client’s support network. Working with another person increases the likelihood that the person in crisis resolves the crisis in a positive way. Often, a state of crisis offers the individual or family great potential for growth and change. 167. Considering a client’s negative pattern of thinking, the nurse-therapist believes the therapy of choice is: 1. 2. 3. 4.

psychoanalytic therapy. behavior therapy. cognitive-restructuring therapy. group therapy.

(3) Cognitive-restructuring therapy attempts to help a client alter dysfunctional beliefs and focus on positive outcomes rather than negative attributions. The client is also taught the connection between thoughts and resultant feelings. This is an active, directive, time-limited, and structured approach used to treat a variety of psychiatric disorders (including depression, anxiety, phobias, and pain problems). It is based on an underlying theoretical rationale that the beliefs and behavior of individuals are largely determined by the way they structure the world. 168. What can a nurse do to avoid feelings of frustration when working with a severely depressed client? 1. 2. 3. 4.

Expect the client to be receptive to the plans for nursing care. Expect the client to be withdrawn and disinterested in a relationship. Expect the client to show signs of improvement after several scheduled sessions. Expect the client to show gratitude for attention.

(2) A depressed person avoids recognition of painful feelings by withdrawing. Clients often reject the overtures of nurses and appear disinterested in nursing interventions. Understanding this can reduce frustration. An awareness of the risk factors for depression, a comprehensive biopsychosocial assessment, and a history of illness and past treatment are keys to formulating a treatment plan and to evaluating outcomes. Individuals experiencing depression have often withdrawn from daily social interaction such as engaging in family activities, attending work, and participating in community activities. Nurses are challenged to help the client balance the need for privacy with the need to return to normal social functioning. 169. A therapeutic relationship is: 1. 2. 3. 4.

unconditional and general. cultural with a plan formulated by the nurse. individualized and client focused. facilitated by interaction and touching.

(3) A therapeutic relationship is individualized, client focused, and aimed at realizing mutually determined goals. Establishing and maintaining a therapeutic nurse-client relationship is key to client achievement of mutually determined outcomes. Nursing interventions that foster the therapeutic relationship include being available in times of crisis, providing understanding and education to clients and their families regarding the goals of treatment, providing encouragement and feedback concerning the client’s progress, providing guidance in a client’s interpersonal interactions with others and in the client’s work environment, and helping to set and monitor realistic goals.

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170. The nurse observes halting speech by a client when his spouse is present. Which of the following questions should the nurse ask to clarify the client’s pattern of interaction with his spouse? 1. 2. 3. 4.

“How do you and your spouse spend your leisure time?” “What is your level of education?” “What is your spouse’s religious preference?” “How does your spouse communicate with you?”

(4) Clarification of the interaction pattern is an important piece of a family process assessment. To learn specifically about the interaction process, the nurse should inquire about communication. Therapeutic communication promotes understanding and can help establish a constructive relationship between the nurse and the client. Nurses need to respond not only to the content of a client’s verbal or nonverbal message(s) but also to the feelings expressed. It is important to understand how the client views the situation and feels about it before responding. Choice 1 does not provide specific information about the relationship, and Choices 2 and 3 are probably irrelevant in this situation. 171. The psychiatric clinical nurse specialist decides to use cognitive therapy techniques as she works with a client who has been diagnosed with anorexia nervosa. Which statement is consistent with cognitive therapy principles? 1. 2. 3. 4.

“You seem to feel much better about yourself when you eat something.” “Being thin doesn’t seem to solve your problems because you are thin now but still unhappy.” “It must be difficult to talk about private matters to someone you just met.” “What are your feelings about not eating the food you prepare?”

(2) Using cognitive-therapy principles is the only strategy that attempts to question the client’s faulty thinking. Cognitive theory, an outgrowth of various theoretical perspectives including behavioral and psychodynamic perspectives, attempts to link internal thought processes with human behavior. A distorted belief is the basis of the client’s faulty thinking. According to this theory, people with faulty thinking commit errors of judgment that can become habitual. These individuals incorrectly interpret life situations and make inaccurate conclusions. 172. A prostitute with HIV and severe complications is being cared for on a medical unit. Which of the following statements or questions best reflects the nurse’s attempt to develop a therapeutic relationship? 1. 2. 3. 4.

“Don’t be embarrassed by your former occupation.” “Whom do you go to for support?” “On what type of schedule do you think you could realistically eat your meals without being nauseated?” “The people who work here are professionals, and we do not judge your actions.”

(2) Asking for information about the client’s support system is an important assessment question asked in a nonjudgmental and open way. Showing understanding and respect is important in developing a trusting therapeutic relationship. In therapeutic communication, the nurse chooses words carefully and uses nonverbal behaviors that are consistent with these words. Choosing the best response begins with assessing the meaning of the client’s communication. 173. A client is concerned about the interactions that she has with her family, and she is in the process of establishing a positive self-image. This client is meeting the developmental needs of which age group? 1. 2. 3. 4.

teens early 20s to mid 40s mid 40s to mid 60s late 60s and older

(2) Concerns related to self-concept in this age range include fulfilling role expectations, developing reasonable expectations of family relationships, gaining a satisfying job, developing new goals, and giving meaning and purpose to life. In this age range, society places emphasis on the intactness of body, fitness, energy, sexuality, style, beauty, and sophistication, and these are important to meet role expectations well.

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174. What is the rationale for making use of congruent levels of communication when interviewing a client? 1. 2. 3. 4.

One statement might simultaneously convey different messages. The mental image of a word might not be the same for the nurse and the client. Many of the client’s remarks are no more than social phrases. The content of the message might be contradicted by the process.

(4) Verbal messages, known as the content portion of the communication, can be reinforced, contradicted, or modified by nonverbal behaviors, known as the process of the message. It is vital to observe both content and process when assessing for congruence/incongruence. Communication is a continuous, dynamic, ongoing, and ever-changing operation. All communication is done with language or nonverbal signals, as gestures, facial expressions, or body cues. 175. Which therapeutic communication technique is the nurse using when asking a client, “What happened that led to your being hospitalized?” 1. 2. 3. 4.

offering general leads giving broad openings encouraging description of perception seeking clarification

(1) General leads are remarks that clarify that the client is to take the lead; in this case, to talk about recent events leading to the client’s hospitalization. An example of a broad opening is, “Where would you like to begin?” Encouraging description of perception is exemplified by, “What is happening, now?” An example of seeking clarification is, “I’m not sure I understand.” 176. On the second day of hospitalization, a client is discussing concerns about unhealthy family relationships with the nurse. During the nurse-client interaction, the client changes the subject to a job situation. The nurse responds, “Let’s go back to what we were just talking about.” Which therapeutic communication technique did the nurse use? 1. 2. 3. 4.

focusing consensual validation silencing reflecting

(1) The therapeutic communication technique used by the nurse to redirect a client back to the original topic of discussion is focusing. Focusing fosters the client’s sense of self-control and helps avoid vague generalizations so that the client can accept responsibility for facing problems. 177. A nurse points out to a client who is in pain that it is normal to feel frustrated about the discomfort. Which skill in the working phase of a helping relationship is the nurse using? 1. 2. 3. 4.

respect genuineness concreteness confrontation

(1) Respect is correct because the nurse is validating the client’s feelings. It is not an example of genuineness because the nurse is simply giving information. Concreteness is giving a specific example. The nurse is not confronting but supporting through respect for the client’s feelings.

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178. A therapeutic nurse-client relationship is best characterized by: 1. 2. 3. 4.

discussion with a client regarding the consequences of manipulative behavior. collaboration with a client and team members to establish limits on manipulative behavior. clarifying the consequences of a client’s manipulative behavior. decreasing the level of demands on a client, which triggers manipulative behavior.

(3) Choice 3 is correct because the primary focus of the therapeutic nurse-client relationship is the client. The therapeutic nurse-client relationship is a mutual and corrective emotional experience. The nurse utilizes self and specified clinical techniques in working with the client to facilitate insight and behavioral change. Choices 1, 2, and 4 are incorrect because the client’s needs are not of primary concern in these choices. 179. In which phase of the nurse-client relationship should the nurse appropriately use the communication technique of confrontation? 1. 2. 3. 4.

Introduction Orientation Working Termination

(3) The correct choice is the Working phase of the relationship. The nurse must establish a working relationship in which the client trusts and accepts the nurse’s feedback and does not experience incongruent levels of communication before being able to use the technique of confrontation effectively. 180. Therapeutic communication differs from social communication in that therapeutic communication requires the nurse to perform which of the following actions? 1. 2. 3. 4.

Limit activities with the client to therapeutic endeavors. Examine the client’s behavior from a theoretical perspective. Focus on mutual sharing so as to not intimidate the client. Avoid setting expectations as part of the contract.

(2) Examining the client’s behavior from a theoretical perspective is a professional obligation in therapeutic communication and is not part of a social interaction. Therapeutic communication promotes understanding and can help establish a constructive relationship between the nurse and the client. Unlike social relationships, where there might not be a specific purpose or direction, therapeutic relationships are client and goal oriented. 181. A 16-year-old client has acne on her face. The client feels rejected and not part of the crowd. This body image alteration is present because the client: 1. 2. 3. 4.

desires to stand out in a crowd. desires to be like her peers. might have scarring on her face. does not see any clearing of the acne.

(2) Body image is more important when strong emotions are attached to the perceived body. Adolescents want to be like their peers. Acne on the face causes embarrassment and feelings of not fitting in. Body image for teens reflects their peer group attitudes and the desire for belonging. 182. Of the following procedures, which one causes a change in body image? 1. 2. 3. 4.

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ingrown toenail facial melanoma fractured ankle fractured finger

Psychosocial Integrity

(2) It is well documented that disfigurement or scarring of the body can profoundly affect a person’s body image. 183. A client is recovering from an amputation, secondary to a motorcycle accident. This dramatic change is most likely to trigger problems in: 1. 2. 3. 4.

body image. role performance. self-concept. personal identity.

(1) All the choices are affected to some degree; however, the most likely problems occur first in body image (the client’s self-perception). This change in body image impacts Choices 2, 3, and 4. 184. A client who has had a mastectomy is likely to have problems initially with: 1. 2. 3. 4.

self-esteem. self-concept. body image. role performance.

(3) Following a surgery such as breast removal, the client might not feel whole because a valued part of the body has been removed. The surgery might change the way a client views her body postoperatively and can cause altered body image. Stressors call forth responses and can mobilize an individual’s strengths, resulting in a positive or negative response. A negative response diminishes self-concept. 185. The altered body image seen in an individual with anorexia nervosa is caused by: 1. 2. 3. 4.

a desire to be thin. a fear of being fat. a need to be like her peers. a genetic trait.

(2) Anorexia nervosa is self-imposed starvation that results from an individual’s fear of being fat. Clients with anorexia nervosa have an altered internal concept of themselves; they see a fat body when they look in the mirror. 186. Which of the following statements by a counselor is most helpful for an individual’s maintenance of a positive body image? 1. 2. 3. 4.

“You are strong and must stand alone.” “Three nutritious meals a day are necessary for your health.” “You need to realize that you need intensive therapy.” “You need to learn about good nutrition and exercise.”

(4) Learning about good nutrition and exercise maintains physical strength and a sense of well-being. Feelings of alertness and physical strength promote a positive body image. Exercise and nutritional assistance through support and teaching can improve a client’s identity and use of personal strengths, help a high-risk client maintain a sense of self, change a client’s self-concept, develop a client’s body image, and increase a client’s self-esteem. 187. The cognitive distortion in body image that thinness causes among clients with an eating disorder is: 1. 2. 3. 4.

Thinness equals self-worth and self-esteem. Being thin is being powerful. Being fat is more harmful than being thin. Fat people are not liked.

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(1) In clients who have eating disorders, thinness is a result of controlling what goes into their body and promotes a positive body image and self-worth. Weight consciousness becomes compulsive in 1% of teenage girls and results in an eating disorder (anorexia nervosa). An eating disorder can result in weight loss, muscle wasting, and decreased self-esteem. 188. When a client with anorexia nervosa is hospitalized as part of a weight-restoration program, the nurse should expect lower extremity edema related to: 1. 2. 3. 4.

liver dysfunction. compromised renal function. endocrine imbalance. poor cardiac function.

(4) When refeeding a client, the increased volume of the circulatory system places a strain on depleted cardiac muscle mass, leading to poor cardiovascular function. Mortality for these clients is 5%–7%. Monitoring the refeeding process is very important, and intake must be strictly monitored under the supervision of the health care team. 189. Which of the following clients is at greatest risk for hypokalemia? 1. 2. 3. 4.

A nonpurging bulimic. An anorexic who loses weight by restricting food intake. An anorexic who purges to lose weight. Clients with eating disorders are more at risk for hyponatremia, not hypokalemia.

(3) When one purges to promote vomiting, hydrochloric acid and K+ are lost from gastric content, leading to K+ deficiency. 190. Which of the following medications is most likely to be used when managing clients with eating disorders? 1. 2. 3. 4.

an SSRI (selective serotonin reuptate inhibitor), such as Fluoxetine a neuroleptic, such as Respiradone an anticonvulsant, such as Dilantin an axialytic, such as Xanax

(1) An SSRI, such as Fluoxetine, has been found helpful in increasing the rate of weight gain and decreasing relapse occurrence. SSRIs are most appropriate after refeeding and weight gain, when the client’s weight is being monitored closely, because some SSRIs can cause weight loss. 191. In the medical history of adolescents with eating disorders, which risk factor is most commonly identified? 1. 2. 3. 4.

excessive exercise purging dieting overeating

(3) Most clients with eating disorders suffer from a fear of being fat, so dieting is the most commonly identified risk factor. The key concepts are the drive for thinness and an emotional response to cues (either internal or external). The causes can be age, ethnic and cultural environment, and family relationships. 192. In caring for a client who has recently had a leg amputated, what subjective data should the nurse collect to assess body image? 1. 2. 3. 4.

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the client’s feelings regarding surgery the client’s description of his or her personality the status of wound healing the strength of femoral pulses, bilaterally

Psychosocial Integrity

(1) In assessing body image, the nurse must gather data about the client’s feelings regarding the surgery and the client’s perception of the change in his or her body. Choice 3 is not related to body image, but wound-healing stages. The nurse must assess all parameters: psychological, biological, cultural, and environmental. These areas help the nurse formulate a plan of care. 193. A client is admitted with a work-related injury that was sustained due to lack of utilization of safety measures. The client tells the nurse that he wasn’t told about the importance of safety devices. When reporting to the next shift, the nurse should state that the client is experiencing: 1. 2. 3. 4.

body-image change. role mastery. role ambiguity. cultural conflict.

(3) Role ambiguity occurs when the person does not know what to do or how to do it. 194. A client complains of decreased sexual desire. Which of the following medications might contribute to this problem? 1. 2. 3. 4.

warfarin (Coumadin) ascorbic Acid (Vitamin C) inderal (Propranolol) azithromycin (Zithromax)

(3) Antihypertensives, diuretics, narcotics, and antipsychotics can decrease sexual desire. Inderal is an antihypertensive agent. 195. Which of the following questions or statements should the nurse use to assess a client’s body image perception? 1. 2. 3. 4.

“Tell me what you like about yourself.” “What changes would you make in your appearance?” “What activities do you enjoy?” “What is your day like?”

(1) To have a positive body image, clients must like themselves. Body image disturbance occurs when there is extreme discrepancy between one’s own mental picture of his or her body and the perception of the outside world.

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Basic Care and Comfort This chapter contains questions and answers from the following topic areas: ■ ■ ■ ■

Assistive Devices Elimination Mobility/Immobility Non-Pharmacological Comfort Interventions

■ ■ ■ ■

Nutrition and Oral Hydration Palliative/Comfort Care Personal Hygiene Rest and Sleep

1. The role of the nurse in rehabilitation care is to: 1. 2. 3. 4.

Focus on interventions that improve the quality of life rather than saving life. Assist the client by continuing to tell him or her what to do. Regulate all the client’s medications. Show concern in secondary prevention only.

(1) The role of the nurse in rehabilitation care is to have the client attain the maximum level of wellness on the continuum of prevention: primary, secondary, and tertiary. The nurse addresses levels of prevention, helps the client become self-reliant, and continues previous therapy. 2. Continuous Passive Motion (CPM) devices are: 1. 2. 3. 4.

machines that are used to stimulate nerve pathways all over the body. used exclusively with Cardiovascular Accident (CVA) clients used to stimulate regeneration of articular tissues. devices for passive range of motion in arms and fingers.

(3) The purpose of CPM devices is to move the knee joint without bearing weight or straining muscles and to stimulate regeneration of articular tissues following orthopedic surgery for the knee. 3. When using a CPM device with a client, the nurse should: 1. 2. 3. 4.

Adjust all parts of the device to the client’s wishes. Adjust and align the device according to the client’s extremity and set the foot cradle at the angle ordered by the physician. Set all speed dials according to the client’s wishes and needs. Check on the client during every shift.

(2) Nursing care of a client using a CPM device includes aligning the extremity in a padded CPM device, adjusting the device for the client’s extremity, and setting the cradle and speed dials as ordered by the physician. The client should be frequently observed and shown how to use the control cord. 4. When teaching a client the four-point gait, the basic principle the nurse should follow is: 1. 2. 3. 4.

The client must bear most of his weight on both legs. Elbows and arms should be held in a rigid extension. The majority of the client’s weight should be supported by the axillae. The affected extremity should be elevated in some manner.

(1) The client must be able to bear most of his weight on both legs. The four-point gait is performed by the client bringing the left crutch forward first, followed by the right foot; then the right crutch is brought forward, followed by

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the left foot. Only the arms are extended, not the elbows; pressure should not be placed on the axillae because nerve damage can occur. Both legs must be able to bear weight. 5. Following an above-the-knee amputation of a leg, the nurse should teach the client who wears a prothesis which gait? 1. 2. 3. 4.

the four-point gait the three-point gait the tri-point gait the swing-through gait

(1) A four-point gait provides for weight bearing on all points that touch the floor and maximum support during ambulation. The three-point gait is used when one extremity cannot bear weight; the tri-point gait does not exist. A swingthrough gait does not stimulate ambulation; it is used when an individual can bear weight but lacks the muscular control needed for ambulation without an assistive device. 6. One of the purposes of mobility-assistance devices is to: 1. 2. 3. 4.

provide for long-term rehabilitative care. relieve the family of client transportation. provide for greater mobility and independence. assist the client in greater speed of transport.

(3) The purpose of mobility-assistance devices is the client attaining a greater mobility, control, and independence. Other purposes are providing rehabilitation in the shortest period of time in a calm, safe atmosphere and including family members in the client’s care to obtain the greatest benefit. 7. When preparing a teaching plan for a client using a walker, the nurse should: 1. 2. 3. 4.

Help the client obtain a quality walker. Assist the client in correct and safe use of the walker. Have the family work with the client for better confidence. Take measurements of the client, including body weight, leg and arm length, and handgrip.

(2) A teaching plan for a client with a walker should include all aspects of the purchase and use of the walker. The client and family should be included in the selection of a walker. 8. An 85-year-old male client has been discharged from the hospital with no explanation about how to use the wheelchair purchased for him. The home health nurse visits and finds the client unable to get from the bed to the wheelchair. The most appropriate nursing intervention is to identify a support person and: 1. 2. 3. 4.

Lift the client to the wheelchair with the assistance of the support person. Tell the client and support person to get instruction from the store where the wheelchair was purchased. Tell the client to do body-building exercises to help with use of the chair. Instruct the client and support person on the correct transfer procedure and make sure the wheelchair is in operating condition, including working brakes and other safety features.

(4) The most appropriate nursing intervention is to secure the safe transfer of the client to a properly functioning wheelchair. The nurse is in an optimal position to teach both the client and support person about the safety features of the wheelchair.

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9. A major consideration in a client’s use of a cane is: 1. 2. 3. 4.

whether the client is able to bear weight on the affected extremity. whether the client is able to walk and advance the cane and the unaffected extremity at the same time. the client’s measurements, to ensure that the client can lean on the cane. the presence of a support person to walk on the client’s unaffected side.

(1) The client must be able to bear weight on the affected extremity to use a cane. The client should advance the cane with the affected extremity and with a support person on the client’s affected side. 10. A client is recovering from back surgery and needs to be fitted for a brace before leaving the facility. The nurse must observe the client closely for: 1. 2. 3. 4.

deformities of the back. weakened muscles of the back, arms, and legs. cardiac output, especially pedal pulses. evidence of skin breakdown at pressure points.

(4) The most important nursing observation in this situation is evidence of skin breakdown, particularly where the skin and brace will be in contact. Any skin breakdown can lead to infection and can delay the rehabilitation process. Back deformities, weakened muscles, and cardiac output should be observed and could be important to the outcome, but these are not the primary observations to make in this situation. 11. CPM devices are set for which of the following? 1. 2. 3. 4.

speed, flexion, and extension of the leg speed, disease, and condition of the leg skin condition and hydration of the body knee bend

(1) A physician orders the setting on a CPM device for speed, flexion, and extension. These settings are increased gradually, as tolerated by the client, to maximum mobility. These devices are most commonly used for passive range of motion for the knee. 12. A nurse caring for a client with a leg brace should: 1. 2. 3. 4.

Observe the client’s level of response. Observe intake and output with limited fluid intake. Keep the leg in a 10-pound suspension. Be sure leg joints align properly with body joints.

(4) The leg joints should be properly aligned with body joints so that the leg heals correctly for optimum mobility. 13. Sometimes a ___________ can act as a full-body splint when a critical client must be immobilized quickly. 1. 2. 3. 4.

wheeled stretcher short brace warm blanket long backboard

(4) Sometimes a long backboard can act as a full-body splint when a critical client must be immobilized quickly.

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14. A client with a fractured right leg and a crushed pelvis is called a _________ client. 1. 2. 3. 4.

lower-extremities multiple-trauma shock stable

(2) The client with a fractured right leg and a crushed pelvis has more than one area of trauma, hence “multiple trauma” is correct. 15. At which point is a multiple-trauma client most likely to be stabilized? 1. 2. 3. 4.

in the Emergency Department after splints and assistive devices have been provided in the surgical suite when the airway is patent

(3) When a client enters the surgical suite, any bleeding can be stopped and the extent of the injuries can be ascertained. Until this happens, a total assessment of internal injuries cannot be completed and appropriate assistive devices cannot be put in place. 16. The indications for a traction splint are a painful, swollen, deformed mid-thigh with: 1. 2. 3. 4.

either knee or ankle involvement. no injury to the joint or lower leg. extensive blood loss. an open fracture.

(2) The indications for a traction splint are a painful, swollen, deformed mid-thigh with no injury to the joint or lower leg. 17. Which health care professional is trained to fit braces, or TED-hoses (used on the lower limbs to prevent deep vein thrombosis), and assistive devices to help with normal movement and prevent secondary complications of corrective braces? 1. 2. 3. 4.

prosthetist registered nurse orthotist nursing assistant

(3) An orthotist is skilled in fitting mechanical appliances for orthopedic use. These appliances stabilize or immobilize a body part to prevent deformity, protect against further injury, or assist with function. 18. The United States act that is significant in advocating for those with disabilities is: 1. 2. 3. 4.

the Equal Opportunity Act (EEOC). the Americans with Disabilities Act (ADA). the Disability Act of 1960 (DA). the Medical Leave Act (ML).

(2) The ADA is a piece of legislation passed by the United States in 1990 to ensure the rights of people with disabilities. It provides enforceable standards to ensure access (to buildings, walkways, and so on) and prohibit discrimination (in employment, public services, and so on).

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19. Which health care professional has the most appropriate training to assess the range of motion, mobility, strength, balance, and gait of an 18-year-old client who has a complete C5-6 spinal cord injury? 1. 2. 3. 4.

recreational therapist physical therapist rehabilitation nurse occupational therapist

(2) A physical therapist can assess a client’s range of motion, mobility, strength, balance, and gait. 20. A client is unable to perform most basic self-care activities such as feeding, bathing, and toileting. Which nursing diagnosis is appropriate? 1. 2. 3. 4.

Self-Care Deficit Impaired Physical Mobility Activity Intolerance Risk for Injury

(1) Self-Care Deficit is an appropriate diagnosis for people experiencing impaired ability to perform any basic self-care activities. 21. Which nursing diagnosis is appropriate for elderly clients who suffer from falls and reduced functional capacity? 1. 2. 3. 4.

Self-Care Deficit Impaired Physical Mobility Activity Intolerance Risk for Injury

(4) Elderly clients sometimes have trouble seeing, hearing, and adjusting to unfamiliar environments, so Risk for Injury would be an appropriate nursing diagnosis. 22. The process of applying tension to straighten and realign a fractured limb before splinting is called: 1. 2. 3. 4.

reduction. closed traction. manual traction. open-extremity traction.

(3) Manual traction is the application of traction to the spine or extremities by a therapist trained in the appropriate positions and intensities for the traction. 23. The nurse in an Emergency Department should know the signs and symptoms of hip fracture so that an assessment can be made quickly. The symptoms are: 1. 2. 3. 4.

The client has localized pain, swelling, and tissue dislocation. The client has sensitivity to pressure on the lateral prominence of the hip, localized pain, is unable to stand, and the foot on the injured side is turned outward. The injured limb appears longer, the client is unable to stand, and swelling and pain are present. The client is unable to move the limb at all; pain, swelling, and tissue dislocation are present.

(2) Signs and symptoms of a hip fracture include sensitivity to pressure on the lateral prominence of the hip, localized pain, swelling, inability to move the limb while on the back, inability to stand, the foot on the injured side is turned outward, the injured limb appears shorter, and the surrounding tissue appears discolored (delayed sign).

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24. Fractures of the femur typically cause a ___________-pint blood loss over the first two hours. 1. 2. 3. 4.

1 2 3 4

(2) Fractures of the femur typically cause a 2-pint blood loss over the first two hours. If additional complications are present, such as artery laceration, blood loss can be more severe. Blood loss from a fracture of the tibia/fibula can be about 1 pint. A fracture of the pelvis can cause a 3- to 4-pint loss. 25. Proper splinting of a possible closed fracture is: 1. 2. 3. 4.

performed with an air splint and gentle traction. performed with the pneumatic antishock garment. designed to prevent closed injuries from becoming open. completed in the hospital by a surgeon.

(3) Proper splinting of a possible closed fracture is designed to prevent closed injuries from becoming open. 26. In assessing a client’s urinary output following surgery, the nurse should suspect renal impairment when output is less than: 1. 2. 3. 4.

30 cc/hr. 60 cc/hr. 300 cc/hr. 1,000 cc/hr.

(1) Urine output of 30 cc/hr is considered minimal and might indicate renal impairment. A urinary output of 60 cc/hr is generally normal. A urine output of 300 cc stimulates micturation. 27. Consumption of alcohol affects urine volume by: 1. 2. 3. 4.

increasing urine production. increasing urine excretion. changing urine color. Consumption of alcohol has no effect on urine volume.

(1) Alcohol inhibits the release of the ADH hormone, which prevents the kidneys from reabsorbing water and results in increased urine production. Caffeine promotes urinary excretion. 28. A client’s renal function has been deteriorating during his hospitalization. The nurse monitors for significant changes by focusing on which of the following laboratory data? 1. 2. 3. 4.

decreased serum creatinine (increased in renal disease) increased blood urea nitrogen (later sign of renal disease) increased creatinine clearance (decreased with renal dysfunction) decreased serum potassium

(3) Serum creatinine level is a constant measure of muscle waste product. In renal insufficiency, creatinine increases because it is normally secreted by the kidney. A BUN measures the kidney’s capability to remove waste products. A rising BUN might indicate renal disease, as creatinine and BUN trend in the same direction.

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29. A client complains of leaking urine when she coughs or laughs. This is known as: 1. 2. 3. 4.

functional incontinence. reflex incontinence. urge incontinence. stress incontinence.

(4) Coughing and laughing increases abdominal pressure above the bladder, causing leakage of urine secondary to the stress of increased abdominal pressure on the bladder. 30. A 28-year-old female complains of having a urinary tract infection (UTI). Which of the following symptoms should the nurse expect her to exhibit? 1. 2. 3. 4.

proteinuria dysuria syncope oliguria

(2) UTIs cause a burning sensation when a person voids. Bacterial toxins cause an irritation of the mucosal membrane leading to pain or burning when voiding. 31. In differentiating pyleonephritis from cystitis, which of the following assessment techniques should the nurse use? 1. 2. 3. 4.

auscultation of lung sounds palpation of costal vertebral angle (CVA) percussion of gastric air bubble measurement of urine output

(2) Pyleonephritis is an inflammation of the kidney. A sharp tap to the CVA elicits pain in nephritis but not cystitis. 32. The nurse is working in radiology with a client undergoing an intravenous pyelogram (IVP). Which of the following complaints by the client is an abnormal finding? 1. 2. 3. 4.

thirst and feeling worn out frequent, loose stools feeling dizzy and warm with obvious facial flushing dyspnea and audible wheezing

(4) Dyspnea and wheezing are indications of the respiratory component of anaphylactic shock, an allergic reaction to the dye/isotope used in an IVP. Choice 3 is a possible physiologic response to the dye/isotope being injected. The thirst in Choice 1 is related to NPO status in preparation for the test. Feeling worn out might be a side effect of the IVP dye injection. 33. A client’s urinalysis reveals a high bacterial count. Gantrisin is prescribed for a UTI. The teaching plan for a UTI should include all the following elements, the most important of which is: 1. 2. 3. 4.

Always wipe perineum back to front. Consume 3000 cc of fluid daily. Drink plenty of cranberry juice. Explain the side effects of medication.

(1) Proper perineal hygiene requires cleaning from front to back to prevent transfer of E. coli towards the urinary meatus. The client should consume 3000 cc of fluid daily to flush the bladder and reduce the number of bacteria present. Acidic juices create a hostile environment for the organisms that cause an infection. Gantrisin can change the color of urine.

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34. Nocturia is best defined as: 1. 2. 3. 4.

total urine output of less than 30 cc/hr. pain and difficulty when voiding. voiding more frequently than every three hours. awakening at night to urinate.

(4) Nocturia is voiding at night. It might indicate kidney problems. It can also occur when a person consumes fluids in the hours just before bedtime or takes a diuretic pill after 3 p.m. 35. In palpation of the kidneys, which of the following is true? 1. 2. 3. 4.

Neither kidney should be palpable. Both kidneys should be palpable. The right kidney is palpable. The left kidney is more easily palpated.

(3) If a kidney is palpable, it will be the right kidney as it’s displaced downward by the liver. The left kidney is not palpable unless enlarged. 36. The most reliable renal function test is: 1. 2. 3. 4.

BUN. Cr. potassium level (K+). calcium level (Ca++).

(2) Cr is waste product of muscle catabolism and is formed at a constant rate. BUN is affected by hydration status and the amount of protein consumed. K+ and Ca++ levels are affected by renal function and are not used to evaluate renal function. 37. Which intervention is the first priority when inserting an indwelling Foley catheter? 1. 2. 3. 4.

aseptic technique instilling water into the balloon inserting the catheter to the point where urine flows taping the catheter tubing to the leg

(1) Aseptic technique is sterile technique and is used to prevent or decrease the risk of infection when inserting a urinary catheter. Aseptic technique begins with the manner in which the box is opened. 38. A 78-year-old male has a continuous bladder irrigation ordered following a transurethral resection of the prostate (TURP).The rationale for this order is to: 1. 2. 3. 4.

prevent infection. maintain dilute urine, decreasing irritation. deliver medication into the operative site. keep the urine flowing to prevent clot formation.

(4) A continuous bladder irrigation of saline keeps the urine flow steady so that blood is not static long enough to form clots.

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39. An indwelling catheter for a male client is correctly taped to: 1. 2. 3. 4.

the inner thigh. the back of the thigh. the lower abdomen. the imbilicus.

(3) Taping the catheter on the lower abdomen prevents downward pressure that can cause a scrotal sac abscess or an erosive ulcer. 40. A client has been diagnosed with Renal Calculi. Which of the following conditions predisposes a client for the development of renal calculi? 1. 2. 3. 4.

glycosuria polyuria presence of a Foley catheter immobility

(4) Immobility promotes osteoclastic activity due to the lack of weight-bearing behavior. Osteoclastic activity can cause calcium to be drawn into the blood and increases the risk of calcium stones. 41. The nurse is instructing a client with a history of Ca++ oxalate stones. In teaching dietary prevention, the nurse should stress that the client avoid which of the following foods? 1. 2. 3. 4.

spinach, green beans, and chocolate red meats, cheese, and butter milk, potatoes, and bread bananas, apples, and apricots

(1) Spinach, green beans, waxed beans, beets, and chocolate are known to be high in Ca++ oxalate and should be avoided by this client. 42. In which of the following positions should a client be placed for the safe insertion of a Foley catheter? 1. 2. 3. 4.

prone supine lithotomy Trendelenberg

(3) This position allows for better visualization of the urinary meatus for catheter insertion. 43. Urinary output in a severely dehydrated client: 1. 2. 3. 4.

increases. is diluted. remains unaffected. decreases.

(4) Decreased fluid intake leads to decreased urinary output. As fluid intake decreases, fluid is drawn from the cells into the vascular system to maintain adequate urine output. Otherwise cells become dehydrated and urine output decreases.

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44. Which of the following hormones is a direct target for the kidney? 1. 2. 3. 4.

progesterone and estrogen progesterone and aldosterone aldosterone and an antidiuretic pituitary and estrogen

(3) Antidiuretic hormone (through the regulation of water) and aldosterone (through the regulation of water, sodium, and potassium) play a major role in fluid and electrolyte homeostasis. 45. When caring for a client with symptoms of left-sided CHF, the nurse should expect urinary output to: 1. 2. 3. 4.

decrease. increase. stay the same. be dilute.

(1) CHF is a problem of volume overload affecting the heart. Cardiac muscle becomes dilated and pumping pressure is decreased due to volume overload. Perfusion of the kidneys is decreased. CHF is a cause of prerenal failure. 46. A client with rheumatoid arthritis is complaining of pain and is on an NSAID medication. The client’s renal studies show a BUN of 40. Which action is most appropriate by the nurse? 1. 2. 3. 4.

No action is needed. NSAIDs have no effect on the renal system. Decrease the NSAID dose to every other day, and reevaluate function in four weeks. Stop the NSAID medication. Increase the NSAID dose to help control the client’s pain.

(2) NSAIDS (Non-Steroidal Anti-Inflammatory Drugs) have a toxic effect on the renal system. Clients must be monitored and reevaluated in three months. 47. When evaluating urine output for a client, the nurse notes that urine output over eight hours is more than 4000 cc. Which of the following processes can cause this increased output? 1. 2. 3. 4.

diabetes insipidus polycythemis ketoacidosis polyuryaigia

(1) Diabetes insipidus is a pathological finding in which the client lacks the antidiuretic hormone (ADH) from the posterior pituitary gland. Lack of the ADH prevents the collecting ducts of the nephrons from reabsorbing water, causing potentially large volumes of urine to be lost. 48. The most frequent postoperative complication of a TURP is: 1. 2. 3. 4.

grape-colored urine. ketchup-colored urine. clear urine. decreased urine output.

(2) The client should be observed for hemorrhage following a TURP. Hemorrhage is evidenced by bright-red bloody urine (ketchup colored). This color of urine signifies postoperative bleeding. A client with this complication must go back to surgery.

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49. A 28-year-old male with chronic renal failure plans to receive a kidney transplant. The physician has told the client he is a poor candidate for renal transplant due to uncontrolled hypertension and diabetes mellitus type 1. While on dialysis the client states, “I want to go off dialysis. I would rather not live than be on dialysis for the rest of my life.” Which of the following responses by the nurse is most appropriate? 1. 2. 3. 4.

Take a seat across the room from the client and sit quietly. Say to the client, “Everybody has days when they don’t feel like going on.” Leave the room to allow the client to collect his thoughts. Say to the client, “You are feeling upset about what the doctor said to you about the transplant.”

(4) Choice 4 illustrates the use of an open-ended statement, a therapeutic communication technique that allows the client to respond or use silence to think. Choices 1, 2, and 3 ignore the statement made by the client. 50. A 13-year-old child presented with a sore throat 20 days ago. He now presents with decreased urinary output, nausea, and hypertension. The mostly likely cause for this client’s renal impairment is an infection of: 1. 2. 3. 4.

shigella. streptococcus. staphlococcus. pneumococcus.

(2) Beta hemolytic streptococcus is a common cause of sore throat (strep throat). If left untreated, this bacterial infection can migrate to the kidneys and cause acute glomerluonephritis via an antigen/antibody reaction. (The drug of choice for strep throat is PCN.) 51. A normal walking gait sequence is: 1. 2. 3. 4.

toe strike, midstance, heel strike. midstance, toe strike, heel strike. heel strike, toe strike, midstance. heel strike, midstance, toe strike.

(4) The normal walking gait is composed of three sequential events: heel push off (or strike), arch (midstance), and then the toe striking the ground. 52. A 52-year-old male complains that he can no longer turn his head to back up his car. The normal body joint movement being affected is: 1. 2. 3. 4.

rotation. lateralization. abduction. flexion.

(1) The movement one uses to look back when driving in reverse is rotation. Normal rotation of the cervical spine is 40° to the right and 40° to the left. 53. A client tore a rotator cuff playing tennis. The normal body joint movement being affected is: 1. 2. 3. 4.

abduction. adduction. internal rotation. inversion.

(2) A tear in the rotator cuff decreases an individual’s ability to reach across her body or toward the midline, which is adduction.

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54. Normal mobility requires: 1. 2. 3. 4.

intact CNS and PNS, a functioning musculoskeletal system, and balance. CNS coordination, intact cerebellar function, and adequate muscle strength. intact PNS, intact pons function, and adequate muscle strength. intact CNS and PNS, adequate muscle strength, healthy bones, and intact cerebellar function.

(4) Normal mobility requires control, coordination, and strength. The CNS (central nervous system) is the controller; coordination and strength are related to muscle strength, bone health, and PNS (peripheral nervous system). Balance and coordination require intact cerebellar function. 55. The best stance for a nurse when supporting a client who is rising from or sitting on a bed is: 1. 2. 3. 4.

feet close together. feet wide apart. pelvic tilt. standing away from the client.

(2) The wider the base of support, the more stable the nurse’s body is for supporting the client. Pelvic tilt is used to prevent lower back strain. Standing far away from the client requires more energy in supporting the client and increases the risk of back strain. 56. A client in a knee cast needs to be taught a type of exercise that maintains strength in immobilized muscles. To prepare the client for ambulation, which of the following exercises should be taught? 1. 2. 3. 4.

aerobic anaerobic isotonic isometric

(4) Isometric exercises can be used to maintain strength in the quadriceps muscle, which helps to stabilize the knee when the cast is removed. Isotonic exercises are active, dynamic exercises requiring constant tension and movement. 57. Which of the following activities is essential to maintain mobility? 1. 2. 3. 4.

walking sitting bed rest reclining

(1) Regular exercise such as walking is essential to maintain normal mobility/function. Choices 2, 3, and 4 are not considered exercise. 58. In which of the following age ranges does muscle tone and bone strength generally decrease? 1. 2. 3. 4.

10–12 14–18 20–30 40–60

(4) Between the ages of 40 and 60, an adult’s muscle tone and bone strength generally decrease.

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59. Which of the following gait patterns is characteristic of a client with Parkinson’s disease? 1. 2. 3. 4.

ataxic gait spastic gait waddling gait festinating gait

(4) Recognition of gait patterns should be a major assessment by the nurse in detecting the existence of specific diseases. A festinating gait is marked by short steps with the feet barely clearing the floor. The client appears to be walking on his toes as though being pushed forward (also known as a cogwheel gait). An ataxic gait is characterized by staggering and unsteadiness, as seen in some clients following a CVA. A spastic gait is characterized by stiff movement in which the toes seem to catch and drag with the legs held together, as seen in some clients with cerebral palsy. A waddling gait is when the feet are wide apart. The walk resembles that of a duck. 60. The most appropriate nursing diagnosis for a client 24 hours after an appendectomy is: 1. 2. 3. 4.

altered comfort secondary to surgery. activity intolerance secondary to pain. altered nutrition secondary to surgery. altered mental status secondary to anesthesia.

(2) A client resists ambulation 24 hours after an appendectomy due to movement and stretching of the lower abdominal muscles when walking. Pain medication given 30–45 minutes prior to ambulation makes movement more comfortable for the client. 61. Which type of contracture is most commonly seen in clients recovering from a CVA? 1. 2. 3. 4.

extension contractures flexion contractures twisted contractures fibrotic contractures

(2) Flexion tendons are stronger than extension tendons, so the position naturally assumed is flexion. 62. A client has problems ambulating secondary to foot drop. A foot drop is which type of contracture? 1. 2. 3. 4.

foot in plantar flexion foot in plantar extension ankle with twisted flexion hip with a fibrotic contracture

(1) Foot drop is also known as plantar flexion. The sole of the forefoot flexes toward the heel. Foot drop is best prevented by using braces or high-top tennis shoes for correct alignment and support. 63. Venous stasis that occurs with decreased muscular contraction while a client is on bed rest (immobility) predisposes the client to: 1. 2. 3. 4.

respiratory acidosis. orthostatic hypotension. decreased cardiac workload. deep vein thrombosis (DVT).

(1) DVT is a complication of immobility secondary to slowed blood flow, lack of laminar flow in vessels, and cellular elements attaching to and damaging vein walls. The risk of DVT can be prevented or decreased by teaching clients to do ankle pumps (pulling their toes toward their nose) 15 times every 30 minutes.

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64. A client’s mental outlook following bed rest can best be enhanced by which of the following interventions? 1. 2. 3. 4.

sleeping for 12 hours a day mobilizing the client with an enjoyable activity giving medications to prevent depression allowing the client personal time when the client is sad

(2) Mobilization of the client with familiar activities increases sensory stimulation, enhances intellectual activity, and promotes a sense of control and independence. 65. Healthy sustaining exercise patterns are developed in which of the following age ranges? 1. 2. 3. 4.

40–60 60–80 20–40 12–17

(4) Adolescence is the time when parents should encourage physical activities in their children. Exercise patterns and habits are developed during this time that continue into later life. 66. The stepping reflex seen in an infant is the precursor for an individual’s ability to: 1. 2. 3. 4.

walk. run. crawl. hop.

(1) The stepping reflex is elicited by holding the infant upright and touching the feet to a surface. The reflex lasts from birth to six weeks of age. 67. Which of the following describes a gross motor skill? 1. 2. 3. 4.

walking backward tooth brushing fastening buttons drawing letters with crayons

(1) Gross motor skills are typically mastered before school. They include riding a tricycle, dancing, running, jumping, climbing walls, and walking backward. 68. The mobility problem most often encountered in a postmenopausal woman is: 1. 2. 3. 4.

osteoarthritis. osteoporosis. rheumatoid arthritis. orthopnea.

(2) Osteoporosis is accelerated during the first two years following menopause secondary to the loss of estrogen. Osteoporosis raises the risk of pathological fractures in females. Postmenopausal women should be routinely screened for risk of osteoporosis. Treatment is available to prevent and/or reverse bone loss in postmenopausal women.

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69. An immobilized client is sitting up for the first time after seven days of bed rest. Which of the following actions is most likely to prevent orthostatic hypotension? 1. 2. 3. 4.

Take several deep breaths before sitting up. Stand up slowly. Dangle the legs over the side of the bed. Raise the head off the bed to a full Fowler’s position, and then stand up.

(3) A prolonged period of immobility predisposes a client to orthostatic hypotension. Choice 3 is correct because this is fundamental care that should be given to anyone who has been on prolonged bed rest. It gives the body time to adjust to position changes. 70. The best position to promote respiratory expansion in an immobilized client is: 1. 2. 3. 4.

supine. prone. full Fowler’s. Sims’ position.

(3) Head elevation reduces the pressure of the abdominal organs on the diaphragm, allowing for deeper ventilation. 71. Decreased depth of breathing in an immobilized client predisposes him to: 1. 2. 3. 4.

chronic bronchitis. wheezing. pneumonia. tuberculosis.

(3) Decreased depth of breathing leads to impaired ventilation and retained secretions, which predispose the client to atelectasis. Atelectasis predisposes the client to developing pneumonia. 72. Babath techniques have shown a higher level of functional gain in clients with cardiovascular disorders, i.e. stroke. This rehabilitation technique is: 1. 2. 3. 4.

inhibition of abnormal muscle tone. monitoring of patient’s knowledge deficit. monitoring of seizure activity. alteration in communication skills.

(1) Babath techniques have shown a higher level of functional gain in clients compared with those receiving traditional care. The focus is on inhibition of abnormal tone through the use of reflex-inhibiting patterns and facilitation of automatic reactions such as righting, equilibrium, and protective extension through the use of handling and sensory stimulation. Establishing reflex postural stability and regaining control over individual movements by breaking up synergistic patterns and by changing treatment during the flaccid period, spastic stage, and stage of relative recovery are the interventions used in this approach. 73. Which of the following positions best promotes urinary flow from the renalcalyces in an immobilized client? 1. 2. 3. 4.

supine prone semi-Fowler’s orthopneic

(3) When lying flat, urine collects in the renal calyces increasing the risk of urinary tract infection (UTI). Elevating the head of the bed positions the renal calyces to promote drainage of urine into the bladder, lowering the risk of infection.

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74. Immobility promotes the release of Ca++ from bones into circulating blood, leading to an increased risk of renal calculi related to: 1. 2. 3. 4.

increased activity of osteoclastic cells in the bones secondary to lower weight bearing. increased activity of osteoblastic cells secondary to lower weight bearing. decreased activity of osteoclastic cells secondary to lower weight bearing. decreased calcium intake secondary to decreased appetite.

(1) Weight bearing stimulates osteoblastic cells in the bones, which build bone matrix. Decreased weight bearing leads to increased osteoclastic activity (breakdown of bone), which leads to Ca++ being lost from bones into the bloodstream, and this increases the risk of developing renal calculi. 75. Muscle ___________ causes weakness that can alter physical mobility. 1. 2. 3. 4.

atrophy spasm hypertrophy calcification

(1) Immobility predisposes a client to the loss of muscle function and mass (atrophy). Atrophy of muscles leads to instability and impairs physical mobility. 76. Identify alternative (nondrug) nursing interventions that can be used to relieve pain in a client with a fracture. 1. 2. 3. 4.

Maintain a patent airway through removal of oral secretions. Maintain nutritional status with foods that are well tolerated and nutritious. Encourage communication of thoughts and feelings to family members, friends, and health care personnel. Maintain the integrity of the oral mucous membrane.

(3) Communication of thoughts and feelings might help to relieve the stress or anxiety of a client who has a fracture, thereby relieving pain. 77. The nurse is caring for a client with a hiatal hernia. The client complains of abdominal pain and sternal pain after eating. The pain makes it difficult for him to sleep. Which of the following instructions should the nurse recommend? 1. 2. 3. 4.

Lie down 30 minutes after eating. Decrease intake of caffeine and spicy foods. Eat three full meals per day. Sleep in Trendelenburg’s position.

(2) The client should avoid caffeine and spicy foods; remain upright for two hours after eating; eat small, frequent meals; and sleep with the upper body elevated. 78. Many authors stress the importance of recognizing the holistic nature of comfort. Which statement should the nurse practice in meeting the holistic nature of comfort? 1. 2. 3. 4.

The nurse is responsible for the physical well-being of the client. The nurse is responsible for her competence in developing interpersonal relationships. The nurse is responsible for the ongoing integrity of the client as a whole person. The nurse is responsible for the exercise routine of the client.

(3) The best expression of the nurse’s practice of the holistic nature of comfort is the responsibility to maintain the integrity of the whole person. Even though the other choices are true, they are not inclusive.

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79. Nurses have worked to keep massage therapy as a part of nursing practice because: 1. 2. 3. 4.

it helps with pain control. it helps with restoration of broken bones. it helps to restore total body health. it helps the body not to develop a blood clot.

(1) Research has shown that massages increase microcirculation and beta-endorphin levels, which helps in pain control. 80. The major goal of cognitive-behavioral interventions is: 1. 2. 3. 4.

to control the disease process. to correct all physical dysfunction. to change the client’s perception of pain. to alter the pain centers.

(3) The goal of cognitive-behavioral interventions is to change the client’s perception of pain, to alter pain behavior, and to provide the client with a greater sense of control. 81. Clients who manage acute pain by nonpharmacological interventions should meet which of the following criteria? 1. 2. 3. 4.

They might benefit from avoiding drug therapy and express anxiety or fear about what is going to happen. They want to cope with the pain so that hospital release is faster. They want cutaneous stimulation of the body with a mechanical vibration. They have prolonged teaching to use this type of therapy.

(1) Nonpharmacological methods are appealing to clients who express anxiety and fear, and might benefit such clients in that they might avoid or reduce drug therapy. 82. A client with acquired immunodeficiency syndrome (AIDS) who appears anxious tells the nurse that he has a burning sensation with shooting pain to both feet that is excruciating in nature. How should the nurse interpret this client’s report? 1. 2. 3. 4.

The client is experiencing neuropathic pain to the distal lower extremities. Psychogenic pain to both feet is accompanied by an anxious appearance. There is referred pain described as excruciating to the bilateral feet. Severe phantom pain is present to the feet, which is resulting in anxiety.

(1) Neuropathic pain is the result of a disturbance in the peripheral or central nervous system that results in pain, not necessarily associated with an ongoing tissue-damage process. It is usually described as shooting or stabbing and is severe in nature. 83. A client is very anxious about the pain he might experience postoperatively. Which of the following interventions is most effective in initially helping the client deal with this fear? 1. 2. 3. 4.

Teach relaxation techniques such as deep breathing and guided imagery. Explain the availability of pain medications after surgery. Demonstrate the various positioning techniques that promote postoperative comfort. Distract the client from discussing pain by focusing on surgical preparation.

(1) The client is most likely experiencing anxiety because of fear related to the postoperative pain. The best intervention is to reassure, listen, and teach relaxation techniques.

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84. A nurse uses the OPQRST scale to assess a client’s muscle weakness from pain. What does this scale mean? 1. 2. 3. 4.

impaired mobility kyphosis development multiple problems causing pain pain associated by a model

(1) Using the OPQRST, the nurse can easily assess, plan, and intervene in the pain of the client. O = Onset of the pain P = Provocating incident that caused the pain Q = Quality of the pain R = Region/Radiation of the pain S = Severity of the pain T = Timing of the pain 85. Which of the following statements is the most appropriate when teaching a client with chronic pain how to use guided imagery? 1. 2. 3. 4.

The exercises decrease the need for analgesia. The exercises enhance the effect of analgesia. The exercises decrease pain sensation. The exercises allow for better rest periods.

(2) Relaxation exercises, such as imagery, enhance other pain relief measures to promote comfort. 86. Pain in elderly clients requires careful assessment because older people have which of the following characteristics? 1. 2. 3. 4.

increased pain threshold decreased pain threshold likeliness to experience chronic pain reduced sensory perception

(4) Elderly clients might have decreased perception of sensory stimuli and a higher pain threshold. 87. A hospitalized client is requesting medication for pain the client rates as severe. The client is watching a sports channel with several visitors, eating pizza, and making frequent phone calls. Which response to the client’s request best reflects the definition of pain? 1. 2. 3. 4.

The distractions must not be very effective. The client is probably anxious about being in the hospital. If the client says he is in pain, he must be in pain. Social stimulation can increase pain.

(3) The best choice for the nurse is to act based directly on the client’s verbal report. Pain is whatever the person says it is, experienced whenever he says he is experiencing it. 88. Which of the following nursing diagnoses relates concerns about spiritual health? 1. 2. 3. 4.

Spiritual Distress Inability to Adjust Lack of Faith Religious Dilemma

(1) Spiritual needs are very important and can be a nonpharmacological distraction for pain.

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89. A client has recently been diagnosed with a malignant tumor. The staff has observed him crying on several occasions, and now he cries as he reads from his Bible. Interventions to help the client cope with his illness include: 1. 2. 3. 4.

asking the hospital chaplain to visit him daily. engaging the client in diversion activities to reduce feelings of hopelessness. eliciting the client’s feelings, thoughts, and values, and centering on achieving the client’s goals. praying with the client as often as possible.

(3) To establish a therapeutic relationship, remain focused on eliciting the client’s feelings, thoughts, and values, and center on achieving the client’s goals. 90. Which definition does not characterize stress? 1. 2. 3. 4.

Stress is characterized by any situation in which a nonspecific demand requires an individual to respond or take action. Stress is a phenomenon affecting social, psychological, developmental, spiritual, and physiological dimensions. Stress is a condition eliciting an intellectual, behavioral, or metabolic response. Stress is a condition in which the body becomes traumatized.

(4) The internal environment creates the basis for dealing with most external stimuli. How a person feels emotionally can produce a positive or negative response. Emotional well-being should be paramount. 91. Which statement about homeostasis is inaccurate? 1. 2. 3. 4.

Homeostatic mechanisms provide long-term and short-term control over the body’s equilibrium. Homeostatic mechanisms are self-regulatory. Homeostatic mechanisms function through inadequate preparation. Illness might inhibit normal homeostatic mechanisms.

(1) Homeostatic mechanisms can be provided by nonpharmacological techniques to maintain stability or equilibrium within an organism. Homeostasis is the tendency of biological systems to maintain relatively constant conditions in the internal environment while continuously interacting with and adjusting to changes originating within or outside the system. 92. Crisis intervention is a specific measure used to help a client resolve a particular, immediate stress problem. This approach is based on: 1. 2. 3. 4.

the ability of the nurse to solve the client’s problems. an in-depth analysis of a client’s situation. teaching the client how to use ego-defense mechanisms. effective communication between the nurse and client.

(4) The major approach to help a client resolve a particular, immediate stress problem is effective communication and interpersonal skills. 93. Clients choose to use unconventional therapy because: 1. 2. 3. 4.

They are willing to pay more to feel better. It is now widely accepted by the Food and Drug Administration. They are dissatisfied with conventional medicine. They want religious approval for the remedies they use.

(3) Clients generally choose unconventional therapy because they are dissatisfied with conventional medicine.

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94. Nurses can best assess a client’s use of alternative therapy by: 1. 2. 3. 4.

asking the client true/false questions about his or her health. asking for a thorough medical history. reviewing laboratory studies that assess levels of certain herbs. asking open-ended questions about alternative therapy.

(4) Communication between the nurse and client is important no matter what therapy is used; this should help the client feel comfortable discussing the therapy. Using open-ended questions, those in which the client cannot give a simple yes or no response, is the best technique. 95. Which of the following steps should nurses take to be better informed about alternative therapies? 1. 2. 3. 4.

Read current books and magazines on alternative therapies. Familiarize themselves with recent case studies on alternative therapies. Familiarize themselves with general principles of pytotherapy. Review herb manufacturers’ literature on specific herbs.

(1) Reading current books and magazines, and participating in discussion groups and informal workshops about alternative therapies, can help nurses be better informed. 96. Pain is a protective mechanism warning of tissue injury and is largely: 1. 2. 3. 4.

a symptom of a severe illness or disease. subjective. objective. an acute symptom of short duration.

(2) Pain is a protective mechanism warning of tissue injury and is largely subjective. 97. A substance that can cause analgesia when it attaches to opiate receptors in the brain is: 1. 2. 3. 4.

substance P. serotonin. prostaglandin. endorphin.

(4) Endorphin is a substance that can cause analgesia when it attaches to opiate receptors in the brain. 98. Which question is most appropriate to adequately assess the quality of a client’s pain? 1. 2. 3. 4.

“Tell me what your pain feels like.” “Is your pain a crushing sensation?” “How long have you had this pain?” “Is it a sharp pain or a dull pain?”

(1) To adequately assess the quality of a client’s pain, the nurse should ask what the pain feels like. 99. The use of client distraction in pain control is based on the principle that: 1. 2. 3. 4.

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Small C fibers transmit impulses via the spinothalamic tract. The reticular formation can send inhibitory signals to gating mechanisms. Large A fibers compete with pain impulses to close gates to painful stimuli. Transmission of pain impulses from the spinal cord to the cerebral cortex can be inhibited.

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(2) Client distraction in pain control is based on the principle that the reticular formation can send inhibitory signals to gating mechanisms. 100. Teaching a child about painful procedures is best achieved by: 1. 2. 3. 4.

early warnings of the anticipated pain. storytelling about the upcoming procedure. relevant play directed toward procedure activities. avoiding explanations until the pain is experienced.

(3) Teaching a child about painful procedures is best achieved by relevant play directed toward procedure activities. 101. As we age, our bones become: 1. 2. 3. 4.

deficient in magnesium. deficient in calcium. high in iron. high in potassium.

(2) As we age, our bones become deficient in calcium. 102. A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid? 1. 2. 3. 4.

cod, liver, sardines liver, chocolate, cod cod, leafy vegetables, eggs chocolate, cod, eggs

(1) Clients with gout should avoid foods that are high in purines, such as liver, cod, and sardines. Green, leafy vegetables, chocolate, and eggs are not high in purines. 103. A client is taking a full liquid diet following gastric surgery. The nurse evaluates that the health teaching has been successful when the family brings in which of the following foods for the client to eat? 1. 2. 3. 4.

pureed fruits custard soft cake chopped vegetables

(2) A full liquid diet allows such items as puddings, creamed soups, sherbet, and strained cereals. (All items must be at room temperature.) 104. While doing a physical assessment on a client, the nurse suspects that the client has poor nutritional status. Which of the following findings confirms the nurse’s observations? 1. 2. 3. 4.

flaccid, soft muscles firm, smooth, pink nails moist buccal cavity mucous membranes erect posture

(1) Soft, flaccid muscles are a sign of inadequate nutritional status. Muscles should be firm and well developed. All other choices are seen in clients with adequate nutrition.

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105. The nurse evaluates the results of laboratory tests completed on a client. Which of the following values indicate an abnormality related to nutritional status? 1. 2. 3. 4.

blood urea nitrogen (BUN) level of 15 mg/dl urinary creatinine level of 800 mg/24 h in an adult female Albumin level of 5 g/dl Serum Potassium level of 2.0 mEg/L

(4) Choices 1 and 3 are normal levels; Choice 4 is indicative of potassium depletion that can occur in severe cases of malnutrition. 106. The Dietary Supplement and Health Education Act states that: 1. 2. 3. 4.

Herbs, vitamins, and minerals may be sold with their therapeutic advantages listed on the label. The Food and Drug Administration must evaluate all herbal therapies. Herbs, vitamins, and minerals may be sold as long as no therapeutic claims are made on the label. In conjunction with the Food and Drug Administration, all supplements are considered safe for use.

(3) The Dietary Supplement and Health Education Act states, “Herbs, vitamins, and minerals may be sold as long as no therapeutic claims are made on the label.” 107. Which foods have the highest content of potassium and should be included in a client’s care plan when the client is at risk for hypokalemia? 1. 2. 3. 4.

potatoes, apricots, broccoli carrots, squash, okra canned soups, milk whole grain products, apples

(1) The fruits and vegetables highest in potassium are potatoes, apricots, and broccoli. Other fruits, vegetables, milk, and whole grain products have some potassium but are not as high as the three foods in Choice 1. 108. Identify the objective data that should be documented after assessing the nutritional status of a newly admitted client. 1. 2. 3. 4.

eats three meals per day has a hearty appetite, likes all food understands the requirements of a well-balanced diet average weight for height, age, and build

(4) Weight and height are quantitative values and, thus, objective data. Choices 1, 2, and 3 are subjective data obtained during communication with the client. 109. Choose the solution that minimizes the risk of electrolyte imbalance when irrigating a nasogastric tube twice a day. 1. 2. 3. 4.

warm tap water distilled water 0.9% saline 0.25% saline

(3) A 0.9% saline solution has the same concentration of solutes as blood plasma and minimizes the risk of an electrolyte imbalance.

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110. Which nursing order in a client’s care plan most accurately measures fluid loss or gain? 1. 2. 3. 4.

Measure fluid loss or gain at meals only. Assess skin turgor. Note increased edema. Weigh client daily.

(4) The most accurate measurement of fluid loss or gain is daily weighing. Presence of edema and poor skin turgor are possible findings when weight has increased or decreased significantly and are not exact measurements. 111. An adult client has taken in approximately 2500 ml of fluids in 24 hours. Indicate the normal output for this client. 1. 2. 3. 4.

4500 cc 1000 cc 2500 cc 500 cc

(3) Normal output for an adult over 24 hours is 2500 cc. 112. Which term best describes the expected output for a severely dehydrated client? 1. 2. 3. 4.

increased decreased unaffected diluted

(2) In a dehydrated client, fluid intake is drawn into the vascular compartment and not eliminated through the normal output process. 113. Which vitamin is deficient in the diet of a client diagnosed with scurvy? 1. 2. 3. 4.

vitamin A vitamin B vitamin C vitamin D

(3) Vitamin C (found in lemons, oranges, and other fruits) prevents scurvy. Vitamin A prevents night blindness. Vitamin B prevents irritability and beriberi. Vitamin D prevents rickets. 114. What foods are most beneficial for a client with scurvy? 1. 2. 3. 4.

oranges, broccoli, liver cereal, peanut butter, fish sweet potatoes, cheese, cantaloupe cheese, cereal, milk

(1) The best source of vitamin C, which is beneficial for a client with scurvy, is fresh fruit, especially citrus (antioxidation). Fats, oils, sugar, bread, cereal, rice, and pasta are not important sources of vitamin C. 115. Choose the diet that best meets the nutritional needs of an elderly client who refuses to wear dentures. 1. 2. 3. 4.

nasogastric feedings full liquid pureed high calcium

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(3) Foods can be pureed to meet the nutritional needs of an elderly client. Refusing to wear dentures is a problem that also needs to be addressed. A diet high in calcium (with vitamin D) is beneficial for bones and teeth but does not meet the client’s total nutritional needs. 116. Which precaution should be included in a teaching plan to avoid trichinosis? 1. 2. 3. 4.

insecticides sprayed on vegetables refrigerating salads with mayonnaise refrigerating raw poultry cooking pork to 160°

(4) Trichinella spiralis, a parasitic roundworm, can be transmitted by eating raw or improperly cooked meat, especially pork. 117. Name the best source of vitamin K. 1. 2. 3. 4.

green, leafy vegetables oranges peanut butter fish

(1) Green, leafy vegetables are the best source of vitamin K. Other sources of Vitamin K are liver, alfalfa, oats, wheat, and rye. 118. A client is well hydrated with no evidence of anemia. Which laboratory value gives the nurse the best measure of a client’s protein uptake and synthesis? 1. 2. 3. 4.

albumin calcium sodium potassium

(1) Albumin is a plasma protein responsible for much of the colloidal osmotic pressure in the blood. A serum albumin level of less than 3.5 grams per deciliter is a criterion for visceral protein depletion and is justification for a diagnosis of malnutrition. 119. Identify the statement that best indicates an understanding of the role of calcium in a diet. 1. 2. 3. 4.

Calcium is involved in muscle contraction. Calcium is the only nutrient needed for bone formation. Calcium is involved in the normal response of the immune system. Calcium aids in maintaining acid-base balance.

(1) Calcium, along with other minerals, strengthens bones and teeth. Calcium also has a vital role in other metabolic functions. 120. Select the food group that is probably lacking in the diet of a client with low calcium levels. 1. 2. 3. 4.

fruits and vegetables breads and grain products meat, fish, and poultry dairy products

(4) Milk and milk products are the best sources of calcium, followed by sardines, clams, oysters, and salmon.

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121. Select the statement that best indicates an understanding of a sodium-restricted diet. 1. 2. 3. 4.

“I can snack on fresh fruit.” “It’s okay to continue to eat low-salt snacks.” “I can use baking soda to treat my indigestion.” “I must restrict my fluids to 1800 cc/day.”

(1) Fruits are “free” on a sodium-restricted diet. Low-salt snacks have some sodium and are usually poor sources of nutrients. Baking soda has a high sodium content. Fluids should not be restricted unless medically indicated. 122. The nurse needs to teach an adult about weight loss. What is the best approach to weight loss? 1. 2. 3. 4.

Avoid floods containing carbohydrates. Reduce daily calorie intake and increase energy expenditure. Eliminate all fats from the diet and decrease water intake. Greatly increase protein intake to prevent body-protein loss.

(2) Reducing total calorie intake while increasing exercise results in weight loss. Diets currently on the market suggest a range of options from decreasing carbohydrates to decreasing fats to increasing protein to combinations of these. The most sensible approach to weight loss is to eat a well-balanced diet with adequate calories to meet energy and bodymaintenance needs, and to increase the consumption of calories through exercise. 123. A client with a low basal metabolic rate (BMR) is most likely to experience which of the following nutritional problems? 1. 2. 3. 4.

malnutrition obesity low serum albumin low hemoglobin

(2) A low BMR results in calories being burned at a slower rate than normal, which usually causes weight gain. Choices 1, 3, and 4 are incorrect because they reflect poor nutritional status, fatigue, and decreased oxygen-carrying capacity. Malnutrition, low serum albumin, and low hemoglobin can occur because of a variety of metabolic factors and are not specifically related to nutritional deficiencies. 124. Which form of protein is unacceptable to a client following a vegetarian diet? 1. 2. 3. 4.

soy beans nuts turkey

(4) Vegetarians do not eat animals that must be killed prior to consumption; most vegetarians (other than vegans) consume eggs, legumes, and dairy products. 125. Which nutritional status-related problem should the nurse detect during a review of systems (ROS)? 1. 2. 3. 4.

oily skin and hair cold hands and feet complaints of frequent headaches complaints of constipation

(4) Complaints of constipation can be associated with nutritional problems such as decreased dietary fiber and fluid intake. Choices 1 and 2 are incorrect because they represent physical assessment data that is not obtained from an ROS. Choice 3 is incorrect because complaints of frequent headaches could be related to factors other than nutrition, such as high blood pressure, low blood glucose level, and visual problems.

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126. A client has been diagnosed with terminal cancer. He is being sent home with Hospice care. His daughter states, “I do not know what to say if he asks me if he is going to die.” The best response is: 1. 2. 3. 4.

“The Hospice nurse will answer his questions.” “You are using denial with your father.” “Tell him everyone has their own time.” “Let’s discuss your father’s illness and its progression.”

(4) Open communication can decrease fear and strengthen one’s sense of control. Knowledge of the illness and its progression can give the daughter a sense of control. Responding in an open and honest manner to the father’s questions helps develop a therapeutic relationship. The other choices block communication. 127. In caring for a female client with colon cancer who has a colostomy, which of the family role concepts should the nurse caring for the client keep in mind? 1. 2. 3. 4.

The illness affects only the client. Children are not affected by the illness. The illness of one family member affects all members. Changes in sleeping and eating patterns in the client mean acceptance of the illness.

(3) The Family Dynamics Theory stresses that what affects one family member has an effect on all members and their roles in the family. 128. A client with a terminal illness has designated a person to be responsible for making decisions about her care. This is known as a: 1. 2. 3. 4.

living will. bill of rights. contracts duos. durable power of attorney.

(4) The designation of a person who has legal rights to make decisions for a terminally ill client (regarding type and length of treatment) is known as durable power of attorney (or an advanced directive). 129. A discharge teaching plan is being implemented for a terminally ill client by a Hospice nurse. Which of the following pieces of information is most appropriate to teach? 1. 2. 3. 4.

The client goes to a Hospice center. Hospice is only concerned about the client. Care occurs in the home without physician input. The focus of care is on control of symptoms and pain relief.

(4) Hospice care is palliative care offered to clients near the end of life. Care is focused on symptom control and pain relief (comfort). Hospice care is a multidimensional team approach and involves all members of the family. 130. A client with breast cancer is undergoing chemotherapy. She develops myelosuppression. Which of the following instructions should her discharge teaching include? 1. 2. 3. 4.

Manage a sore throat with over-the-counter preparations. Wear a mask when going out to shop. Continue to baby-sit for ill grandchildren. Avoid activities that might cause bleeding.

(4) Myelosuppression is an inhibition of bone marrow function. This client has increased risk for bleeding, infections, anemia, and healing difficulties.

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131. A recent diagnosis of cancer has caused a client severe anxiety. The plan of care should include: 1. 2. 3. 4.

teaching the stages of grieving. providing distraction during the time of stress. teaching aspects of chemotherapy. encouraging verbalization of concerns regarding the diagnosis.

(4) Verbalizing concerns helps the client face the unknown and gives a sense of control. 132. A client has undergone a classic cholecystectomy. To promote comfort when coughing, the nurse should teach the client which of the following activities? 1. 2. 3. 4.

Lean forward when coughing. Lie down on the left side when coughing. Sit up and support the abdomen with a pillow. Dangle the feet on the side of the bed before coughing.

(3) Applying external pressure at the site of an abdominal incision decreases the distention of muscles when coughing. 133. A client is undergoing chemotherapy following a laryngectomy for laryngeal cancer. The client begins complaining of a sore mouth. The nurse should assess for: 1. 2. 3. 4.

xerostomia. halatosis. stomatitis. dysgeusia.

(3) One of the earliest side effects of many chemotherapy drugs is stomatitis. 134. A client with advanced cancer of the stomach is undergoing surgery to take out part of or debulk the tumor. This is known as ______________ surgery. 1. 2. 3. 4.

tertiary restorative curative palliative

(4) Debulking a tumor is done to decrease the symptoms of the disease and is known as palliative surgery. It does not effect a cure. 135. When administering pain medication to terminal clients, the nurse should be least concerned about: 1. 2. 3. 4.

addiction. allergy. tolerance. side effects.

(1) Medication for cancer clients often involves opioid use. Addiction of the client is not a primary concern. The goal is pain control and comfort. Other nonaddicting pain medications such as NSAIDS can be added as an adjunct to opioid medications.

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136. Which of the following primary precautions is aimed at reducing the risk of breast cancer in a female who is 50 years of age or older? 1. 2. 3. 4.

pap smear colonoscopy ultrasound mammography

(4) Mammography is suggested annually for every female over the age of 50 as a primary preventative measure. 137. Which test is performed when screening a client for early colon cancer? 1. 2. 3. 4.

RBCs UA guiac ova and parasite

(3) One early warning sign of lower gastrointestinal cancer is rectal bleeding, which is identified by a guiac test, also known as a hemocult test. 138. A permanent sigmoid colostomy results in which type of discharge? 1. 2. 3. 4.

liquid feces urine containing mucous semimusky feces solid feces

(4) Given the location of a sigmoid colostomy, most of the fluid has been absorbed from the stool. The result is a normal or formed consistency. 139. A terminally ill client complains of pain in a lower extremity. Which of the following observations should indicate to the nurse that the client has developed deep vein thrombosis (DVT)? 1. 2. 3. 4.

pain in the calf when the foot is extended pain in the calf with the foot dorsiflexed increased leg circumference decreased leg circumference

(2) One assessment finding that might indicate DVT is a positive Homans’ sign. The client has pain in the calf when the foot is passively dorsiflexed. Other signs of DVT include coldness of an extremity; this finding is more ominous. 140. In managing the acute pain of a cancer client using Music therapy, the nurse should: 1. 2. 3. 4.

Increase the volume of the music. Decrease the volume of the music. Instruct the client to analyze the music. Play only hymns.

(1) In acute pain, the volume of the music should be increased. As pain decreases, the volume of the music should be reduced. Clients should focus on the rhythm rather than analyzing the music.

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141. A bedfast client complains of feeling wrinkles under him in bed. Which of the following methods is the best way to control this painful stimuli in the client’s environment? 1. 2. 3. 4.

Position the client in anatomical alignment. Leave the client alone to listen to music. Tighten and smooth wrinkles in the bed linen. Loosen constricting binding.

(3) Tightening sheets and smoothing out the bed linen makes a client more comfortable by decreasing wrinkle pressure on the client’s skin. 142. To promote comfort in a bedfast client with a Foley catheter, the nurse should: 1. 2. 3. 4.

Avoid mucous membrane irritation. Keep the catheter curled up on the side of the bed. Keep the catheter patent and free flowing. Lift the client in bed, do not pull.

(3) Foley catheter tubing must be straight and free flowing to prevent bladder distension and resulting lower abdominal discomfort. 143. Initial support of a bedfast cancer client includes which of the following? 1. 2. 3. 4.

bed baths medications smooth, cool linens kinked drainage tube

(3) Smooth, cool linen decreases wrinkle pressure on the skin and promotes comfort. 144. Ice Massage therapy is most effective when: 1. 2. 3. 4.

applied near the actual pain site. applied on the opposite side of the pain site. continued until the site turns dark blue in color. applied after acupuncture is performed.

(1) Ice Massage therapy is most effective near the site of pain. Ice Massage therapy should last no more than 5–10 minutes. When the area becomes numb, therapy should be discontinued. Extreme temperatures, either high or low, can cause tissue damage. 145. When employing a transcutaneous electrical nerve stimulation (TENS) unit to manage severe pain, which theory of pain control is being utilized? 1. 2. 3. 4.

Stimulation Gate Control Spinothalamic Gate Stimulation Caudal-Spinal Transmission

(2) TENS is one of several types of electrotherapy devices that deliver small doses of electric current through electrodes placed on the skin. The current interrupts a pain message following a nerve pathway to the brain, hence utilization of the Gate Control theory.

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146. A terminally ill client is complaining of early morning stiffness similar to arthritis. Which of the following nonpharmacological therapies should be used with this client? 1. 2. 3. 4.

TENS unit ice massage moist heat (shower) dry heat

(3) Moist heat applied 20 minutes at a time relieves early morning stiffness without causing muscle spasm. Moist heat increases blood flow to the area and decreases stiffness. 147. Ice Massage therapy is effective for tooth and gum pain when the ice is placed on the web between the thumb and index finger. This is an example of what treatment modality? 1. 2. 3. 4.

acupressure Gate Control therapy numbing stimulation leading to decreased sensation Touch therapy

(1) The web area on the hand is an acupuncture point that influences nerve pathways to the foot and head. 148. For client safety, the duration of Ice Massage therapy should not exceed: 1. 2. 3. 4.

5–10 minutes. 20 minutes. 30 minutes. 60 minutes.

(1) Ice Massage therapy should be applied for 5–10 minutes to achieve full effect. 149. Which of the following statements is true with regard to morphine administration in patient-controlled analgesia (PCA)? 1. 2. 3. 4.

More morphine is used with PCA than with injections in the hips. The nurse can give the injections whenever the client calls for them. Use of PCA keeps the client comfortable, and she has control over the pump. If the client pushes the control button too often, she might get more medicine than she needs.

(3) Research has shown that clients use less pain medication with PCA than with traditional administration routes. The client can administer safe amounts of pain medication with PCA. 150. A home health nurse is applying a fentanyl (duragesic) patch for pain management. Which of the following criteria contraindicates the application of the patch to the upper arm? 1. 2. 3. 4.

The client had bilateral mastectomies performed. The client has minimal hair disturbance to the arm area. The client has IV catheters placed in the hands. The client uses his arms to lift his body.

(1) Placement of a pain patch on the arm of a client with same-side mastectomy is contraindicated. The patch is placed for 72 hours on an area without hair.

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151. What should a nurse take into consideration when determining the type of bath to give a client? 1. 2. 3. 4.

nurse’s schedule client’s energy level availability of linen staffing

(2) The client’s energy level, desires, and personal considerations should be the major considerations. 152. Which of the following data supports a nursing diagnosis of Risk for Impairment of Skin Integrity? 1. 2. 3. 4.

serum albumin < 3.0, peripheral edema, signs of depression serum albumin > 4.0, slow rebound of skin, p02 = 80 hematocrit 39, BUN 10, slight intention tremor of hands hematocrit 32, stress incontinence, ambulatory as tolerated

(4) Hematocrit of 32 is below the normal range of 37%–47% (±2), which could indicate iron deficiency and possibly affect skin status. Presence of urine (ammonia) on the skin, as in stress incontinence, can cause skin impairment. In Choice 1, serum albumin is below normal, which could affect skin status. Peripheral edema affects skin integrity. Signs of depression are not involved unless the client becomes immobile. 153. Which of the following activities is most appropriate when assisting with the hygiene needs of a client whose culture is different from that of the nurse? 1. 2. 3. 4.

Acquire knowledge of diseases typical of that culture. Obtain detailed knowledge of cultural characteristics. Demonstrate respect for the individuality of the client. Ask the client for information about folk medicine practices.

(3) Obtaining detailed knowledge about the culture takes time and might not help individual clients. 154. Which finding indicates to the nurse that the client has poor personal hygiene practices? 1. 2. 3. 4.

dry, flaking skin strong breath odor itchy patches on the scalp unkempt finger and toenails

(4) Unkempt finger and toenails are most indicative of poor personal hygiene practices. Choices 1, 2, and 3 suggest possible underlying disease processes. 155. The nurse is providing oral care for a client who is unconscious. How should the client be positioned? 1. 2. 3. 4.

Sims’ position high-Fowler’s position side-lying position with the head of the bed slightly elevated semi-Fowler’s position with the head turned upward

(1) The correct position is Sims’ or a side-lying position with the client’s head turned toward the dependent side to prevent aspiration.

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156. The nurse is teaching a client’s spouse to care for the client’s dentures. While observing the performance of the procedure, which behavior indicates a lack of understanding? 1. 2. 3. 4.

using a popular brand of toothpaste brushing the dentures with a toothbrush cleaning the dentures over a terrycloth towel rinsing the dentures thoroughly in hot water

(4) Hot water can cause warping or softening of the dentures; to protect dentures against breakage, dentures should be brushed with toothpaste. 157. A client who is recovering from a mastectomy is severely depressed. Which statement describes the purpose of bathing that is recognized as the most applicable and beneficial for this client? 1. 2. 3. 4.

promoting comfort and relaxation promoting cleanliness and self-image conditioning the skin and promoting ROM stimulating respirations and circulation

(1) Bathing can be a form of comfort and relaxation, which can have a positive effect on the client’s mental status. 158. Which of the following nursing activities are appropriate when giving perineal care to a female? 1. 2. 3. 4.

Wear sterile gloves. Wash from the pubis toward the anus. Wash from the most-contaminated area to the least-contaminated area. Do not use soap.

(2) In giving perineal care, the nurse needs clean gloves (not sterile) and should wash from the pubis toward the anus (front to back) so that E. coli and other bacteria are not brought toward the urethra. 159. A nurse is assigned to take two clients’ vital signs, complete a focused assessment for a client, provide hygiene care for a client, administer medications to assigned clients, and complete a dressing change for a client with an abdominal wound. Which task has priority? 1. 2. 3. 4.

Take vital signs and provide hygiene care for the first client. Administer medications to assigned clients. Complete the dressing change. Take vital signs for the first two clients.

(4) Taking vital signs for the first two clients is the priority nursing action because this determines whether emergent problems exist. Next, in order of priority, the nurse should give the medications that need to be given within a certain time frame. The dressing change should be done last because it might also involve a pain assessment and could take more time. 160. While bathing an adult client, the nurse observes slight bruising on the client’s forearm. The nurse correctly documents this assessment of the client’s integumentary system as: 1. 2. 3. 4.

sebaceous. ecchymosis of the dermis. sebaceous cyst. epidermal abrasion.

(2) Ecchymosis is a collection of blood in the subcutaneous tissues (dermis), which causes purplish discoloration. The other choices are not classified as bruising. Sebaceous glands secrete an oil that lubricates the skin. A sebaceous cyst is an infection of the sebaceous gland. Epidermal abrasion is an abraded area of the outer layer of the skin.

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161. An adult client from West Africa is hospitalized following abdominal surgery. On the second postoperative day, the client refuses an assisted bath by the nurse. The nurse should: 1. 2. 3. 4.

Tell the client that it is hospital policy. Ask another nurse to assist in giving the client a complete bath. Negotiate with the client for a partial bath if his culture influences his hygiene practices. Contact the charge nurse and ask for advice on how to accomplish the bath with this client.

(3) Cultural practices can influence personal hygiene preferences. 162. The nurse is assessing a 76-year-old client with dry, scaly skin. An appropriate question for the nurse to ask during the assessment is: 1. 2. 3. 4.

“Are you experiencing itchiness?” “Do you find that you have more bruising?” “Is your skin warm to the touch?” “Have you noticed any moles on your skin?”

(1) The skin of an elder client might be dryer, thinner, and more easily injured; itchiness can be normal or a sign of infection. 163. The nurse delegates morning care of a client to a new, certified nursing assistant (CAN). Which of the following actions by the assistant is appropriate? 1. 2. 3. 4.

placing the client’s dentures in a tissue and putting them in a drawer cutting the client’s nails with scissors washing the client’s body with appropriate care and respect using soap to cleanse the client’s eye orbits

(3) The evaluation of the client regarding hygiene care is the responsibility of the nurse. Only specified skills can be delegated to the CNA. 164. A 61-year-old client with diabetes mellitus has physician’s orders for foot care. Which of the following is the best rationale for this order? 1. 2. 3. 4.

The aging process causes increased skin breakdown. Diabetes mellitus puts a client at risk for neuropathy and poor peripheral circulation. The client probably has a history of poor hygienic care. The lower extremities are difficult to see, and it is therefore hard to maintain good hygiene for that area.

(2) A client with diabetes mellitus is at risk for neuropathy, which can prevent the client from feeling pain, heat, or cold, and puts the client at higher risk for injury. The diabetic client is also at risk for poor peripheral circulation, which can make healing difficult. 165. A client is unable to rest. The nurse decides to give the client a backrub. Which of the following strokes should the nurse use? 1. 2. 3. 4.

long firm strokes down the back light strokes while moving up the back in a circular motion kneading movements toward the sacrum circular motion upward from the buttocks to the shoulders

(1) A backrub given with long firm strokes can increase client comfort and encourage rest.

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166. The nurse should avoid using lemon-glycerin swabs on a client’s tongue and mucous membranes because regular use of this product: 1. 2. 3. 4.

erodes tooth enamel. reduces adhesion to the mucous membrane. swells gums and mucous membranes. destroys normal mouth bacteria.

(1) The acidity of lemon-glycerin swabs can erode tooth enamel. Use should be limited. 167. An older client’s skin requires special care because: 1. 2. 3. 4.

subcutaneous fat increases. sebaceous glands secrete more oil. the skin becomes increasingly dry. the skin thickens.

(3) With age, the skin becomes increasingly dry, subcutaneous fat decreases, sebaceous glands secrete less oil, and the skin becomes thinner. 168. During a bath, the nurse observes that a client, age 35, has dry skin. The nurse’s best action is to: 1. 2. 3. 4.

Bathe the client more frequently. Use an emollient on the dry skin. Massage the skin with alcohol. Discourage fluid intake.

(2) An emollient soothes dry skin, whereas frequent bathing increases dryness. Alcohol is a drying agent. Discouraging fluid intake leads to dehydration and subsequently to dry skin. 169. A marked inflammation of the gums involving the alveolar tissue is referred to as: 1. 2. 3. 4.

glossitis. caries. halitosis. gingivitis.

(4) Gingivitis is an inflammation of the gums, usually marked by bleeding of the gums. It is an early stage of periodontal disease. Caries refer to the presence of tooth decay. Halitosis is bad breath. Glossitis is an inflammation of the tongue. 170. A priority nursing action when administering oral care to a dependent client is: 1. 2. 3. 4.

assisting the client to the dorsal recumbent position. wearing disposable gloves. using a firm toothbrush to cleanse the teeth and gums. irrigating the mouth forcefully with hydrogen peroxide.

(2) Disposable gloves provide a barrier to protect the nurse and client. The dorsal recumbent position is unsafe because the client can easily aspirate any secretions or fluids. A soft toothbrush is recommended to avoid causing irritation and bleeding. Forceful irrigation is never safe. Water should be used for any gentle irrigation.

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171. A client has an eye infection with a moderate amount of discharge. To clean this client’s eyes, the nurse should: 1. 2. 3. 4.

Use hydrogen peroxide. Wipe from the outer canthus to the inner canthus. Position the client on the same side as the eye to be cleansed. Use only one cotton ball per eye.

(3) Positioning the client on the same side as the involved eye discourages contamination of the other eye. Water or normal saline should be used for cleansing the eye of discharge. One cotton ball should be used for each stroke. Always cleanse from the inner canthus to the outer canthus to avoid introducing debris into the nasolacrimal duct. 172. The nurse’s responsibility when giving foot care to an older client includes: 1. 2. 3. 4.

using scissors to correct an ingrown toenail. trimming toenails as short as possible. using an alcohol rub if the feet are dry. bathing the feet daily.

(4) Elder clients should have daily foot care. Treatment of an ingrown toenail is done by a podiatrist. Trimming the toenails might require a physician’s order. Cutting toenails as short as possible exposes tender areas to friction and can lead to injury during trimming. Alcohol is drying and should not be used on dry feet. 173. Providing perineal care to a client requires that the nurse: 1. 2. 3. 4.

Use a clean portion of the washcloth for each stroke. Proceed from the most-contaminated area to the least-contaminated area. Use sterile gloves. Leave the foreskin undisturbed in an uncircumcised male.

(1) Using a clean portion of the washcloth for each stroke prevents contamination of other areas. Cleansing should always proceed from the least-contaminated area to the most-contaminated area. Clean gloves, not sterile gloves, are used to provide perineal care. The foreskin of an uncircumcised male should be gently retracted, cleaned underneath and then gently returned to its former position. 174. A nurse is caring for an 80-year-old client who requires total assistance with his personal and oral hygiene. He is thin, has few visitors, and prefers to remain in bed in a semisitting position. The priority nursing diagnosis is: 1. 2. 3. 4.

Risk for Impaired Skin Integrity (related to immobility). Bathing/Hygiene Self-Care Deficit (related to decreased strength and endurance). Social Isolation (related to lack of visitors). Activity Intolerance (related to generalized weakness).

(1) Although Bathing/Hygiene Self-Care Deficit, Social Isolation, and Activity Intolerance might be appropriate nursing diagnoses for this client, the priority at this time is Risk for Impaired Skin Integrity. A break in his skin, such as that from a pressure ulcer, might lead to infection, which could potentially be life threatening. 175. An older client with an unsteady gait requests a tub bath. The nurse should be aware that: 1. 2. 3. 4.

Oil should be added to the water to prevent dry skin. The client should lock the door to guarantee privacy. The client requires assistance in and out of the tub to prevent falling. The water temperature should be very warm because the client chills easily.

(3) Safe nursing practice requires that a client with an unsteady gait be assisted in and out of the tub. Oil is dangerous for this client because it makes the tub slippery. Although privacy is important, if the client locks the door, the nurse cannot help in the event of an emergency. The water temperature should be comfortably warm (43°C–46°C). Older clients have an increased susceptibility to burns.

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176. A person spends the most sleeping hours in which type of sleep? 1. 2. 3. 4.

REM non-REM (NREM) physiologic synchronized

(2) A person spends the most hours in NREM sleep. NREM is deep and restful sleep in which vital signs decrease. 177. The stage of sleep in which a person feels drowsy or relaxed, and the eyes roll from side to side is known as: 1. 2. 3. 4.

REM I NREM I NREM IV REM IV

(2) NREM I sleep is characterized by a very light sleep in which the person feels drowsy or relaxed and the eyes roll from side to side. The heart and respiratory rate drop slightly. 178. Which of the following stages of NREM sleep is thought to restore the body physically? 1. 2. 3. 4.

REM NREM II NREM III NREM IV

(4) NREM IV is thought to be the stage that restores the body physically. NREM III is the domination of PSNS and the sleeper is difficult to arouse. 179. The typical sleeper experiences how many sleep cycles during eight hours of sleep? 1. 2. 3. 4.

1–2 2–4 4–6 7–10

(3) The typical sleeper experiences four–six cycles during eight hours of sleep. 180. Which of the following is most important to know about sleep and health? 1. 2. 3. 4.

Eight hours of sleep is mandatory for health. A regular sleep-wake rhythm is more important than the number of hours of sleep. Sleep patterns depress protein synthesis. Four hours of sleep is mandatory for good health.

(2) The maintenance of a regular sleep-wake rhythm is more important than the actual number of hours of sleep. Some individuals function well on more or less than seven to eight hours of sleep each night. 181. Which of the following changes occurs during NREM sleep? 1. 2. 3. 4.

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decreased systolic pressure, increased pulse rate, increased cardiac output decreased systolic pressure, decreased pulse rate, decreased cardiac output decreased intracranial pressure, increased muscle tension, decreased growth hormone levels increased systolic pressure, decreased intracranial pressure, increased cardiac output

Basic Care and Comfort

(2) Systolic pressure, pulse rate, and cardiac output decrease or slow during NREM sleep due to drowsiness and relaxation. 182. What is the best indication that a client is not getting adequate sleep? 1. 2. 3. 4.

the amount of time the client sleeps or doesn’t sleep a report from the client of not sleeping well the client’s inability to concentrate the client’s general appearance

(3) Lack of sleep is reflected by a decrease in cognitive process in which thinking and problem-solving are slowed. 183. Sleep is quite a complex state. Which of the following is the most appropriate statement in regard to this process? 1. 2. 3. 4.

Sleep is associated with coma and lack of memory. Sleep is associated with lack of consciousness and activity. Sleep is maintained by continuous stimulation of the cerebral cortex. Sleep relies on the nuclei of the cerebellum.

(3) Consciousness, or awareness of one’s self and one’s environment, relies on the active function of the cerebral cortex. The RAS (reticular activating system) is responsible for initiating and terminating sleep. Sleep is associated with the lack of consciousness and with inhibition of the perception of sensory stimuli. 184. When a client is deprived of sleep, the nurse might assess such symptoms as: 1. 2. 3. 4.

elevated blood pressure (BP) and confusion. rapid respirations and inappropriateness. confusion and mistrust. decreased temperature and talkativeness.

(3) Sleep deprivation increases confusion, disorientation and misinterpretation of environmental events (resulting in mistrust). 185. A client is having difficulty sleeping. Which of the following reflects the most appropriate nursing intervention? 1. 2. 3. 4.

“What do you do just prior to bedtime?” “Let’s make sure your bedroom is completely dark at night.” “Why don’t you try power napping more during the day?” “You should always eat something just before bedtime.”

(1) Activities prior to bedtime can affect the client’s ability to sleep. Eating and drinking should be avoided for two hours prior to bedtime. 186. The most significant difference between narcolepsy and insomnia is that: 1. 2. 3. 4.

Narcolepsy occurs as an obstructive disorder of the muscles of the oral cavity. Insomnia is a dyssonmia. Insomnia can be voluntarily managed. Narcolepsy causes vivid dreaming states.

(3) Insomnia can be managed through manipulation of the environment such as use of the bedroom for sleep only, not for watching TV.

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187. Which of the following sleep disorders could place a client at risk for stroke, hypertension, and/or cardiac arrhythmias? 1. 2. 3. 4.

narcolepsy insomnia sleep apnea sleep deprivation

(3) Sleep apnea decreases the amount of oxygen delivered to all the cells of the body, causing hypoxia that can result in cardiac irregularities and lead to increased BP and possibly stroke. 188. Which of the following is conducive to sleep? 1. 2. 3. 4.

stress loud noises caffeine before bedtime soft music

(4) Choices 1, 2, and 3 are stimulants and, therefore, are not sleep promoting. 189. A client who has more REM sleep than NREM sleep is most likely to: 1. 2. 3. 4.

be very relaxed. have a lowered BP. feel poorly rested. be easily awakened.

(3) REM sleep is less restful and is often associated with dreaming. 190. Sleep research has demonstrated a relationship between the client’s longevity and the number of hours slept per night. The number of hours associated with increased longevity is: 1. 2. 3. 4.

4 hours. 7 hours. 8.5 hours. 10 hours.

(2) Research has demonstrated that the greatest longevity is found in those clients who sleep 7 hours per night. Longevity is found to be shortest in clients who sleep more than 8.5 hours or less that 4.5 hours per night. 191. Clients with gastric ulcers are deprived of sleep due to pain caused by: 1. 2. 3. 4.

decreased gastric acid secretion in NREM sleep. increased gastric acid secretion in REM sleep. increased gastric acid secretion in NREM sleep. decreased gastric acid secretion in REM sleep.

(2) Gastric acid secretion is increased in REM sleep. 192. The elderly client feels sleep-deprived due to: 1. 2. 3. 4.

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NREM IV sleep decreased. REM IV sleep decreased. NREM I sleep decreased. NREM II sleep decreased.

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(1) Elder adults sleep approximately six hours a night. Twenty-five percent is REM sleep. NREM IV sleep is decreased and absent in some instances. 193. Which of the following medical conditions can cause insomnia in a client? 1. 2. 3. 4.

hyperthyroidism euthyroidism normal body temperature renal failure

(1) Hyperthyroidism causes an increased cellular metabolic rate with excessive heat production, which can cause sleep disturbances (including insomnia). 194. An elderly client is admitted to the hospital and becomes confused. The nurse relates this occurrence to: 1. 2. 3. 4.

lights in the hallway. being in an unfamiliar environment. the bed being too soft. the room being too cold.

(2) When an older client is moved into an unfamiliar environment in which normal sleep is disturbed, the client might become confused. 195. Newborn infants spend what percentage of sleep in REM sleep? 1. 2. 3. 4.

10% 20% 50% 70%

(3) Nearly 50% of a newborn’s sleep is REM sleep. 196. Which nursing intervention is inappropriate when promoting rest and sleep in a depressed client? 1. 2. 3. 4.

Teach deep breathing and relaxation techniques. Explore what the client is thinking and feeling when he is unable to sleep. Help the client express his feelings more clearly. Administer a sedative (hypnotic medication) at bedtime.

(4) Medication should be used only when other measures are ineffective. Choices 1, 2, and 3 are important nursing interventions when helping a depressed client rest and sleep. 197. A client is complaining of inability to sleep through the night since admission to the hospital three days ago. Which of the following factors is most likely to affect the client’s sleep patterns negatively? 1. 2. 3. 4.

presence of pain absence of unfamiliar stimuli ability to talk about the day’s events moderate fatigue

(1) Pain can interfere with sleep. Choices 2, 3, and 4 do not negatively affect or interfere with sleep. Absence of unfamiliar stimuli promotes relaxation and can lead to sleep; moderate fatigue can also lead to restful sleep.

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198. Teaching by the nurse for a client who is about to have surgery should include all the following except: 1. 2. 3. 4.

The surgery will not interrupt your rest and sleep patterns. The surgery might make your feel tired afterward. Plan regular naps and rest periods after surgery. Begin exercise slowly after surgery.

(1) It is common after surgery to feel tired, restless, and have irregular patterns of sleep. The type of surgery, the reason for the surgery, and the client’s condition following surgery can all affect rest and sleep patterns. 199. Clients with severe sleep apnea should learn to plan frequent rest periods and activities based on how well they feel to maximize energy levels and to prevent: 1. 2. 3. 4.

cardiac arrhythmias. fatigue. jaw pain. productive cough.

(2) The deprivation of oxygen during the night often leaves individuals tired during the day. Any activity increases the need for oxygen, which is already limited in a client with severe sleep apnea. 200. A seven-week-old infant is brought in for a well-child clinic visit. The infant’s mother says to the nurse, “I’m concerned that my baby is sleeping a lot, a lot more than his brother or sister did.” The nurse’s best initial response should be: 1. 2. 3. 4.

“How much did his brother and sister sleep?” “Why do you think this is a concern?” “Most babies sleep a lot.” “How old are his brother and sister?”

(2) This response opens a discussion about sleep patterns and the differences in each child.

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Pharmacological Therapies This chapter contains questions and answers from the following topic areas: ■ ■ ■

Adverse Effects Expected Effects Medication Administration

■ ■ ■

Pharmacological Actions Pharmacological Agents Side Effects

1. A client is taking atorvastatin (Lipitor) to treat high cholesterol and is having pain in both legs. Which instruction should be given to this client? 1. 2. 3. 4.

Stop taking the drug, and make an appointment to be seen next week. Continue taking the drug, and make an appointment to be seen next week. Stop taking the drug, and come to the clinic to be seen today. Walk for at least 30 minutes, and call if symptoms continue.

(3) Muscle aches, soreness, and weakness might indicate side effects of the HMG-CoA reducatase inhibitor class of antilipemic agents, which include myopathy, arthralgia, and rhabdomyolysis. Choice 1 is incorrect because an immediate evaluation is indicated. Choice 2 is incorrect because additional doses might exacerbate the problem. Choice 4 is incorrect because exercise does not reverse myopathy and might delay diagnosis. 2. Which of the following adverse effects is associated with levothyroxine (Synthroid) therapy? 1. 2. 3. 4.

tachycardia bradycardia hypotension constipation

(1) Levothyroxine, especially in higher doses, can induce hyperthyroid like symptoms, including tachycardia. Choice 2 is incorrect because an agent that increases the basal metabolic rate is not expected to slow the heart rate. Choice 3 is side effect of bradycardia. Choice 4 is a symptom of hypothyroid disease. 3. Which of the following adverse effects is specific to the biguanide diabetic drug metformin (Glucophage) therapy? 1. 2. 3. 4.

hypoglycemia GI distress lactic acidosis somnolence

(3) Lactic acidosis is a rare but serious complication of metformin accumulation during treatment. When this occurs, it is fatal in approximately 50% of cases. Choice 1 is incorrect because metformin does not induce insulin production; thus, its use does not usually result in hypoglycemia. Hypoglycemia can result from deficient calorie intake, strenuous exercise not supplemented by increased calorie intake, or when metformin is taken with alcohol. Nausea, vomiting, and diarrhea (GI distress) might develop but are usually not severe. Choice 4, somnolence (or prolonged sleepiness), is not a side effect of metformin.

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4. The most serious outcome of tricyclic antidepressant (TCA) overdose is: 1. 2. 3. 4.

seizure. hyperpyrexia. metabolic acidosis. cardiac arrhythmias.

(4) Overdose of TCAs can result in life-threatening ventricular tachycardia or fibrillation, as well as sudden cardiac arrest. TCA overdose can induce seizures, but they are typically not life threatening. TCA overdose does not cause an elevation in body temperature (hyperpyrexia) but can cause flushing. TCA overdose does not cause metabolic acidosis. 5. Clients taking monoamine oxidase inhibitors (MAOIs) should be educated that MAOIs interact with tyraminerich foods and beverages, and that eating such foods can cause: 1. 2. 3. 4.

shock. hypertensive crisis. bleeding episodes. sedation.

(2) The antidepressant drugs known as MAOIs can precipitate a hypertensive crisis when given with foods containing certain amines. Such foods include aged cheeses, beer, Chianti wine, canned meats, raisins, and avocados. The crisis can occur many hours after the drug serum level has declined. Because of the number and severity of adverse effects associated with them, MAOIs are not first-line therapy for depression. Choice 1 results in a hypotensive condition. Choice 3 is incorrect because MAOIs do not interfere with the clotting cascade. Choice 4 is incorrect because MAOIs are not sedating. 6. Why is it important to monitor a complete blood count with differential when a client is being treated with an antiepileptic drug (AED)? 1. 2. 3. 4.

The hematocrit is adversely affected due to increased vascular volume. AEDs affect immune modulators, increasing the risk of infection. Some AEDs cause blood dyscrasias. AEDs induce fever.

(3) Some older AEDs—such as phenytoin (Dilantin), carbamazepine (Tegretol), and felbamate (Felbatol)—can induce aplastic anemia, megaloblastic anemia, blood cell deficiencies (including leukopenia, granulocytopenia, and thrombocytopenia), and immune hemolytic anemia. Choice1 is incorrect because AEDs have no effect on vascular volume. Choice 2 is incorrect because AEDs do not affect immune modulators. Choice 4 is incorrect because AEDs do not induce fever. 7. A client newly diagnosed with hypertension tells the nurse he or she has bronchial asthma. The physician is unlikely to prescribe the beta blocker propranolol (Inderal) because the drug can: 1. 2. 3. 4.

increase the heart rate by stimulating beta 1 receptors. increase calcium influx into the myocardial cells, increasing contractility and myocardial oxygen consumption. antagonize beta 2 receptors. inhibit angiotensin II receptors at the angiotensin receptor blocking site.

(3) Nonselective beta blockers, such as Inderal, competitively block the effects of adrenergic agonists at beta 1 and beta 2 receptor sites. Beta 2 receptor sites are found in the smooth muscle of the airways. Blockage of beta 2 receptor sites can result in narrowing of the airways. In a client with asthma, a narrowed airway could precipitate a respiratory crisis. Choice 1 is incorrect because beta blockers slow the heart rate. Choice 2 is incorrect because beta blockers do not block calcium movement into myocardial cells. Choice 4 is incorrect because beta blockers are not angiotensin receptor blockers.

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8. A client’s blood work shows a low serum albumin level. The client is receiving the anticonvulsant phenytoin (Dilantin), which is 90%–95% protein bound. This client should be monitored for signs of: 1. 2. 3. 4.

hypokalemia. CNS depression. drug toxicity. hyperalbuminemia.

(3) With a low serum albumin level, more free phenytoin is available in the circulation. Free phenytoin is the active form of the drug. Choices 1, 2, and 4 are incorrect because hypoalbuminemia does not induce hypokalemia, CNS depression, or hyperalbuminemia. 9. A client is seen in his physician’s office and is diagnosed with the cardiac glycoside digoxin (Lanoxin) Toxicity. Which set of assessment data supports this diagnosis? 1. 2. 3. 4.

dyspnea and pulmonary edema visual disturbances, nausea, and vomiting dry mouth, sleep disturbances, and constipation hypertension and flushing

(2) Visual disturbances (including blurring, halo effect, double vision, and yellow vision) can occur with digoxin toxicity. The client might vomit initially due to the effect of digoxin on the GI tract and later due to stimulation of the vomiting center of the brain, which occurs after the heart muscle has been saturated with digoxin. Digoxin toxicity does not induce the symptoms in Choices 1, 3, and 4. 10. The loop diuretics such as furosemide (Lasix) and bumetanide (Bumex) can be ototoxic. This effect is enhanced when certain antibiotics are given concomitantly. An example of an antibiotic that could potentiate ototoxicity is: 1. 2. 3. 4.

an aminoglycoside antibiotic, such as gentamicin (Garamycin). a beta-lactam antibiotic, such as ampicillin (Omnipen, Polycillin). a cephalosporin antibiotic, such as cefoxitin (Mefoxin). a macrolide antibiotic, such as azithromycin (Zithromax).

(1) Both loop diuretics and aminoglycoside antibiotics can lead to ototoxicity. When given concomitantly, ototoxicity is enhanced. The nurse should observe the client for subtle changes in hearing. The antibiotics in choices 2, 3, and 4 are not known to be ototoxic. 11. A client is being treated with the potent loop diuretic bumetanide (Bumex). She complains of intermittent, intense flank pain. The nurse should suspect: 1. 2. 3. 4.

acute pancreatitis, a common side effect of bumetanide administration. nephrocalcinosis with some red blood cells in the urine. hypoglycemia secondary to the increased insulin production caused by this drug. muscle cramping secondary to the hyperkalemic effect of this drug.

(2) In addition to the excretion of sodium, chloride, and water, bumetanide administration results in the urinary excretion of calcium and phosphate (proximal tubule effect). Calcium and phosphate are major components of renal stones. The possibility of nephrocalcinosis increases with prolonged use of bumetanide. Choice 1 is incorrect because bumetanide does not induce acute pancreatitis. Bbumetanide can induce hyperlipidemia and aggravate diabetes, resulting in hyperglycemia and glycosuria, but not in hypoglycemia (as in Choice 3). Choice 4 is incorrect because muscle cramping can occur secondary to the hypokalemic effect of bumetanide.

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12. The nonsteroidal, anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen are nonselective cyclooxygenase (COX) inhibitors. Adverse effects of these drugs are common in which system? 1. 2. 3. 4.

central nervous system (CNS) respiratory system gastrointestinal system (GI) cardiovascular system (CV)

(3) COX is an enzyme that catalyzes the first step in the synthesis of prostaglandins from arachidonic acid. If COX is blocked, prostaglandin cannot be produced. Prostaglandin has a cytoprotective effect on the GI tract. Blockage of this protection can result in GI bleeding and peptic ulcer disease. Choice 1 is incorrect because, though still investigational, NSAIDs might slow the progression of Alzheimer’s disease. Choices 2 and 4 are incorrect because NSAIDs do not directly affect the respiratory or cardiovascular systems. 13. When a client is receiving a medication that is known to cause nephrotoxicity, which parameters should be monitored? 1. 2. 3. 4.

alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels intake and output levels balance when standing cognitive level

(2) Nephrotoxic drugs can affect renal function. Therefore, it is imperative to measure the amount of fluid taken in and excreted by clients receiving this medication. ALT and AST levels measure liver function. Balance is a function of the cochlear apparatus in the inner ear. Cognitive function is a high-brain function. 14. Tinnitus can be a symptom of which kind of toxicity? 1. 2. 3. 4.

aspirin, a salicylate methotrexate, for arthritis infliximab (Remicade), the biologic response agent prednisone, a steroid

(1) Moderately high therapeutic doses of aspirin can cause tinnitus, the perceived sensation of sound in the absence of acoustic stimulation. The noise can be described as a ringing in the ear or a hissing, roaring, humming, whistling, chirping, or clicking. Tinnitus is not reported with use of the medications in choices 2, 3, and 4. 15. The physician orders 250 milliliters (ml) of packed red blood cells (RBCs) for a client. This therapy is administered for treatment of: 1. 2. 3. 4.

thrombocytopenia. anemia. leukopenia. hypoalbuminemia.

(2) An RBC transfusion is used to correct anemia in clients when the RBC count must be rapidly increased. Choice 1 is incorrect because RBC transfusion does not correct a low platelet count. Choice 3 is incorrect because RBC transfusion does not correct a low white blood cell (WBC) count. Choice 4 is incorrect because packed RBCs contain very little plasma and, thus, only a small amount of albumin. This amount does not correct low albumin levels.

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16. A client needs a whole blood transfusion. For transfusion services (the blood bank) to prepare a compatible product, a sample of the client’s blood must be obtained for: 1. 2. 3. 4.

a complete blood count and differential. a blood type and cross-match. a blood culture and sensitivity. a blood type and antibody screen.

(2) A blood type and cross-match are needed to ensure that the correct type of donor blood is used and to match the donor product with the client. Incompatible matches result in severe adverse events and possible death. The tests in Choices 1 and 2 are unnecessary. Choice 4 is a test that is utilized to determine the client’s blood type and presence of antibodies to blood antigens; it does not determine donor blood compatibility with the client. 17. A client needs to receive a unit of whole blood. Which type of intravenous (IV) device should the nurse consider starting? 1. 2. 3. 4.

a small, bore catheter to decrease client discomfort the same type of device the client has had in the past (provided that it worked well) a large, bore catheter the type of device preferred by the physician

(3) Large, bore catheters prevent damage to blood components and are less likely to develop clotting problems than a small, bore catheter. Choices 2 and 4 are incorrect because the nurse should determine the correct device. 18. The physician orders a gram of human salt-poor albumin product for a client. The product is available in a 50 ml vial with a concentration of 25%. Which dosage should the nurse administer? 1. 2. 3. 4.

The entire 50 ml vial. The volume determined by the physician. This concentration of product should not be used. 4 ml.

(4) A 25% solution contains one quarter of a gram per ml. Thus, the nurse should administer 4 ml to provide a complete gram of albumin. Choice 1 provides 12.5 grams of albumin. Choice 2 is incorrect because the nurse should determine the volume and consult with a nurse colleague and/or pharmacist as needed to ensure correct dose calculation, as with any product given to a client. Choice 3 is incorrect because a 25% solution is an acceptable product and can safely be used. 19. The physician orders 25 milligrams (mg) of diphenhydramine hydrochloride (HCl), or Benadryl, prior to a blood transfusion for a client. This product is often given prior to a blood transfusion because: 1. 2. 3. 4.

It prevents a minor reaction to the blood. It makes the client drowsy so that he sleeps during the blood transfusion. It prevents sneezing and accidental dislodgement of the IV. It prevents the transmission of hepatitis.

(1) Diphenhydramine HCl is an antihistamine. It is used prior to a blood transfusion to prevent minor reactions. Epinephrine and corticosteroids must be available in case of an anaphylactic reaction to the blood, which can be life threatening. Choice 2 is incorrect because this product might or might not induce drowsiness in a client. However, it is not necessary for clients to sleep during a blood transfusion. Choice 3 is incorrect because, although this product might decrease or eliminate sneezing related to an allergy in a client, if the IV device is properly secured, sneezing does not dislodge it. Choice 4 is incorrect because this product does not prevent the transmission of hepatitis.

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20. Which of the following clients might require platelet transfusions? 1. 2. 3. 4.

a client who underwent chemotherapy two years ago a bone-marrow donor a client with thrombocytopenia a client with congenital heart disease

(3) Platelets can be given when a client’s platelets are not functioning properly due to illness or medicines. Choice 1 is incorrect because thrombocytopenia resulting from chemotherapy does not last for two years. Choice 2 is incorrect because donating bone marrow does not necessitate a platelet transfusion for the donor. Choice 4 is incorrect because congenital heart disease does not result in thrombocytopenia. 21. A client with hemophilia A lacks clotting factor VIII. Which blood product does this client require? 1. 2. 3. 4.

albumin platelets cryoprecipitate granulocytes

(3) Cryoprecipitate contains clotting factors, including factor VIII, fibrinogen, and von Willibrand factor. Choices 1, 2, and 4 do not replace the missing clotting factor. 22. A newborn infant has rapidly rising indirect (unconjugated) bilirubin levels and is not responding to therapy. To prevent brain damage (kernicterus neonatorum), the physician performs an exchange transfusion. This procedure replaces the infant’s blood, containing bilirubin, with donor blood. The product used for this procedure is: 1. 2. 3. 4.

whole blood. packed RBCs. neutrophils. platelets.

(1) Whole blood is used for this procedure in a ml-to-ml ratio. The volume utilized is usually twice the infant’s calculated blood volume. The bilirubin level is significantly reduced. Choice 2 is too concentrated for a double-volume exchange transfusion. Choice 3 and 4 are not used solely for an exchange-transfusion procedure. 23. Fresh frozen plasma (FFP) is administered to a client to treat which of the following conditions? 1. 2. 3. 4.

bone-marrow suppression caused by chemotherapy hemophilia A overwhelming sepsis disseminated intravascular coagulopathy (DIC)

(4) The primary illness causing DIC should be treated and Heparin should be administered first. FFP contains clotting factors and is used in the treatment of bleeding related to DIC only after Heparin is given to block the throbotic process. Choice 1 is incorrect because FFP is not used to treat myelosuppression. Choice 2 is incorrect because hemophilia A is caused by a lack of clotting factor VIII. Cryoprecipitate is the blood product that contains therapeutic levels of factor VIII. Choice 3 is incorrect because FFP is not an agent to treat infection.

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24. The physician orders 20 ml of a 5% albumin and lactated Ringer’s solution to be administered immediately to a pediatric client. A 25% solution of albumin product is available. What amount of 25% albumin and what amount of lactated Ringer’s solution should the nurse prepare? 1. 2. 3. 4.

The physician’s order cannot be fulfilled using the 25% albumin product. The nurse should ask the pharmacy for a 5% solution. The nurse should use 4 ml of albumin product and 16 ml of lactated Ringer’s solution. The nurse should administer 20 ml of the albumin product and follow it with 20 ml of lactated Ringer’s solution.

(3) To dilute a 25% solution to a 5% solution, the nurse needs a ratio of 1 ml of the 25% solution and 4 ml of dilutent (1:5). For a final volume of 20 ml, the nurse needs 4 ml of 25% albumin and 16 ml of lactated Ringer’s solution to maintain the 1:5 ratio. Choice 1 is incorrect because the 25% product can be used safely. Choice 2 is incorrect because the physician has ordered this treatment to be given immediately; the nurse can safely and quickly prepare the product. Choice 4 is an incorrect ratio (1:1) and does not provide a final 5% solution. 25. The physician orders the administration of acetaminophen (Tylenol) prior to a client’s blood transfusion. Acetaminophen is used in this case: 1. 2. 3. 4.

to prevent or treat fever. to alleviate pain and discomfort. to reduce inflammation. to prevent Reye’s syndrome.

(1) Common side effects of blood administration include fever, headache, and chills. These effects can occur during the blood transfusion and up to 24 hours afterward. In this case, the drug is not given for the reasons cited in Choices 2 and 3. Tylenol does not have anti-inflammatory properties; it has antipyretic and analgesic properties. Choice 4 is incorrect because acetaminophen is given to children with a viral illness and/or fever rather than aspirin. Aspirin use has been associated with Reye’s syndrome. 26. A client has a severe, overwhelming infection that is not responding to treatment with antibiotics. The physician can order which of the following products to assist this client in fighting the infection? 1. 2. 3. 4.

von Willibrand factor granulocyte transfusion fibrinogen FFP

(2) Granulocytes, also known as neutrophils, help the body fight infections due to bacteria and fungi. Choices 1, 3, and 4 are used for bleeding disorders. 27. A client asks the nurse what kind of infections can result from a blood transfusion. The best response is: 1. 2. 3. 4.

“I do not know.” “Hepatitis B and C infections can result from a blood transfusion.” “You’ll need to discuss this with your physician.” “Any bacteria, virus, or parasite in the blood component can cause infection.”

(4) Any bacteria, virus or parasite in the blood component can cause infection in a blood-product recipient. The U.S. blood supply is screened for these agents and filtered, which decreases (but does not completely eliminate) the likelihood of infection. Choices 1 and 3 are not therapeutic responses. Choice 2 is incomplete.

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28. A client voids clear, straw-colored urine prior to receiving a blood transfusion. After the transfusion, the client’s next voided urine is a very dark amber color. The nurse suspects: 1. 2. 3. 4.

dehydration. medication as the cause of the discolored urine. urethral trauma. hemolysis of RBCs due to a blood-transfusion reaction.

(4) Incompatibility between donor blood and recipient blood can result in hemolysis of RBCs. Excretion of the heme pigment can discolor urine. Choices 1, 2, and 3 can result in urine color changes, but the question has no indicators for these events. 29. A new staff nurse asks the preceptor how to obtain a blood sample from a client with a central venous access device (CVAD). The preceptor nurse should teach the new staff nurse that: 1. 2. 3. 4.

The sample is drawn into a syringe attached to the CVAD needle, and then placed in a vacutainer. CVADs are not used to obtain blood samples because of the risk of clot formation. The vacutainer is attached to the CVAD needle to obtain a direct sample. Any needle and syringe can be utilized to obtain the sample.

(1) A special CVAD needle is used to access the CVAD. A syringe is attached, and the sample is obtained. Choice 2 is false; one of the primary reasons for insertion of a CVAD is the need for frequent or long-term blood sampling. Choice 3 is incorrect because a vacutainer exerts too much suction on the central line, resulting in collapse of the line. Choice 4 is incorrect because only special CVAD needles should be used to access the CVAD. 30. What is the purpose of tunneling (inserting a catheter 2–4 inches under the skin) when the surgeon inserts a Hickman central catheter device? 1. 2. 3. 4.

to increase the client’s comfort level to decrease the risk of infection to prevent the client’s clothes from coming in contact with the catheter to make the catheter less visible to other people

(2) Access to the subclavian vein is just under the clavicle, but by tunneling the distal portion of the catheter several inches under the skin, the risk of migratory infection is reduced compared to inserting a catheter directly into the subclavian vein. Choices 1, 3, and 4 are incorrect because tunneling is used to prevent infection. 31. The primary complication of a central venous access device (CVAD) is: 1. 2. 3. 4.

thrombus formation in the vein. pain and discomfort. infection. occlusion of the catheter as the result of an intralumen clot.

(3) A foreign body in a blood vessel increases the risk of infection. Catheters that extend outside the body increase the risk of infection. Most of these infections are caused by skin bacteria. Other infective organisms include yeasts and fungi. Choices 1 and 4 are complications of a CVAD but are not the primary complication. Choice 2 is incorrect because, when in place, these lines usually do not cause pain and discomfort. 32. The nurse is educating a client about CVADs. Which of the following statements should the nurse include? 1. 2. 3. 4.

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These devices are essentially risk free. These devices seldom work for more than a week or two, necessitating replacement. The dressing should only be changed by the physician. Heparin is instilled into the lumen of the catheter to decrease the risk that blood will clot and block the catheter.

Pharmacological Therapies

(4) A solution containing Heparin is used to reduce catheter clotting and maintain patency. The concentration of Heparin used depends on the client’s age, comorbidities, and the frequency of catheter access/flushing. Choice 1 is incorrect because, although clients usually have few complications, these devices are not risk free. Clients might develop infection, blood clots in the catheter, vascular obstruction, pneumothorax, hemothorax, or mechanical problems (catheter malfunction). Choice 2 is incorrect because strict adherence to protocol enhances the longevity of CVADs; they routinely last weeks or months, sometimes years. Choice 3 is incorrect because the client should be taught to perform dressing changes at home. 33. A CVAD does not flush because of a clot. The physician is likely to order instillation of which product into the catheter to restore patency? 1. 2. 3. 4.

a fibrinolytic agent Heparin sodium Protamine sulfate an acidic solution containing H+ ions

(1) Fibrinolytics (such as streptokinase, urokinase, and alteplase) stimulate the conversion of plasminogen to plasmin. Plasmin is a proteolytic enzyme that is able to disrupt fibrin stability and production and dissolve clots. Choice 2 is incorrect because Heparin prevents but does not dissolve clots. Choice 3 is incorrect because Protamine counteracts the anticoagulant effect of Heparin. Choice 4 does not dissolve clots or restore patency of the catheter. 34. Which type of client monitoring can be accomplished with a CVAD (such as a subclavian vein catheter)? 1. 2. 3. 4.

arterial blood pressure (ABP) central venous pressure (CVP) left ventricular end diastolic pressure (LVEDP) cardiac output (CO)

(2) CVP represents the average blood pressure within the superior vena cava and measures the pressure at which blood returns to the right atrium. It is measured in the thoracic vena cava near the right atrium. It is used to measure a client’s blood pressure and volume to identify fluid overload or loss. Choices 1, 3, and 4 require other measurement devices. 35. When administering multiple medications through a CVAD, the nurse flushes well between each medication. This action helps prevent catheter occlusion due to: 1. 2. 3. 4.

mechanical factors. venous thrombus development. precipitate formation. catheter migration.

(3) Some medications can precipitate in the catheter causing an occlusion. Flushing well between medications prevents medications from mixing and forming a precipitate. Choices 1, 2, and 4 are incorrect because the key to this question regards administering multiple medications. 36. What is a CVAD? 1. 2. 3. 4.

It is a convenient method of obtaining blood samples. CVADs are part of long-term client care. It is a type of IV placed in a large blood vessel. It is an IV device placed in a vein leading to the heart.

(4) By definition, CVADs must be placed in a central vein. Central veins lead to the heart. Even though Choices 1, 2, and 3 provide information about CVADs, they do not define CVADs.

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37. A client, who had been an active swimmer, needs a CVAD (called a port) to be inserted for long-term medication administration. The client asks the nurse about permitted activities. The nurse should explain that: 1. 2. 3. 4.

After the port-insertion site has healed, the client can resume swimming. The area near the port can never be immersed in water. The physician has to discuss bathing options with the client. An occlusive dressing over the port permits showers but not swimming.

(1) The port and tubing inserted into the vein are under the skin. After the surgical incision sites have healed, the client can resume previous activities, including showering and swimming, so Choice 2 is incorrect. Choice 3 is incorrect because the nurse can discuss bathing options with the client. Choice 4 is incorrect because any dressing, including an occlusive one, is unnecessary when the surgical incisions have healed. 38. What is the main benefit of receiving chemotherapy through a CVAD? 1. 2. 3. 4.

There is no benefit; a CVAD is contraindicated because of the risk of infection in immunocompromised clients. It is optimal for medication administration and nutritional support. There is no obvious benefit; CVADs are seldom used for this purpose. It eliminates the need for frequent venous punctures.

(2) A client can receive chemotherapy and parenteral nutritional support (hyperalimentation), if needed, through a CVAD. Choice 1 is incorrect because a risk of infection is present with all foreign objects, and CVADs (especially if tunneled under the skin and scrupulously maintained) have a low infection rate. Choice 3 is incorrect because CVADs are routinely used for chemotherapy administration. Choice 4 is incorrect because the need for venous punctures might be reduced or eliminated, but this is not the primary benefit of a CVAD. 39. A client with a seizure disorder is receiving the anti-epileptic drug phenytoin (Dilantin) intravenously through a central venous catheter. The nurse must only flush with normal saline before and after administering the drug. Why? 1. 2. 3. 4.

to determine whether the catheter is patent to assess the line for infiltration to maintain catheter patency to eliminate phlebitis caused by other flush agents

(3) Contact between Phenytoin and dextrose solutions can result in precipitate formation that can occlude the catheter and require removal. Flushing the catheter before administering a drug is one method to insure at least partial patency of the catheter. However, if the IV has been infusing without difficulty this maneuver is unnecessary: Unnecessary opening of the line increases the chances of line contamination; unnecessary flushing provides additional fluids to a patient who may not tolerate the increased volume. A central venous catheter infiltration cannot be detected by simple flushing of the catheter. Normal saline is generally a well-tolerated solution, but does not prevent phlebitis. 40. The most common skin microorganism that causes CVAD infections is: 1. 2. 3. 4.

hepatitis B virus. cytomegalovirus (CMV). escherichia coli. staphylococci.

(4) Staphylococci have emerged as one major cause of nosocomial infection, particularly in hospitalized clients with indwelling devices and in immunocompromised clients. Choices 1, 2, and 3 are not common skin microorganisms.

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41. The primary advantage of using a peripherally inserted central catheter (PICC) rather than a broviac, subclavian, or Hickman catheter is: 1. 2. 3. 4.

PICCs are cost effective. PICCs decrease allergic responses to the device. PICCs cannot be inserted by nurses. PICCs seldom get infected.

(3) PICC lines are relatively inexpensive to insert and maintain. They do not require surgical insertion like other CVADs. Choice 2 is incorrect because all central venous catheters are relatively nonallergenic. Choice 3 is incorrect because specially trained RNs can insert PICC lines; this contributes to their cost effectiveness. Choice 4 is incorrect because all foreign objects, including PICCs, pose a risk of infection. 42. A client with a CVAD notices several centimeters of air in the IV tubing leading into her device. The client calls the nurse to check the line. Proper action for the nurse includes: 1. 2. 3. 4.

assuring the client that she are safe. stopping the infusion and removing the air from the tubing. preparing a new IV solution and tubing, and discontinuing the current one. educating the client that the volume of air is not significant.

(2) Even small amounts of air entering the central venous system can produce a pulmonary embolus. Most pulmonary emboli are the result of blood clots, but air, fat, amniotic fluid, and clumps of parasites or tumor cells can obstruct pulmonary vessels. Choice 1 is incorrect because the client is not safe until the air has been removed from the IV setup and cannot enter her circulation. Choice 3 is unnecessary, expensive, and wastes valuable time. Choice 4 is incorrect because this volume of air is significant. 43. The most serious dose-limiting side effect of chemotherapy is: 1. 2. 3. 4.

nausea and vomiting (N&V). bloody stools. myelosuppression. inability to ingest food orally due to stomatitis and mucositis.

(3) The overall goal of cancer chemotherapy is to give a dose large enough to be lethal to the cancer cells, but small enough to be tolerable for normal cells. Unfortunately, some normal cells are affected, including bone marrow cells. Myelosuppression limits the body’s ability to prevent and fight infection, produce platelets for clotting. and manufacture red blood cells (RBCs) for oxygen portage. Even though choices 1, 2, and 4 are uncomfortable and distressing to the client, they do not have the potential for lethal outcomes that myelosuppression has. 44. Chemotherapy induces vomiting by: 1. 2. 3. 4.

stimulating neuroreceptors in the medulla. inhibiting the release of catecholamines. causing autonomic instability. irritating the gastric mucosa.

(1) Vomiting (emesis) is initiated by a nucleus of cells located in the medulla called the vomiting center. This center coordinates a complex series of events involving pharyngeal, gastrointestinal, and abdominal wall contractions that lead to expulsion of gastric contents. Choice 2 does not induce vomiting. Autonomic instability (Choice 3) does not induce vomiting. Autonomic instability affects the vital signs and vascular tone. Choice 4 is incorrect because chemotherapy, especially oral agents, can have an irritating effect on the gastric mucosa that could result in afferent messages to the solitary tract nucleus, but these pathways do not project to the vomiting center.

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45. Myeloablation, using chemotherapeutic agents, is useful in cancer treatment because: 1. 2. 3. 4.

It destroys the myelocytes (muscle cells). It reduces the size of the cancer tumor. It reduces the amount of chemotherapy required after surgery. It destroys the bone marrow prior to transplant.

(4) Myelo comes from the Greek word myelos, which means marrow. Ablation comes from the Latin word ablatio, which means removal. Thus, myeloablative chemotherapeutic agents destroy the bone marrow. This procedure destroys normal bone marrow as well as cancerous marrow. The client’s bone marrow is replaced with a bone marrow transplant. Choice 1 is incorrect because myelocytes are not muscle cells. Choice 2 is incorrect because tumors are solid masses typically located in organs. Choice 3 is incorrect because surgery can be performed to reduce the size of a tumor and the chemotherapy required afterward. 46. Anticipatory N&V associated with chemotherapy occurs: 1. 2. 3. 4.

within the first 24 hours after chemotherapy. one–five days after chemotherapy. before chemotherapy administration. while chemotherapy is being administered.

(3) N&V are common dose-limiting side effects of chemotherapeutic drugs. In some clients, N&V are triggered prior to actually receiving chemotherapy by the anticipation of these side effects. Choices 1, 2, and 4 occur after or during chemotherapy administration, so they are not anticipatory events but rather side effects of the drug or drugs. 47. Antimetabolites used for cancer treatment work by: 1. 2. 3. 4.

enhancing cell growth. bone marrow ablation. inhibiting cell growth and proliferation. limiting the capability of the cancer to metastasize.

(3) Antimetabolites are structural analogues of folic acid, purine, or pyrimidine bases found in DNA. They inhibit cell growth and proliferation by inhibiting enzymes required for DNA base synthesis. This limits the chemical and physical processes of the cell. Choices 1 and 2 are not effects of antimetabolites. Choice 4 is incorrect because antimetabolites might limit cancer metastasis, but this is an indirect effect caused by inhibition of cell growth and proliferation. 48. The synthetic cannabis derivative dronabinol (Marinol) can be used to treat cancer clients for: 1. 2. 3. 4.

depression. nausea. pain. mucositis.

(2) The active ingredient in this agent is ∆9—tetrahydrocannabinol or THC. THC modulates the activity of acetylcholine, dopamine, and serotonin. Dopamine and serotonin activate the chemoreceptor trigger zone, which activates the vomiting center in the medulla. Choice 1 is incorrect because dronabinol can induce mild stimulation followed by depression. Choice 3 is incorrect because dronabinol has no pain-relief properties. Choice 4 is incorrect because dronabinol does not reduce or treat inflammation of the oral mucosa.

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49. Many clients receiving chemotherapy are tired and weak as a result of anemia. Anemia in these clients is likely a result of: 1. 2. 3. 4.

decreased erythropoiesis. iron deficiency. poor folic acid intake. exsanguation.

(1) Chemotherapy produces bone marrow suppression, decreasing the marrow’s capability to produce RBCs and leading to anemia and fatigue. Bone marrow suppression is not the result of Choice 2 or 3. Choice 4 is direct blood loss, which might lead to anemia but is not caused by chemotherapy. 50. The main goal of cancer chemotherapy is to: 1. 2. 3. 4.

limit the toxic side effects. attack the cancer as early as possible. cure or provide palliation if the cancer is not curable. provide the client with a suitable quality of life.

(3) Ideally, a cancer cure is elicited. If no cure is possible, cancer palliation prolongs life and reduces incapacitating symptoms. Choice 1 is a secondary goal of treatment. Early recognition and treatment of cancer enhances the cure rate in most cases. A suitable quality of life is part of the main goal of cancer chemotherapy and is related to palliation. Choices 2 and 4 are parts of Choice 3. Choice 3 is more comprehensive and addresses the entire main goal of cancer chemotherapy. 51. Cancer chemotherapy drugs can sometimes be administered intermittently. This technique can be advantageous because: 1. 2. 3. 4.

It enhances the kill rate of cancer cells. It prevents relapse. The client can increase the dosing intervals when affected by uncomfortable side effects. The bone marrow can recover between treatment courses.

(4) Intermittent courses allow bone marrow recovery, reducing the level of hematotoxicity. Choice 1 is incorrect because Intermittent is required to limit bone marrow suppression, not enhance the kill rate of cancer cells. Choice 2 is incorrect because it is Maintenance therapy, not Intermittent therapy that is used to prevent relapse. Maintenance therapy works to sustain remission as long as possible. Choice 3 is incorrect because dosing intervals are determined by bone marrow response and recovery, not uncomfortable side effects. 52. A client with acute lymphocytic leukemia is given chemotherapy to produce a rapid reduction in the tumor cell burden. This regimen is called: 1. 2. 3. 4.

Consolidation therapy. Cyclical therapy. Ablation therapy. Induction therapy.

(4) Therapy to rapidly reduce the number of cancerous cells upon initial diagnosis is the Induction phase. Choice 1 seeks to complete or extend the initial remission and often uses a different combination of drugs than those used for induction. Choice 2 is incorrect because Cyclical therapy is chemotherapy administered at set intervals. Choice 3 seeks to completely destroy the bone marrow.

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53. Palliative chemotherapy is given to clients: 1. 2. 3. 4.

with newly diagnosed lymphoma or leukemia. who have an excellent chance of complete cure. with a solid tumor to reduce tumor burden prior to surgery. to prolong useful life and reduce incapacitating symptoms.

(4) When cancer cannot be cured, the goal of chemotherapy is palliation. Palliative therapy lessens the symptoms of illness without producing a cure. Palliation seeks to assist the client in maintaining his or her lifestyle. Choice 1 is incorrect because newly diagnosed hematologic cancers are treated aggressively, not palliatively. Choice 2 is incorrect because clients with an excellent chance of complete cure are not given palliative chemotherapy. Choice 3 is incorrect because chemotherapy is used to reduce the size of a solid tumor making excision easier and reducing the potential for micrometastases and recurrence, but it is not Palliative therapy with the need for symptom control without impacting survival. 54. Chemotherapy is often administered in intermittent courses called Pulse therapy. An advantage of Pulse therapy over Continuous therapy is: 1. 2. 3. 4.

significant cost savings. client compliance. bone marrow recovery between courses. coordination with the client’s work or vacation schedule.

(3) Chemotherapy has adverse affects on the bone marrow. These pancytopenic effects are the main dose-limiting factor for chemotherapy. Pulse therapy allows the bone marrow to recover function before another course is given. Choice 1, 2, and 4 are important factors in health care. Choice 1 is incorrect because financial savings is not a factor in Pulse therapy. Choice 2 is incorrect because Pulse therapy does not enhance patient compliance with the chemotherapeutic regimen. Choice 4 is incorrect because chemotherapy administration is determined by pharmacokinetics, cancer cell kinetics, and host sensitivity to drugs, not the client’s work or vacation schedule. 55. Chemotherapeutic agents produce a log kill effect. What is the log kill effect? 1. 2. 3. 4.

the time it takes to eradicate approximately half of the cancer cells the acquired drug resistance of the cancer cells to chemotherapy a constant fraction of tumor cell death with each course of chemotherapy the dose-limiting degree of chemotherapeutic toxicity

(3) Antineoplastic drugs tend to kill a constant portion of cancer cells with each course of treatment. The cancer cell volume is calculated using laboratory methods. The number of courses of chemotherapy needed for complete elimination of the cancer is then calculated based on the number of cells killed with each course. Choice 1 is incorrect because the log kill effect refers to a set number of cancer cell deaths; it is not a time factor. Choice 2 is incorrect because cancer cells may develop resistance to chemotherapy but do not have acquired drug resistance. Choice 4 is incorrect because myelosuppression, not log kill effect, is the factor that limits the dose of a chemotherapeutic agent. 56. A cell-cycle-specific antineoplastic drug: 1. 2. 3. 4.

is active throughout DNA replication and mitosis. is effective in the four cell-replication phases (G1, S, G2 and M). has no effect during DNA replication or the mitotic process. is a DNA-alkylating agent.

(1) Cell-cycle-specific agents are active during specific phases of the cell cycle, including DNA replication and cell division. Choice 2 is incorrect because cell-cycle-nonspecific drugs are effective in all four phases of cell replication. Choice 3 is incorrect because cell-cycle-specific drugs work during DNA replication and mitosis. Choice 4 is incorrect because cell-cycle-nonspecific agents are DNA-alkylating drugs.

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57. Valacyclovir (Valtrex) is the drug of choice for treating genital herpes because: 1. 2. 3. 4.

It is inexpensive. It relieves herpetic pain faster than other antiviral medications. It has relatively few serious side effects. It is approved for usage in all clients above two years of age.

(2) Valacyclovir is rapidly absorbed after oral administration and nearly completely converted to acyclovir by first-pass intestinal or hepatic metabolism. It inhibits replication of viral DNA and results in reduced viral shedding. Choice 1 is incorrect because valacyclovir is expensive. Choice 3 is incorrect because valacyclovir can have serious hematologic, renal and hypersensitivity effects. Valacyclovir is approved for use in adults. Safety and efficacy has not been determined in children. 58. Oseltamivir (Tamiflu) is given to reduce the duration of influenza A and B. When is it most effective? 1. 2. 3. 4.

when started prior to flu season when given anytime during the infected period within 24 hours of the onset of symptoms when flu symptoms do not subside within five to seven days

(3) The manufacturer recommends initiation as soon as possible after the first appearance of infection symptoms. Efficacy in clients who begin treatment more than 40 hours after the onset of symptoms has not been determined. Choice 1 is incorrect because oseltamivir has not been studied as a prophylactic agent. (It is not a substitute for an annual influenza injection.) Choice 2 is incorrect because the manufacturer recommends starting oseltamivir sooner in the infection period. Choice 4 is later than recommended by the manufacturer. 59. The Diabetic Control and Complications Trial showed that tight glycemic control prevented many diabetic sequelae such as nephropathy and retinopathy. Tight control is defined as a HgbA1c (A1C) of: 1. 2. 3. 4.

an undetermined adequate value. any value that does not induce hypoglycemia. less than 7%. any variation between 10 and 12, as long as it is within the range.

(3) The American Diabetes Association and the National Diabetes Education Program strongly recommend an A1C of less than 7%. This is also known as glycated hemoglobin or glycosylated hemoglobin, and it indicates a client’s blood sugar control over the last two to three months. A1C is formed when glucose in the blood binds irreversibly to hemoglobin to form a stable glycated hemoglobin complex. Because the normal life span of red blood cells (RBCs) is 90 to 120 days, the A1C is only eliminated when RBCs are replaced. A1C values are directly proportional to the concentration of glucose in the blood over the full life span of RBCs. A1C values are not subject to the fluctuations that are seen with daily blood glucose monitoring. Choices 1, 2, and 4 are incorrect because recommended values have been established at less than 7%. 60. Carbidopa-levodopa (Sinemet, Sinemet CR) is preferred over levodopa alone in the treatment of Parkinson’s disease because: 1. 2. 3. 4.

It is better absorbed from the GI tract. It induces less central nervous system (CNS) adverse effects. It allows more dopamine to reach the brain. It can be administered once a day.

(3) Dopamine does not cross the blood-brain barrier (BBB). Levodopa does cross the BBB, where it is converted to dopamine, increasing the amount of dopamine in the brain. Carbidopa prevents the peripheral breakdown of levodopa, further increasing the amount of levodopa crossing the BBB and being converted to dopamine in the brain. Choice 1 is

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incorrect because absorption is not a factor. Choice 2 is incorrect because carbidopa does not cross the BBB; therefore, it does not change the number of CNS adverse effects of levodopa. Choice 4 is incorrect because even the sustained release formulation must be given a minimum of twice a day; usual dosing is every four to eight hours. 61. Aspirin can be effective in the treatment of myocardial infarction (MI) because it reduces: 1. 2. 3. 4.

fever. inflammation. platelet aggregation. chest pain.

(3 Aspirin inhibits platelet aggregation by decreasing synthesis of thromboxanes and endoperoxides, both mediators of platelet aggregation. Choices 1 and 2 are incorrect because aspirin is an antipyretic and anti-inflammatory agent; however, in the treatment of MI, it is used to prevent platelet aggregation in the coronary arteries. Choice 4 is incorrect because the analgesic effect of aspirin does not sufficiently reduce the pain associated with MI. 62. The nonsteroidal anti-inflammatory drugs (NSAIDs) are beneficial in treating arthritis because they: 1. 2. 3. 4.

are considerably cheaper than steroids. mediate the inflammatory response. have relatively few side effects and are well tolerated. are available over-the-counter.

(2) NSAIDs inhibit cyclooxygenase enzymes (COX-1 and COX-2). Inhibition of either COX-1 or COX-2 (depending on the NSAID) decreases the enzyme responsible for prostaglandin synthesis and results in an anti-inflammatory effect, which reduces the inflammation and pain associated with arthritis. Choices 1, 3, and 4 are incorrect because the key word is in the question is treating. Mediating inflammation is the only possible choice because the other three choices are not treatments. 63. The potassium-sparing diuretic spironalactone (Aldactone) is not useful in emergency situations such as acute pulmonary edema because: 1. 2. 3. 4.

numerous clients have an allergic reaction to the drug. the onset of action is approximately 2–3 days. the IV form of the drug is highly caustic to veins. more than one dose results in hyperkalemia and cardiac dysrhythmias.

(2) Spironalactone is a synthetic steroid that competes with aldosterone for the mineralocorticoid receptors in the renal tubules. It exerts a mild natriuretic effect, increasing secretion of sodium and water in the distal renal tubule and conserving potassium. The peak effect of the drug is not reached for two to three days. Due to its mild diuretic effect and extended time of onset, spironalactone is not the diuretic of choice to treat pulmonary edema in an emergency. Choice 1 is incorrect because this drug has numerous side effects but causes few allergic reactions. (It is contraindicated in clients with renal disease or clients who are on potassium supplements.) Choice 3 is incorrect because spironalactone is not available in an intravenous form. Choice 4 is incorrect because it is prolonged therapy that might result in hyperkalemia. 64. High-potency topical corticosteroids should not be applied to which of the following areas? 1. 2. 3. 4.

legs arms face abdomen

(3) High-potency topical corticosteroids, especially if used long term, can cause hypopigmentation. Hypopigmentation of the face is an unacceptable outcome for most clients. Hypopigmentation in the areas described in choices 1, 2, and 4 is less noticeable and less of an issue for most clients.

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65. Which form of topical corticosteroid is the strongest? 1. 2. 3. 4.

ointment cream spray lotion

(1) Ointments usually have petroleum jelly or lanolin as a base, which is thicker than the other choices and enables the drug to adhere to the tissue for a longer period of time. Choice 2 is incorrect because creams have a slightly less semisolid base. Choices 3 and 4 are incorrect because sprays and lotions are often formulated as oil-in-water emulsions, and the water evaporates. 66. A five-year-old client has atopic dermatitis (eczema). The pediatrician prescribes a first-generation antihistamine at bedtime. The desired effect is: 1. 2. 3. 4.

to treat concomitant allergies. to prevent postnasal drip. to break the itch-scratch cycle. to prevent nighttime coughing.

(3) First-generation antihistamines are sedating. By administering the drug at bedtime, the client might have improved rest, reducing the itch-scratch cycle. Choice 1 is incorrect because this client might or might not have concomitant allergies. Choices 2 and 4 are incorrect because atopic dermatitis is not accompanied by postnasal drip or coughing. 67. Which statement is true about antiepileptic drugs (AEDs)? 1. 2. 3. 4.

They reduce the excitatory neurotransmitter gamma-aminobutyric acid (GABA). They are generally safe for use in pregnant women with epilepsy. They stabilize neuronal cell membranes. They potentiate the effect of the inhibitory amino acid aspartate.

(3) Epileptic seizures are the result of synchronous neuronal discharges. These abnormal discharges spread to other neurons. The cause is often unknown. No pathology exists in the majority of cases. AEDs (or anticonvulsives) work by stabilizing neuronal cell membranes, preventing electrical discharges. GABA is an inhibitory neurotransmitter. Choice 2 is incorrect because many AEDs are teratogenic and should not be used during pregnancy. Aspartate is an excitatory neurotransmitter. 68. Benzodiazipines are useful in treating seizures. They are rapid acting because: 1. 2. 3. 4.

They are highly lipid soluble. They exhibit minimal adverse effects outside the CNS. They immediately block GABA action, reducing neuron excitation. There is less potential for tolerance and abuse.

(1) Being highly lipid soluble, benzodiazipines can rapidly cross the BBB and terminate a seizure. Choice 2 is incorrect because they do exhibit minimal adverse effects outside the CNS, but this is not the mechanism for treating seizures. Choice 3 is incorrect because GABA is an inhibitory neurotransmitter, and blockage of GABA promotes (rather than reduces) neuronal electrical discharges. Choice 4 is incorrect because benzodiazepines can trigger tolerance within two weeks, reducing their efficacy. Seizure activity may recur.

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69. The physical agents in sunscreen, such as titanium dioxide and zinc oxide, are effective because they: 1. 2. 3. 4.

are inexpensive and readily available. absorb ultraviolet radiation. cool and moisturize the skin. scatter ultraviolet (UV) rays.

(4) Sunscreens act by providing a physical or chemical barrier to sunlight. Sunscreens that provide a physical barrier, such as titanium dioxide and zinc oxide, either reflect or scatter light in the visible and UV range. Choices 1 and 3 are incorrect because the key word in the question is effective. Sunscreens are not effective because they are inexpensive or because they moisturize skin. Choice 2 is incorrect because chemical sunscreens act by absorbing UV light, but the question asks about physical agents. 70. Tricyclic antidepressants (TCA) such as amitriptyline (Elavil) are effective in treating disorders other than depression. In chronic pain conditions, TCAs: 1. 2. 3. 4.

prevent night terrors. might cause somnambulism. control obsessive-compulsive disorders. exhibit analgesic and sedative effects.

(4) The key to the correct choice is the phrase chronic pain conditions. TCAs have an analgesic effect and are sedating. They work by moderately inhibiting neuronal reuptake of norepinephrine and considerably inhibiting neuronal reuptake of serotonin. TCAs are used to prevent night terrors and somnambulism (sleepwalking) in clients with sleep disorders, not chronic pain. TCAs have been effective in treating anxiety disorders, such as obsessive-compulsive disorder, but these are not related to chronic pain. 71. Many medications given intravenously are initially formulated as sterile powders for reconstitution with sterile liquids at the time the drug is to be infused. What is the reason for this? 1. 2. 3. 4.

It increases the convenience of the product. Refrigeration is not necessary. The medication is better tolerated by clients. The drug might not be stable for long periods of time in solution.

(4) Because of product instability, the powdered form of the drug is reconstituted just prior to administration. Choice 1 is incorrect because a product in powder form might actually be less convenient than a product already in solution because of the extra steps and time required to reconstitute the powder. Choice 2 is incorrect because whether the powdered product needs refrigeration is a storage convenience. Choice 3 is incorrect because reconstitution of a powdered product does not increase tolerance by clients. 72. An advantage of giving a medication intravenously is: 1. 2. 3. 4.

It bypasses the digestive process in the gastrointestinal (GI) tract. The risk for toxicity is lower. The intravenous route is less expensive. It is painless.

(1) Bypassing the digestive process in the GI tract is an advantage of the intravenous route of medication. The IV route is more efficient because less of the drug is lost (in the digestive process) and more of the drug is available to be rapidly distributed via the circulatory system. Choice 2 is incorrect because the risk for toxicity is higher with the entire dose readily available to the tissues. Choice 3 is incorrect because the intravenous route is more expensive due to the need for an access device, IV tubing and the syringe with which to administer the drug. Choice 4 is incorrect because numerous medications can cause pain and vessel irritation at the injection site.

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73. Before giving an IV medication, the nurse must check the IV site to ensure the IV is patent and without problems. The nurse notices that the site and the area slightly above it are warm and reddened. The client reports the area is tender when touched. This client is exhibiting: 1. 2. 3. 4.

a wheal. thrombophlebitis. erythema. edema.

(2) Irritation or injury to the vein results in formation of a blood clot. Symptoms include redness, edema, tenderness, and a surface vein that feels firm. Choice 1 is a raised mark on the skin often caused by an allergic response. Choice 3 is abnormal redness of the skin related to vasodilation. Choice 4 is swelling from an accumulation of fluid. 74. The nurse can ensure the patency of an IV prior to administering medication to a client by: 1. 2. 3. 4.

asking the client whether she is experiencing any discomfort at the IV site. loosening the tape holding the IV device. flushing the IV with 3 milliliters (ml) of normal saline. disconnecting the IV tubing to see whether blood is able to back up into the IV catheter.

(3) Flushing the IV and observing for any abnormal signs, such as swelling or blanching of the site, can ensure patency of the IV. Choice 1 is incorrect because the client might not be experiencing discomfort even if the IV is not patent. Choice 2 does not check for patency. Choice 4 is incorrect because disconnecting the IV tubing opens a sterile line and might allow microbes to enter the tubing. Blood backing up to the catheter might form a clot. 75. When administering an IV medication into a medication port on IV tubing, the nurse must select the proper gauge of needle. Gauge is: 1. 2. 3. 4.

the length of the needle. the diameter of the syringe barrel. the area where the needle attaches to the syringe. the inner diameter of the needle.

(4) The term gauge is a standard method of measuring the internal diameter of a needle. The higher the number, the smaller the gauge. For example, a 20-gauge needle is smaller than a 16-gauge needle. Choices 1 and 2 are incorrect. Choice 3 is called the hub. 76. The physician orders a liter of normal saline IV for a client. It should infuse over four hours. The nurse should set the infusion pump rate: 1. 2. 3. 4.

at 250 ml per hour. after asking the physician for the rate. at a rate that is comfortable for the client. at the rate suggested by the pharmacy.

(1) A liter of IV fluid contains 1000 ml. This amount divided by a run time of 4 hours equals 250 ml per hour. Choices 2 and 4 are incorrect because the nurse can calculate this rate without input from the physician or pharmacy. Whenever infusion is causing a client discomfort, the situation must be assessed and the infusion discontinued or slowed by the RN (depending on the individual case). The physician must be contacted. If the infusion is uncomfortable at the correct rate, the PN must consult with the RN.

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77. No infusion pump is available. The nurse needs to infuse IV fluid at 120 ml per hour. The IV administration set provides 1 ml of IV fluid for every 20 drops. The nurse should: 1. 2. 3. 4.

Wait until an infusion pump is available. Calculate, and then infuse 40 drops of IV fluid per minute. Check the drip rate with the pharmacy. Hang the bag at keep-open rate until an infusion pump is available.

(2) Forty drops per minute delivers 2 ml per minute. Two ml per minute for 60 minutes provides the correct 120 ml per hour rate. Choices 1 and 4 delay administration of the prescribed fluid. Choice 3 is unnecessary. The nurse can calculate the correct drip rate. The nurse must always consult with an RN and/or pharmacist when in doubt about the dose of any infusion or medication. 78. A requirement for administration of IV doses of potassium chloride is that they be verified by two RNs prior to administration to a client. What is the rationale for this policy? 1. 2. 3. 4.

to ensure this expensive medication is not wasted to ensure adequate renal clearance to ensure the correct dose of this agent, which has a narrow therapeutic range, is administered to ensure normal electrolyte balance

(3) Correct dosing with potassium is critical because overdose can result in ventricular fibrillation and respiratory failure leading to death. Doses must be checked with two RNs. Potassium chloride is relatively inexpensive. Double-checking the dose does not perform the activities described in Choice 2 or 4. 79. Hospitals and other sites where drugs are administered have restrictions regarding the qualifications of an RN to administer certain medications via an IV. An example of these medications is: 1. 2. 3. 4.

antimicrobial agents. antiretroviral drugs. antifungal agents. antineoplastic medications.

(4) RNs administering antineoplastic medications via an IV must be chemotherapy-certified. This credential requires advanced knowledge of chemotherapeutic agents and their administration to reduce the likelihood of errors. Choices 1, 2, and 3 can be given by an RN and require no advanced education or training. 80. A pediatric postoperative client has an order for 2 milligrams (mg) of morphine sulfate via IV every 6–8 hours, as needed for pain. Morphine sulfate is available in a 10 mg/ml concentration. To ensure the correct volume is administered, the nurse: 1. 2. 3. 4.

should draw up and administer 0.2 ml. should check with the pharmacy regarding the correct amount to prepare. should wait and let the oncoming shift give the initial dose. should ask the physician for further clarification of the order.

(1) Each 10th of a ml contains 1 mg of morphine sulfate. To give the client 2 mg, the nurse should administer 0.2 ml. Choices 2 and 4 are unnecessary. The nurse can calculate and prepare the correct dose. Choice 3 delays appropriate pain control for the client. The nurse must always consult with the RN and/or pharmacist if in doubt about the dose of any medication.

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81. The nurse is preparing an IV medication that comes in a glass vial. To correctly prepare this dose, the nurse should: 1. 2. 3. 4.

Send the vial to the pharmacy to draw up. Use a filter needle to withdraw the medication from the vial. Wiggle the top of the vial back and forth until it snaps. Obtain a glass cutter made specifically for medication vials to open this product.

(2) Use of a filter needle to withdraw the medication from the vial prevents any glass shards from being drawn into the client’s dose. Choice 1 is unnecessary because the pharmacy also uses a filter needle. Choices 3 and 4 are incorrect because caution should be used when opening glass vials to prevent injury to the nurse. The proper method involves holding the vial with a protective gauze while snapping the top away from the nurse’s face. 82. Before administering an IV medication to a client, the nurse must: 1. 2. 3. 4.

Ask the client whether he or she has ever taken this medication before. Check the client’s blood sugar. Ensure the IV is patent. Ensure the client is voiding.

(3) Patency of the IV must be ensured prior to administration of a medication intravenously. This prevents extravasation of the medication and injury to the client’s tissues. It also ensures the client receives the prescribed dose. If the IV is not patent, the client will not receive the medication or may have adverse extravasation effects. Therefore, insuring patency of the IV is necessary. Choices 1, 2, and 4 are not steps in the administration of an IV medication and do not affect the need to ensure IV patency. 83. A client has an IV solution of 5% dextrose in water (D5W) infusing. The nurse must now administer an IV medication. The nurse should: 1. 2. 3. 4.

Stop the IV solution, give the medication, and then resume the IV fluid. Change the D5W solution to normal saline, and then give the IV medication piggyback. Piggyback the IV medication into the D5W solution at the medication injection port closest to the client. Ensure the medication and D5W are compatible. If so, piggyback the IV medication into the D5W solution at the injection port closest to the client.

(4) Some medications, such as phenytoin (Dilantin) are not compatible with dextrose solutions. Choices 1 and 2 are unnecessary. Choice 3 is incorrect because it omits the important step of checking for compatibility of the medications. 84. Vasoactive medications, such as dopamine (Intropin) and nitroprusside (Nipress), can be administered intravenously by continuous infusion. Why is a continuous infusion of these agents used? 1. 2. 3. 4.

The half-life of the medications is very short. It is inexpensive. The amount of nursing time is reduced. The clients are more satisfied.

(1) The half-life of some vasoactive drugs is 2 minutes. Others have a half-life of up to 60 minutes. A stable blood level is achieved when the medication is administered by continuous drip. The drug is rapidly cleared upon termination of the infusion. Choice 2 is incorrect because the equipment and supplies necessary for a continuous IV infusion are expensive. Choice 3 is incorrect because an RN must set up and maintain the infusion; monitoring of the infusion site and the client’s condition must be continuous. Choice 4 is incorrect because clients are tethered to an infusion pump during the procedure.

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85. Injected insulin is most rapidly absorbed from: 1. 2. 3. 4.

any subcutaneous site. the abdomen. the thigh. the arm.

(2) Insulin absorption from subcutaneous injection is most rapid at an abdominal site. Choices 1, 3, and 4 are incorrect because absorption is progressively slower from sites on the arm, thigh, and buttock. 86. A diabetic client reports that his insulin is clumpy. The nurse should advise the client to: 1. 2. 3. 4.

Shake the vial vigorously to resuspend the insulin particles. Warm the vial to room temperature, and see whether the clumps disappear. Discard the vial and open a new one. Gently roll the vial between his hands to rewarm the solution and resuspend the insulin particles.

(3) Insulin manufacturers recommend that clumped insulin be discarded and a new vial be opened. Choices 1, 2, and 4 are incorrect because agitating and warming the vial does not eliminate clumped material. Minute clumps might remain that render the product less effective and promote injection-site atrophy. 87. A client is taking alendronate (Fosamax) for the treatment and prevention of osteoporosis. Client education should include taking the medication: 1. 2. 3. 4.

first thing in the morning with a glass of orange juice. at bedtime with a glass of milk. first thing in the morning with water before eating or drinking. and then lying down for 30 minutes.

(3) Benefit is seen only when the medication is taken with plain water in the morning at least 30 minutes before the first food, beverage, or medication of the day. Choices 1 and 2 markedly inhibit absorption. Choices 2 and 4 are incorrect because the client should remain upright for 30 minutes after taking the drug to facilitate delivery to the stomach and reduce irritation of the esophagus. 88. Which of the following type(s) of insulin can be given intravenously? 1. 2. 3. 4.

regular intermediate acting long acting none of the above

(1) Regular insulin is a clear solution that can be given intravenously. Choices 2 and 3 are suspensions of insulin particles and should never be delivered intravenously. 89. Which of the following methods of drug administration is the most expensive parenteral route? 1. 2. 3. 4.

intravenous subcutaneous intramuscular intradermal

(1) All the choices require a needle/syringe for administration. The intravenous route also requires an infusion catheter and, if indicated, IV tubing and an infusion pump. Choices 2, 3, and 4 are less expensive because only a syringe is used for administration.

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90. In adults, the preferred site of administration for most injections is the: 1. 2. 3. 4.

deltoid muscle. gluteus maximus. anterolateral thigh. abdomen.

(1) The deltoid site is readily available, and injections are generally well tolerated at this site. Choice 2 can be used for very thin adults with little deltoid muscle mass or for a larger volume of medication to be administered. Choice 3 is the preferred injection site for infants and small children. Very few medications are administered to the subcutaneous tissues of the abdomen, of note are insulin and Heparin. 91. The only type of drug that is available to exert its therapeutic activity at the site of action is: 1. 2. 3. 4.

hydrophilic. pH neutral. protein bound. unbound from albumin.

(4) An unbound, or free, drug is available to bind to a cell receptor and exert its effects. Choice 1 is incorrect because hydrophilic drugs are agents that interact with polar ends of phospholipids (water and charged particles). Hydrophilic drugs are repelled by the lipid membrane of the cell preventing cell receptor binding and thus, there is no drug effect. Choice 2 is incorrect because the vast majority of drugs are either weak acids or bases, not pH neutral. Hydrophobic drugs cross lipid membranes. Choice 3 is incorrect because protein-bound drugs are not free to bind with a cell receptor and exert an effect. 92. Drugs that have a high hepatic extraction ratio: 1. 2. 3. 4.

have excellent oral bioavailability. have significantly reduced bioavailability. are unaffected by the first-pass effect. require a reduction in dosage when administered orally.

(2) A drug with a high hepatic extraction ratio is reduced significantly during the first pass through the liver, reducing the amount of active drug available to the tissues. Choices 1 and 3 are incorrect because of this reduction. Choice 4 is incorrect because a reduction in dosage further reduces the amount of bioavailable drug. A drug with a high hepatic extraction ratio requires an increase in dosage. 93. A client has both liver and kidney disease. He takes several oral medications. The nurse should expect the duration of action of these medications to: 1. 2. 3. 4.

decrease. increase. stay the same. be absent.

(2) Hepatic and renal disease slow metabolism and elimination of drugs, increasing the duration of drug action. 94. Before administering digoxin (Lanoxin) to a client, the nurse must: 1. 2. 3. 4.

have the client not eat or drink for 4–6 hours prior to the dose. count the apical pulse for one full minute. give the client a potassium supplement based on the client’s amount of urine output. ensure the client’s blood glucose is normal.

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(2) Cardiac glycosides such as digoxin slow the heart rate and increase cardiac output. Digoxin has a very narrow therapeutic range, which necessitates close monitoring for signs of toxicity. The nurse should obtain written parameters for the low heart rate threshold at which cardiac glycosides are to be withheld. The physician must be notified immediately about changes in rate or rhythm, including a heart rate above the normal range. Choice 1 is incorrect because adequate hydration is optimal for clients, and withholding food and water is unnecessary. Choice 3 is incorrect because hypokalemia is a serious side effect of digoxin administration; a potassium supplement is prescribed by a physician, and the dose is adjusted based on regular monitoring of serum potassium. Choice 4 is incorrect because a blood glucose check is not indicated. 95. Some medications in tablet form have an enteric coating. This prevents: 1. 2. 3. 4.

the tablet dissolving in the stomach. the need for more than one daily dose of a medication. children and elderly clients swallowing the tablet. anaphylaxis.

(1) Enteric coatings consist of polymers that do not dissolve in gastric acid but do dissolve in the more alkaline fluid of the small intestines. Enteric coatings protect drugs that can be dissolved in gastric acid. Choice 2 is incorrect because enteric coatings do not affect dosing schedules. Choice 3 is incorrect because the coating contains polymers that make a tablet easier to swallow. Choice 4 is incorrect because an enteric coating does not prevent anaphylaxis if the client is allergic to the drug. 96. When medications are applied to the skin for absorption into the circulation, such as via a skin patch, the process is known as: 1. 2. 3. 4.

intrathecal administration. transdermal administration. topical administration. enteral administration.

(2) Transdermal administration bypasses the liver and its first-pass effects. It is a reliable route of administration for drugs. Drugs commonly administered by the topical route include fentanyl, estradiol, nitroglycerin, and clonidine. Drug-delivery systems of specific transdermal patches determine their length of effect. Choice 1 is injection of a drug through the theca of the spinal cord and into the subarachnoid space. Choice 3 refers to the application of drugs to the surface of the body to produce a localized effect such as treating disorders of the skin, eyes, nose, mouth, throat, rectum, and vagina. Choice 4 refers to administration where the drug is absorbed from the GI tract, such as sublingual, buccal, oral, and rectal routes. 97. An elixir is described as: 1. 2. 3. 4.

a crushed tablet suspended in a solution. a sweetened aqueous-alcoholic solution. a sweetened aqueous solution. the covering of a soft capsule.

(2) Elixirs contain water and alcohol. The alcohol is a solvent for drugs that are not sufficiently soluble in water alone. Choice 1 describes a suspension. Choice 3 describes a syrup. Choice 4 describes a gelatin shell. 98. Initially, new medications are protected from being copied by another manufacturer by a patent. Which type of medication is not covered by patent protection? 1. 2. 3. 4.

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(1) Generic drugs are nonproprietary. When patent protection has expired on a branded drug, other companies may manufacture the medication under a generic name. Choices 2, 3, and 4 are synonymous terms for patent-protected drugs. 99. The nurse observes air in the IV tubing of a solution that is infusing into a client. The nurse: 1. 2. 3. 4.

can ignore it if the air volume is less than 5 milliliters (ml). should stop the infusion, purge the air from the line, and then resume the infusion. should put an air filter in line to catch future air bubbles. should insert a needle in the medication port to vent the air out of the system.

(2) Even small amounts of air entering the venous system can produce a pulmonary embolus. Most pulmonary emboli are the result of blood clots, but air, fat, amniotic fluid, and clumps of parasites or tumor cells can also obstruct pulmonary vessels. Choice 1 is incorrect because the client is not safe until the air has been removed from the IV setup and cannot enter the client’s circulation. Choice 3 is incorrect because, although this is a useful step in preventing future air emboli, the current problem needs immediate attention. Choice 4 opens the system to room air and might introduce microbes. 100. A client is to receive a liter of normal saline. The physician has ordered it to run over 6 hours. The nurse should set the infusion pump rate: 1. 2. 3. 4.

at a rate that is comfortable for the client. after asking the physician for the appropriate rate. at 167 ml per hour. at the rate suggested by the pharmacy.

(3) A liter of IV fluid contains 1000 ml. This amount divided by a run time of 6 hours equals 167 ml per hour. The IV fluid is prescribed by a physician, nurse practitioner, or physician assistant. If the patient is uncomfortable further orders can be obtained from the prescriber. Consulting with another nurse or pharmacist is certainly valid when necessary. The nurse must always consult with another nurse or pharmacist when in doubt about the dose or infusion rate of any medication or fluid. 101. The nurse notices that a client’s IV fluids are slightly cloudy. The nurse should: 1. 2. 3. 4.

Permit the fluids to continue to infuse. Do nothing. This is normal with some parenteral fluids. Check the expiration date on the fluids. Stop the infusion.

(4) Solutions should be clear: free of cloudiness and particulate matter. Choice 2 is incorrect because this is not a normal process; a contaminant or precipitate might be present. Choice 3 is incorrect because the expiration date should be checked prior to starting a bag of IV fluid to ensure it is not out of date. 102. A liter bag of IV fluid is running at 125 ml per hour on an infusion pump. How long will this bag of fluid last? 1. 2. 3. 4.

It will last 8 hours. It depends on the client’s condition. It depends on the size of the IV catheter. It will last until the next shift change.

(1) A liter contains 1000 ml. By dividing 1000 by 125, the nurse can calculate that the IV fluid should take 8 hours to infuse. Choices 2 and 3 do not affect infusion rates. Choice 4 is irrelevant.

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103. An IV fluid of dextrose 5% in water (D5W) contains how many grams of dextrose in a liter bag? 1. 2. 3. 4.

5 grams 50 grams 200 grams 500 grams

(2) D5W contains 5 grams of dextrose per 100 ml. A liter bag contains 1000 ml. Thus, if 100 ml contain 5 grams of dextrose, 1000 ml contain 50 grams. 104. A physician orders a client’s IV fluids to run through a peripheral IV. A very common site for a peripheral IV in an adult is: 1. 2. 3. 4.

the femoral vein. the saphenous vein. the basilic or cephalic vein. a scalp vein.

(3) These antecubital veins are commonly used in adult IV therapy. Choice 1 is generally reserved for very ill clients requiring monitoring. Choice 2 is not a common IV site in adults; it is used more often in children and neonates. Choice 4 is commonly used in neonates. 105. Hospitals have policies regarding the dextrose concentration of IV fluid that can be administered through a peripheral IV. This is necessary: 1. 2. 3. 4.

to increase client comfort. to decrease the risk of bacterial growth. to maintain a normal blood glucose level. to decrease complications.

(4) A direct relationship exists between increasing dextrose concentrations in peripheral IV fluid and complications. Complications include vein irritation, discomfort, infiltration, and extravasation with tissue damage, elevated serum glucose levels, and infection. Choices 1, 2, and 3 are important factors. They are all part of Choice 4, which is more comprehensive. 106. The nurse initiates a new bag of IV fluid for a client. Which information should be documented in the client’s chart regarding the fluid? 1. 2. 3. 4.

date, time, and type of fluid the appearance of the IV site the expiration date of the IV fluid that the IV fluid is clear without precipitate or particulate matter

(1) This action provides necessary information regarding the IV fluid itself. Choices 2, 3, and 4 provide pertinent information, but it is not applicable to the IV fluid itself. 107. Normal saline IV fluid is the common name for: 1. 2. 3. 4.

1.0% sodium chloride. 0.9% sodium chloride. 0.45% sodium chloride. 0.025% sodium chloride.

(2) A sodium chloride concentration of 0.9% is considered normal saline. Choice 1 is a slightly hyperosmotic fluid. Choice 3 is one-half normal saline. Choice 4 is one-quarter normal saline.

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108. A bag of IV fluid wrapped in dark plastic arrives from the pharmacy for a client. This indicates that the product requires dark administration tubing, which is necessary to: 1. 2. 3. 4.

prevent leakage. alert the nurse that this is a dangerous medication. prevent photodecomposition. maintain federal HIPAA regulations regarding client privacy.

(3) Photodecomposition of this specific solution can render it ineffective. Protection from light prevents photolysis. Leakage is not prevented by placing the IV fluid in a dark plastic bag. Specific alert and precaution stickers are placed on medications and IV fluids by the pharmacy. Choice 4 is incorrect because even though privacy issues related to client care are important, the rationale for dispensing this IV in dark plastic is not a privacy issue. A label containing patient and fluid information is placed on the IV bag and also on the outside of the dark plastic. Placing this information on the outside alleviates the need to expose the IV fluid to light to read the label. 109. Giving fluids by the intravenous route is advantageous because: 1. 2. 3. 4.

The intravenous route is less expensive. The risk for adverse events is low. It can be closely monitored by the nurse. It bypasses the absorption process in the gastrointestinal (GI) tract.

(4) Absorption in the GI tract is unnecessary. All the IV fluid is rapidly distributed by the circulatory system and available to the body. Choice 1 is incorrect because the intravenous route is more expensive because of the need for an access device, IV tubing, and infusion pump. Choice 2 is incorrect because IVs carry risk including infection, thrombus formation, infiltration, and mechanical problems. Choice 3 is incorrect because an IV site and the rate of fluid infusion can be monitored, but tabulating the oral intake of a client is simpler. 110. The D in the parenteral fluid D5W stands for the: 1. 2. 3. 4.

solute. solvent. solution. solubility.

(1) A solute is a substance that is dissolved in a solvent. In this case, dextrose is the solute. Choice 2 is a liquid in which a solute is dissolved. In this case, the solvent is water. Choice 3 is a homogeneous mixture formed by mixing a solute with a solvent. Choice 4 is the capability of a solute to dissolve in a solvent. 111. Which of the following parenteral fluids is isotonic? 1. 2. 3. 4.

3% sodium chloride 0.9% sodium chloride 0.45% sodium chloride 0.33% sodium chloride

(2) This solution is physiologic or isotonic with an osmolarity of 308 milliosmols per liter. Blood and serum osmolarity ranges from 280–320 milliosmols per liter. Choice 1 is hypertonic. Choices 3 and 4 are hypotonic. 112. A primary parenteral infusion has a secondary infusion piggybacked into it. An infusion pump is not being used for either fluid. Assuming equal volume and equal position of the roller clamp, which fluid infuses first? 1. 2. 3. 4.

They finish at the same time. The primary fluid infuses first. The fluid that is positioned higher infuses first. The secondary fluid infuses first.

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(3) Because of gravitational pull, the fluid that is positioned higher infuses first. This setup is commonly used to administer fluid boluses and medications. 113. The minimum inhibitory concentration (MIC) of an antibiotic is: 1. 2. 3. 4.

the persistent suppression of microorganism growth after an antibiotic is discontinued. the lowest concentration of a drug that kills 99.9% of initial microorganism density. the amount of antibiotic that prevents visible growth of microorganisms after 24 hours’ incubation. the amount of antibiotic needed to prevent emergence of resistant microorganisms.

(3) The MIC is the lowest concentration of a drug that inhibits bacterial growth. MIC is not an amount of drug; that is a dose. It really is a concentration of the agent. MIC is determined in a lab by exposing a standard inoculum of a bacterium to a range of concentrations of an antibiotic. Based on the MIC, a particular strain of bacteria can be classified as susceptible or resistant to a particular drug. Choice 1 is incorrect because a persistent antibiotic effect after the antibiotic has been discontinued is called the postantibiotic effect (PAE). Choice 2 is incorrect because the lowest concentration of a drug that kills 99.9% of the initial microorganisms is called the minimum bactericidal concentration (MBC). Choice 4 cannot be determined. 114. A child has been diagnosed with Atopic Dermatitis (Eczema). The RN should advise the parents to use a lotion that: 1. 2. 3. 4.

contains alcohol because it is cool and soothing. does not have water as the first listed ingredient. contains a corticosteroid to decrease itching. contains water as the main ingredient because it moistens skin well.

(2) The goal in treating atopic dermatitis is to restore moisture to the skin. Lotions that contain water as the first ingredient temporarily soothe the skin, but the dermatitis returns rapidly as the water evaporates, so Choice 4 is incorrect. Emollients do not evaporate, and skin moisture is protected. Choice 1 is incorrect because alcohol evaporates and has a drying and cooling effect on intact skin; it should not be applied to skin that manifests atopic dermatitis. Even though topical corticosteroidal preparations are sometimes used in Atopic Dermatitis therapy, Choice 3 is incorrect because even though topical corticosteroidal preparations are sometimes used in Atopic Dermatitis therapy, they are only available by prescription and, therefore, would not be recommended. 115. Which phase of drug action includes the absorption, distribution, metabolism, and excretion of a drug? 1. 2. 3. 4.

pharmaceutical phase pharmacokinetic phase pharmacodynamic phase pharmacolygenic phase

(2) Pharmacokinetics is the study of the metabolism and action of drugs. In other words, it describes the method and rate of drug absorption, how the drug is distributed to the tissues, how the drug is metabolized, and how the drug is excreted from the body. Choices 1 and 4 are incorrect because these phases do not exist. Choice 3 is the study of drugs and their actions on the body. 116. A client has liver disease and is receiving a drug that is highly metabolized by the liver. To achieve the usual pharmacodynamic response to the drug, the drug’s dose should be: 1. 2. 3. 4.

greater than a standard dose. smaller than a standard dose. the same as the standard dose. the same as the standard dose, but given more frequently.

(2) The drug cannot be metabolized at the usual rate secondary to liver disease. The dosage must be reduced to prevent drug accretion and toxicity. Choices 1, 3, and 4 all contribute to toxic levels.

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117. Drugs that block prostaglandin production reduce inflammation. Which enzyme responsible for prostaglandin production is affected by these medications? 1. 2. 3. 4.

arachidonic acid sterol thromboxanes cyclooxygenase

(4) Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce pain by blocking the undesirable effects of prostaglandins. They inhibit the enzyme cyclooxygenase and prevent the formation of prostaglandins. Choice 1 is incorrect because NSAIDs have no effect on arachidonic acid. Choice 2 is an alcohol related to fats and included in lipids; it is not involved in prostaglandin production. (Cholesterol is a sterol.) Choice 3 acts to aggregate platelets and is a potent vasoconstrictor. 118. Biotransformation is also known as: 1. 2. 3. 4.

absorption. distribution. metabolism. elimination.

(3) A drug is transformed from one form to another when it is metabolized. Metabolism is the process by which the drug is converted to its metabolites by an enzyme-catalyst reaction. Choice 1 is the passage of drugs from the site of administration to the circulation. Choice 2 is the process by which drugs are transported via the circulatory system to tissues and organs. Choice 4 is the removal of drugs from the body; it occurs primarily via the renal and hepatic system. 119. Vasodilators, such as nitroglycerin, reduce: 1. 2. 3. 4.

after-load. preload. myocardial contractility. sodium and water retention.

(2) These agents relax vascular smooth muscle, primarily in the venous system, slowing the volume of blood returning to the atria of the heart. This reduces cardiac workload by decreasing intramyocardial wall tension and intraventricular work. Choice 1 is the resistance against which the left ventricle has to work to eject blood. Choice 3 is the capability of the myocardial muscle to contract or shorten. Choice 4 is incorrect because vasodilators have no effect on sodium and water retention or excretion. 120. The capability of a drug to dissolve and form a solution is called: 1. 2. 3. 4.

solubility. efficacy. potency. affinity.

(1) The drug (solute) is dissolved in a liquid (solvent). Choice 2 is the capability of a drug to produce a desired effect (or effectiveness). Choice 3 is the degree of power or strength of a drug. Choice 4 is a close relationship, mutual attraction or similarity; it relates to the tendency of a drug to combine with its receptor. 121. Catecholamines (such as dopamine, dobutamine, and epinephrine) are effective within a narrow pH range of: 1. 2. 3. 4.

7.15–7.25. 7.25–7.35. 7.35–7.45. 7.45–7.55.

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(3) The pH range 7.35–7.45 is the number corresponding to homeostasis, a state of body equilibrium or the maintenance of a stable internal environment of the body. Within this range, all systems and hormones work more effectively. Choices 1, 2, and 4 are outside the normal pH range for the body. 122. A client has both liver and kidney disease. The client is taking several oral medications that are metabolized and/or excreted by these organs. The duration of action of these medications can be expected to: 1. 2. 3. 4.

decrease. increase. stay the same. be absent.

(2) The liver and kidneys are primarily responsible for drug metabolism and elimination. If diseased, these organs are unable to process drugs at normal rates. The duration of action of drugs metabolized and eliminated by diseased organs is prolonged. Choice 1 is incorrect because the length of time drugs remain in the body is not decreased; therefore, the duration of the effect of those drugs is not decreased. Choice 3 is incorrect because drugs processed by diseased organs remain in the body longer, so the duration of their action is prolonged; it does not stay the same. Choice 4 is incorrect because drug effects are prolonged, not absent. 123. Pharmacotherapeutics is the: 1. 2. 3. 4.

adsorption, distribution, metabolism, and elimination of a drug. use of medicinal agents for preventing, managing, and curing disease and illness. study of inherited conditions that affect the pharmacokinetics and pharmacodynamics of drugs. effect of drugs on the body.

(2) Pharmaco comes from the Greek word pharmakon, meaning a drug. Therapeutics comes from the Latin word, therapeuticus, meaning serving to cure or heal, curative. Pharmacotherapeutics is the use of drugs to prevent, manage, or cure disease. Choice 1 is called pharmacokinetics. Choice 3 is called pharamacogenetics. Choice 4 is called pharmacodynamics. 124. A physician orders the nurse to draw blood levels of a certain drug when steady state has been achieved. The medication is administered every 12 hours. The drug reaches steady state: 1. 2. 3. 4.

in four–five days. when the client has normal electrolyte levels. with the fifth dose. after the initial maintenance dose.

(3) When a client has reached steady-state blood levels, there is a consistent level of the drug that corresponds to the maximum therapeutic effect. The rate of administration and elimination of the drug are equal and elimination is a function of the half-life of the drug. Any first-order process requires about five drug half-lives to reach steady state. Steady state is independent of the drug dose and frequency of drug administration. Choice 1 is incorrect because steady state is achieved prior to this time. Choice 2 is incorrect because steady state is not dependent on normal electrolyte levels. Choice 4 is incorrect because the initial dose of a drug does not achieve a steady-state blood level. 125. A client has developed tolerance to a drug. The physician increases the dose without any effect. This phenomenon is known as: 1. 2. 3. 4.

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anaphylaxis. tachyphylaxis. tachycardia. acardia.

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(2) The rapid and progressive decrease in response to a drug after its repeated administration is called tachyphylaxis. Choice 1 is a hypersensitivity reaction. Choice 3 is an abnormally rapid heart rate. Choice 4 is a congenital absence of the heart. 126. Which of the following is most likely to be affected by ischemia? 1. 2. 3. 4.

absorption distribution metabolism elimination

(2) Drug distribution is dependent on dispersion via the circulatory system. A drug cannot reach a body part that has no blood flow, such as ischemia. Choices 1, 3, and 4 are not as dependent on adequate blood flow as distribution. 127. A client has recently had a bone-marrow transplant and is currently being treated for disseminated herpes infection with a high dose of IV acyclovir (Zovirax). The client wants to know why acyclovir cannot be taken orally at home. How should the nurse respond? 1. 2. 3. 4.

“You are too sick to go home.” “Oral acyclovir is not as well absorbed as the IV form and cannot adequately treat your infection.” “You can. I’ll ask the physician to switch your medicine to oral tablets.” “Oral acyclovir further irritates oral lesions.”

(2) Oral acyclovir has a relatively low bioavailability (22%). Absorption from the GI tract is slow. Immunocompromised clients with disseminated herpes require predictable blood levels for effective therapy. Choice 1 is not a therapeutic response. Choice 3 is erroneous. Choice 4 is incorrect because oral acyclovir can cause nausea and vomiting but is not routinely associated with oral lesions. 128. Empiric antibiotic therapy is: 1. 2. 3. 4.

a cause of microorganism resistance. reserved for immunocompromised clients. started immediately after cultures are obtained. costly with undesirable side effects and seldom utilized.

(3) Infections are the cause of significant client morbidity and mortality. When an infection is suspected or present, cultures are obtained to determine the exact cause of the infection. Antibiotics are often initiated to prevent sepsis before the culture results are known. This practice is called Empiric therapy, which means the therapy is based on experience, observation, and the infectious agent likely to be present. Choice 1 is incorrect because bacterial resistance is not increased with Empiric therapy. Choice 2 is incorrect because Empiric therapy is used for any client when it is deemed necessary. Choice 4 is incorrect because Empiric therapy is often utilized and is not cost prohibitive. 129. Antiretroviral agents, which act against retroviruses such as the human immunodeficiency virus (HIV), inhibit viral replication by: 1. 2. 3. 4.

fusing the intracellular contents, rendering them harmless. inhibiting the fusion of virus-positive cells to each other, permitting macrophages to move in and phagocytose positive cells. fusing the virus-positive cells with killer T cells. inhibiting the virus from fusing with normal cells.

(4) Fusion drugs inhibit the fusion of viral and cellular membranes. Choices 1, 2, and 3 are not actions of the fusion class of antiretroviral agents.

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130. Medications still in the clinical trial process can be prescribed for certain clients with life-threatening illnesses. This action is called: 1. 2. 3. 4.

compassionate use. expedited availability. high-throughput screening. phase IV clinical trial provision.

(1) An agent not approved for general use and still in the clinical trial process might have unknown deleterious effects on humans. However, if the health care team determines that the client is not likely to survive or is likely to experience extreme morbidity without the drug, a process can be initiated allowing the manufacturer to release a specified amount of such a drug to the physician. Choice 2 occurs when a drug is rushed through development and clinical trials in an effort to make it rapidly available. Choice 3 is incorrect because high-throughput screening is the rapid examination of thousands of pharmaceutical compounds per day to determine if new compounds are effective agonists or antagonists. Choice 4 is incorrect because phase IV clinical trials regard ongoing data collection about a drug after it has FDA approval and is marketed to the public. 131. A client with congestive heart failure (CHF) is taking a daily diuretic. The client’s condition has progressed from Class I (ordinary activity that does not cause undue dyspnea or fatigue) to Class II (ordinary activity that causes dyspnea or fatigue). This client is a good candidate for additional drug therapy including: 1. 2. 3. 4.

cardiac glycosides. sodium and water restriction. antiarrhythmics. daily aspirin.

(1) Cardiac glycosides are inotropic and can improve myocardial contractility, leading to enhanced cardiac output, renal blood flow, and glomerular filtration. Choice 2 is indicated in clients with CHF, but is not a drug therapy. Choice 3 is used to treat CHF caused by rhythm disturbances. Choice 4 is indicated for antiplatelet and anti-inflammatory effects, not to treat CHF. 132. High-alert drugs: 1. 2. 3. 4.

are expensive in most cases. are the most effective medications available. can be lethal if given incorrectly. should be considered for pediatric clients.

(3) High-alert drugs can cause considerable morbidity and mortality if administered incorrectly. Choices 1 and 2 are incorrect because cost and effectiveness do not make certain drugs high alert. Choice 4 is incorrect because high-alert drugs are to be used cautiously in all clients, not one specific group. 133. A 67-year-old client has a history of a gastric ulcer. The physician wants to send the client home on celecoxib (Celebrex) to treat rheumatoid arthritis. This client asks the nurse why a prescription medicine is necessary and why aspirin or ibuprofen, which can be purchased over the counter at the drugstore, can’t be used. How should the nurse respond? 1. 2. 3. 4.

“Aspirin or ibuprofen can be substituted if the client doesn’t want to take a prescription medicine.” “Aspirin and ibuprofen do not relieve arthritis pain.” “Celecoxib might not be as likely to cause adverse GI effects as aspirin or ibuprofen.” “Celecoxib is prescription-strength aspirin.”

(3) Celecoxib is a nonsteroidal anti-inflammatory drug that blocks cyclooxygenase-2 production (COX-2) but does not block cyclooxygenase-1(COX-1) production. Thus, it is not as likely to cause side effects as drugs that block COX-1 isoenzymes. These side effects include decreased platelet aggregation, renal effects and GI complications such as bleeding

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and perforation. Choice 1 is incorrect because aspirin and ibuprofen block COX-1 isoenzymes. Choice 2 is incorrect because aspirin and ibuprofen are often taken to relieve arthritis pain. Choice 4 is incorrect because Celecoxib is not prescription-strength aspirin. 134. Which class of diuretics is the most potent? 1. 2. 3. 4.

thiazides loop diuretics potassium-sparing diuretics carbonic anhydrase inhibitors (CAIs)

(2) Loop diuretics act along the ascending limb of the loop of Henle (in the nephron tubule) blocking chloride and, secondarily, sodium resorption. Loop diuretics are powerful and provide a very rapid onset. Choice 1 works on the distal convoluted tubule, where it inhibits sodium and chloride resorption. Choice 3 works in the collecting ducts and distal convoluted tubules, where it inhibits sodium-potassium exchange. Choice 4 inhibits the enzyme carbonic anhydrase; the site of action of CAIs depends on the distribution of carbonic anhydrase along the nephron. 135. Epoetin alfa (Epogen, Procrit) is a recombinant form of erythropoietin (EPO), a hematopoietic growth hormone produced by the kidneys. It is administered to clients undergoing chemotherapy to stimulate the production of: 1. 2. 3. 4.

platelets. white blood cells (WBCs). red blood cells (RBCs). macrophages.

(3) EPO is secreted primarily by the kidney in response to hypoxia. Epoetin alfa is a colony-stimulating factor (CSF) drug. This group of drugs regulates growth, differentiation, and function of bone-marrow stem cells. The cell line stimulated by this erythropoietic agent is Erythrocytes or RBCs. CSFs are not toxic to cancer cells but are used in cancer treatment to reduce the neutropenia often caused by chemotherapy. Epoetin alfa does not stimulate the production of the cells in choices 1, 2, and 4. 136. An adult incurs a scalp laceration secondary to a car accident. He asks about a tetanus booster. It has been almost 9 years since the client’s last booster. How should the nurse respond? 1. 2. 3. 4.

“Adults do not require tetanus boosters.” “Tetanus is a childhood disease.” “Adult boosters are only given every 10 years.” “Your protection might have diminished; it is best to receive a booster now.”

(4) Vaccines are given to stimulate antibody production to prevent subsequent disease when the person is exposed to the causative agent. Immunity can be long term but eventually diminishes, making boosters necessary to continue protection against disease. A tetanus booster is recommended every 10 years for adults. This client’s passive immunity has probably significantly diminished over the 9-year period. This client should receive a tetanus booster now. Adults require tetanus boosters, and tetanus can affect all age groups. 137. In type I diabetes mellitus, the pancreas fails to produce insulin and the client requires administration of supplemental insulin. Which portion of the pancreas is responsible for insulin production? 1. 2. 3. 4.

alpha cells beta cells delta cells F cells

(2) The beta cells secrete insulin. Choice 1 produces glucagons. Choice 3 produces somatostatin. Choice 4 produces pancreatic peptide that facilitates the digestive process.

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138. Corticosteroids are very effective in treating asthma because they: 1. 2. 3. 4.

provide quick relief of symptoms. provide an anti-inflammatory effect that leads to decreased airway obstruction. treat only the large airways. prevent exercise-induced asthma.

(2) Corticosteroids prevent the release of substances that produce inflammation in the lungs. Choice 1 is incorrect because anti-inflammatory drugs do not relieve the symptoms of acute asthma attacks, though they are often used in prophylactic treatment regimens. Choice 3 is incorrect because the late-phase reaction of asthma involves the small airways. Choice 4 is incorrect because exercise-induced asthma is not an inflammatory response. 139. Children who are receiving intranasal corticosteroids should be vaccinated against: 1. 2. 3. 4.

pneumococcus. hepatitis A. varicella zoster. tetanus.

(3) Although routine vaccination against varicella zoster is recommended for all children, it is especially important for children on intranasal corticosteroids to prevent fulminant disease. Choices 1, 2, and 4 are recommended for all children. 140. A physician orders human immunoglobulin (Sandoglobulin, Venoglobulin, Iveegam, Polygam) for a client. Immunoglobulin is an example of: 1. 2. 3. 4.

an active immunization. herd immunity. an antigen. an antibody.

(4) An antibody is an immunoglobulin. Immunoglobulins are any of five distinct antibodies present in the serum and secretions of the body that bind antigens to prevent certain diseases. Choice 1 is obtained by administering an antigen. Choice 2 involves vaccinating a portion of a population; it can reduce the spread of a disease by limiting the number of potential hosts for the pathogen. Choice 3 causes disease. 141. A client takes levothyroxine (Synthroid) for hypothyroidism and warfarin (Coumadin) for prophylaxis of deep vein thrombosis. What is a possible interaction between these drugs? 1. 2. 3. 4.

No interaction exists. The risk for bleeding is increased. The risk for cardiovascular effects from levothyroxine is increased. The warfarin dose might need to be increased to anticoagulate the blood.

(1) These agents work independently and have no known interactions. Choices 2, 3, and 4 are not possible interactions. 142. Which class of medications to treat hyperlipidemia significantly decreases the absorption of several other drugs when taken simultaneously? 1. 2. 3. 4.

bile-acid-binding resins fibric-acid derivatives (the fibrates) niacin (nicotinic acid) HMG-CoA reductase inhibitors (the statins)

(1) The bile-acid-binding resins can bind to digoxin, thyroxin, warfarin, fibrates, and other drugs. This effect is reduced if the resins are taken two hours before or after taking other medications. The agents in Choice 2 can cause blood cell deficiencies and myopathies. Choice 3 should be avoided in clients with hepatic disorders, peptic ulcers, or diabetes

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mellitus. The agents in Choice 4 might interact with other drugs that are metabolized by the cytochrome P450 system, such as a slight elevation of warfarin levels. 143. A client is taking the antiobesity drug sibutramine (Meridia) and a serotonergic drug fluoxetine (Prozac) for depression. The nurse should caution this client about which of the following potential drug interactions: 1. 2. 3. 4.

serotonin syndrome. gastroenteritis. seizure. hypertensive crisis.

(1) Sibutramine works by inhibiting the reuptake of norepinephrine (NE) and serotonin (5HT) resulting in enhanced NE and 5HT activity. Fluoxetine is also a selective serotonin reuptake inhibitor (SSRI). Concurrent administration of these agents can precipitate dangerously high levels of serotonin, producing serotonin syndrome manifested by agitation, restlessness, confusion, insomnia, seizures, severe hypertension, and GI symptoms; death can ensue. Choices 2, 3, and 4 are part of serotonin syndrome. 144. A client takes digoxin with the loop diuretic furosemide (Lasix).This morning the client complains of anorexia and nausea. The client vomited once yesterday. What should the nurse do first? 1. 2. 3. 4.

Contact the physician, and obtain an order for a nutritional supplement. Contact the physician for an order to withhold oral fluids and food for 24 hours. Contact the physician for an order to obtain a serum Digoxin level and an electrolyte panel. Contact the physician for an order to obtain a potassium level.

(3) Digoxin toxicity is evidenced by anorexia, nausea, and vomiting, as well as visual changes. (The first and most likely concern is due to narrow safety range.) Loop diuretics can cause significant renal potassium losses. Digoxin administration can cause hypokalemia, which can lead to life-threatening arrhythmias. This client requires a digoxin level and a potassium level, which can be obtained from an electrolyte panel. The electrolyte panel also provides the physician with a more complete picture of this client’s electrolyte status. Choices 1 and 2 provide no data regarding digoxin toxicity or electrolyte status. Choice 4 is important but omits the necessary digoxin-level information. 145. A client has Class III heart failure (marked limitation of physical activities) and is scheduled to have a cardiac ultrasound today. The client’s medications include furosemide (Lasix) and digoxin (Lanoxin), both administered parenterally. The physician has ordered midazolam HC1 (Versed) by the IV route as sedation for the procedure. What precaution should the nurse take to prevent a drug interaction between the client’s current medications and midazolam? 1. 2. 3. 4.

Do not administer the scheduled dose of furosemide. Ask the physician if the digoxin dose can be given after the cardiac ultrasound. Dilute the midazolam in a normal saline IV solution. Do not give furosemide and midazolam concurrently.

(4) Furosemide and midazolam are incompatible (Nurse’s Drug Guide, 2005). With choices 1 and 2 the nurse should remember that a patient with Class III heart failure requires medications to be administered at appropriate times to provide maximal benefit. With Choice 3, diluting midazolam in NS will not eliminate an incompatability with another drug. 146. A client has been taking two anticonvulsant medications for three years with excellent control of seizures. The physician decides to discontinue antiseizure medications. How will this proceed? 1. 2. 3. 4.

Both medications are stopped simultaneously. One agent must be totally eliminated before beginning to eliminate the second agent. Each drug is reduced approximately 10% percent each week until it is discontinued. Each drug is alternately reduced approximately 10% each week until it is discontinued.

(2) One agent must be totally eliminated before beginning to eliminate the second agent. Choices 1, 3, and 4 could trigger seizures, and the physician would not know which drug had been preventing their occurrence.

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147. A client with depression initially failed to respond to numerous SSRI medications. Subsequently, the physician placed the client on tricyclic antidepressant (TCA) medications, which were also ineffective in treating the client’s depression. The physician has now decided to prescribe a monoamine oxidase inhibitor (MAOI) agent, an older class of antidepressant agents with serious drug and food interactions. When educating the client about his new medication the nurse should: 1. 2. 3. 4.

encourage the client to finish his old medications before starting the MAOI. tell the client to immediately discontinue his TCA and start the MAOI. explain that the TCA will be tapered off over a 1–2 week period then the MAOI will be started approximately two weeks later. tell the client to taper off the TCA medication while increasing the MAOI dose.

(3) TCAs are tapered off over a 1–2 week period to prevent withdrawal symptoms of headache, nausea, malaise, musculoskeletal pain, panic attacks, and weakness. Thus, choices 1 and 2 are inappropriate. The half-life of most TCAs ranges from 10–50 hours. Complete elimination requires 5 half-lifes, or 10 days. This action will prevent a drug interaction between the TCA and the MAOI. Thus, Choice 4 is inappropriate. 148. Concurrent administration of which of the following medications could cause a drug interaction with digoxin (Lanoxin)? 1. 2. 3. 4.

a diuretic such as furosemide (Lasix). potassium chloride (KCl) folic acid ferrous sulfate

(1) Diuretics, especially the potent loop diuretics such as furosemide, can cause rapid loss of significant amounts of fluid and electrolytes. Furosemide should be used with caution in patients receiving concurrent digitalis glycoside preparations. Hypokalemia can trigger serious cardiac dysrhythmias. This potential is exaggerated in the presence of digoxin. Choice 2 is commonly administered with digoxin to ensure an adequate level; the dosage of KCl is determined by laboratory studies. Choices 3 and 4 do not affect renal function. 149. Interactions can occur when two or more drugs are administered to the same client. An additive effect can be achieved with the addition of a second drug. An additive effect is described as: 1. 2. 3. 4.

each drug acting on receptors having the opposite effect. one drug adding to the action of another drug. a second drug enhancing the response of receptors stimulated by the first drug. a greater effect than the sum of each individual drug effect.

(2) An additive effect is described as one drug adding to the action of another drug. Choice 1 is incorrect because when drugs act in opposition to each other, the effect is antagonistic. Choices 3 and 4 are the same; when a second drug enhances the effect of the first drug, the effect is synergistic. 150. Clients receiving theophylline for reactive airway disease (asthma) should be counseled that which of the following can decrease the clearance of theophylline resulting in an increased serum theophylline level? 1. 2. 3. 4.

viral infection erythromycin fever penicillin

(2) Erythromycin is an antibiotic that can cause drug interaction. Erythromycin can increase the plasma levels of theophylline because it can decrease liver metabolism. Choices 1, 3, and 4 do not decrease theophylline metabolism.

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151. A client is taking oral antacids for gastric discomfort. The client’s lab work shows anemia, and the physician orders twice daily ferrous sulfate (iron) therapy. The nurse should educate the client that: 1. 2. 3. 4.

Iron should be taken on an empty stomach to prevent interference with iron absorption. Simultaneously taking iron and antacids lessens the irritating effect of iron therapy on the gastrointestinal mucosa. These agents do not interact, so the client can take them whenever it is convenient. The nurse should have the physician discontinue the antacids until the anemia is resolved.

(1) Concurrent administration of iron products and oral antacids results in significant reduction in iron absorption. Choice 2 is wrong because ferrous sulfate can cause GI distress, including constipation, gastric irritation, nausea, and abdominal cramps. To minimize these effects the drug can be administered as a coated tablet. Choice 3 is incorrect because as stated in Choice 1, there is a significant interaction between oral iron products and oral antacids. Choice 4 is incorrect because it is not necessary to discontinue the antacids if the iron preparation is given on an empty stomach, thus preventing an iron-antacid interaction. 152. Which medications, when used with oral contraceptive (OC) therapy, require the use of an additional form of contraceptive therapy? 1. 2. 3. 4.

Ampicillin, Tetracycline, Phenybutasone, anticonvulsants, and Rifampin antacids nonsteroidal anti-inflammatory agents digoxin (Lanoxin)

(1) These medications require the use of an additional form of contraceptive therapy. Choices 2, 3, and 4 do not interact with OCs. 153. Why is it important to check for a history of cardiovascular disease before using sildenafil (Viagra) therapy? 1. 2. 3. 4.

The client might not be physically fit. Sex is contraindicated in clients with cardiovascular disease. The client’s degree of exercise tolerance must be determined. Combining these agents might result in sudden cardiac death.

(4) Sildenafil use is of special concern in clients with heart, kidney, and liver disease. Sildenafil can cause interactions with nitrates because of their hypotensive effect. Its use is also of special concern in clients using other antihypertensive drugs and several other drugs that might interact. A physician should always be consulted if a client has any history of cardiovascular disease before initiating therapy. Choices 1, 2, and 3 are incorrect because even though these points should be assessed in any patient with cardiovascular disease they are not related to the use of sildenafil. 154. A 36-year-old client is taking warfarin (Coumadin) secondary to a deep vein thrombosis. The client has also developed severe diarrhea. Cultures show the presence of Clostridium difficile. The drug of choice for treating Clostridium difficile infections is metronidazole (Flagyl). The nurse should educate the client that: 1. 2. 3. 4.

Warfarin should be stopped until the infection is cleared. The physician should prescribe another agent to eradicate the Clostridium difficile. Metronidazole increases the anticoagulant effect of warfarin. These two agents have little or no effect on each other.

(3) The azole class of drugs inhibits the cytochrome P450 enzyme system in the liver, thus decreasing the metabolism of warfarin. The client should be monitored for a lengthened PT or INR, which requires a warfarin dosage reduction. Choice 1 is incorrect because warfarin should only be stopped with a physician’s order. Choice 2 is incorrect because metronidazole is the drug of choice to treat this microbe. Choice 4 is incorrect because the two drugs have a significant interaction.

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155. Most analgesic medications that are administered orally are absorbed from the: 1. 2. 3. 4.

stomach. large intestine. small intestine. mouth.

(3) Some agents are absorbed from the stomach, but the majority are absorbed from the small intestine. Very few medications are absorbed from the sites in choices 1, 2, and 4. 156. The preferred route of administration of analgesic medications is: 1. 2. 3. 4.

intravenous. sublingual/buccal. rectal. oral.

(4) Clients and care providers prefer the oral route when possible. Choice 1 is of higher risk due to its invasive nature, and it is expensive. Choices 2 and 3 are incorrect because few analgesic medications are prescribed for these routes. Choice 3 is usually prescribed only for a short-term therapy when the client is unable to take oral medications. (Both oral and rectal routes absorb medication across mucous membranes.) 157. A client has been on a narcotic analgesic for chronic pain. The original dose is no longer bringing about the same pain relief as it once did. The client asks why the medicine doesn’t work anymore. The nurse should educate this client about: 1. 2. 3. 4.

tolerance. potency. receptor agonists. efficacy.

(1) Repeated administration of an opioid agonist leads to pharmacodynamic tolerance of the drug. Tolerance is primarily due to down-regulation of opioid receptors. Choice 2 is the degree of power or strength of a medication. Choice 3 represents drugs that have both receptor affinity and intrinsic activity (the ability to initiate a cellular effect). Choice 4 is the capability of a medication to produce a desired effect (effectiveness). 158. A client returns from recovery following surgery. The nurse assesses the client, determines he is in pain and administers an opiate analgesic for pain control. The patient suddenly exhibits oxygen desaturation followed by decreasing heart rate. The patient’s deterioration may be caused by: 1. 2. 3. 4.

respiratory depression. rapid elimination of anesthetic gases. a vagal response. hypothermia.

(1) Narcotic analgesics can cause respiratory depression and apnea, and may lead to respiratory arrest. The symptoms described in the question are not a result of Choice 2. Choice 3 results in bradycardia followed by oxygen desaturation. Choice 4 can lead to compromise, but it is not an acute event. 159. When is naloxone (Narcan) effective? 1. 2. 3. 4.

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Naloxone is effective when a client has overdosed on Valium, a benzodiazepine. Naloxone reverses the central nervous system (CNS) depressant effects of opiate agonists. Naloxone is rapidly effective against CNS depression related to tranquilizer ingestion. Sedative/hypnotic respiratory depression can be reversed by naloxone.

Pharmacological Therapies

(2) Naloxone is an opioid antagonist. It combines competitively with opiate receptors and blocks or reverses the action of narcotic analgesics. Choices 1, 3, and 4 are incorrect because naloxone has virtually no pharmacologic effects in the absence of opioids. 160. Acetaminophen (Tylenol, Datril, Tempra, Panadol) is: 1. 2. 3. 4.

a synthetic non-narcotic analgesic used for mild-to-moderate pain relief. an anti-inflammatory useful in the treatment of arthritis. like aspirin, used for mild-to-moderate pain relief and to prevent platelet aggregation in clients at risk for myocardial infarction and stroke. of little use as an antipyretic to treat fever.

(1) Acetaminophen is a non-narcotic analgesic. Choice 2 is incorrect because this agent has minimal effects on peripheral prostaglandin synthesis and, therefore, has no anti-inflammatory effects. Choice 3 is incorrect because acetaminophen has no anticoagulant effect. Choice 4 is incorrect because acetaminophen is an antipyretic that decreases fever by a hypothalamic effect. 161. Respiratory depression that can follow narcotic analgesic administration: 1. 2. 3. 4.

occurs rarely and is of little importance. is the result of a depressed respiratory-center sensitivity to carbon dioxide. can be alleviated by giving the client oxygen. precludes opiate analgesic administration at night.

(2) The respiratory-center sensitivity to carbon dioxide (CO2) can be diminished in the presence of narcotic analgesics; thus, the client fails to respond to increasing CO2 levels by increasing the depth and rate of respirations. Choice 1 is incorrect because respiratory depression can occur when an opiate analgesic is administered. Choice 3 is incorrect because oxygen does not stimulate the respiratory center. Hyperoxygenation, especially in clients with chronically elevated CO2 levels such as with chronic obstructive pulmonary disease, can respond to oxygen with apnea. Choice 4 is incorrect because pain management is necessary at all times; clients require careful evaluation and ongoing assessment. 162. Narcotic analgesics attach to specific receptors in the CNS; this might result in a decrease in transmission of pain impulses. These receptors: 1. 2. 3. 4.

are known as nociceptors. are subdivided into mu, delta, kappa, and sigma receptors. block the release of prostaglandins. are up-regulated by the administration of opiate analgesics.

(2) Mu, delta, kappa, and sigma receptors are located in different parts of the CNS. Narcotic analgesic administration results in altered perceptions (including brain and spinal cord analgesia, sedation, euphoria, and autonomic stimulation). Choice 1 is incorrect because nociceptors are found in the skin, joints, viscera, and other peripheral tissues. Choice 3 is incorrect because prostaglandins contribute to sensations of pain; the opiate receptors in the CNS do not block prostaglandin release. Choice 4 is incorrect because the CNS narcotic receptors are not up-regulated by narcotic analgesics. Opiate analgesics block the receptors’ sensation of pain. 163. The tricyclic antidepressant (TCA) amitriptyline (Elavil) has significant anticholinergic and sedative effects. Therefore, in addition to depression, it has also been useful in treating some clients with: 1. 2. 3. 4.

chronic pain conditions such as diabetic neuropathy and postherpetic neuralgia. idiopathic, hypertrophic, subaortic stenosis (IHSS). attention deficit, hyperactivity disorder. urinary retention.

(1) TCAs block the uptake of serotonin and norepinephrine. In addition, amitriptyline has significant anticholinergic and sedative effects. TCAs are used as adjunctive therapy in numerous chronic pain processes. TCAs are not used in

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treating the conditions described in Choices 2 and 3. Choice 4 is incorrect because the anticholinergic effect of TCAs could make urinary retention worse. 164. A client returns to her room following abdominal surgery. The nurse should: 1. 2. 3. 4.

Refrain from administering any analgesics until the anesthesia has completely worn off. Administer pain medication as soon as the client is settled in bed. Encourage the client not to take analgesics unless absolutely necessary to prevent respiratory depression and drug dependence. Teach the client to request pain medication before the pain escalates and becomes severe.

(4) Pain control is enhanced when pain-relief medication is given early rather than after pain is severe. For effective pain control, analgesics are now recommended to be given on a regular schedule for the first 24 hours following surgery. The client should be assessed completely upon returning from surgery and periodically thereafter, including pain experience and respiratory status. The client should be medicated appropriately to treat pain. 165. The medication administration record (MAR) might list more than one analgesic order for the same client. This requires the nurse to: 1. 2. 3. 4.

Call the physician for clarification about which medication to administer. Ask the client which medication works best for her and which one she prefers. Alternate medications. Use judgment in choosing the correct medication based on assessment data.

(4) The nurse must use clinical judgment and should confer with the client in deciding which medication is most appropriate when there is an option. Judgment is based on client assessment and the physician’s orders. The physician must be called if clarification is needed. The client should be asked which medication provided better or longer relief, but client preference might not be an option due to time limits or physician orders. The physician might order alternating medications. Otherwise, client assessment and nursing judgment dictate drug selection. 166. A method of analgesic administration that allows the client to have some control over pain relief and eliminates the need for the client to wait for a nurse to answer the call light, check the last dose of analgesics given, and prepare and administer the medication is called: 1. 2. 3. 4.

personal-choice administration. persistent-confirmed analgesia. permanent-conducted anesthetic. patient-controlled analgesia.

(4) Patient-controlled analgesia (PCA) is a method of intravenous administration that permits the client to selfadminister preset amounts of an analgesic via a pump that is interfaced with a timing device. Choices 1, 2, and 3 are not valid methods. 167. Which type of anesthesia blocks nerve impulses in a small area of the skin? 1. 2. 3. 4.

topical regional epidural general

(1) The topical application of local anesthetics is used for anesthetization of the skin, mucous membranes, or cornea. Choice 2 is incorrect because regional anesthetics anesthetize an area of the body by blocking the conductivity of sensory nerves from that area. Choice 3 is incorrect because epidural anesthesia is produced by injecting a local anesthetic into the lumbar or caudal epidural (extradural) space. Choice 4 is incorrect because general anesthetics prevent the perception of pain by the sensory cortex.

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168. Sodium thiopental (also known as Sodium Pentothal, trademark of Abbott Labs) is a short-acting barbiturate drug that induces brief, general anesthesia lasting approximately 10–30 minutes. This agent: 1. 2. 3. 4.

is used as an agent for most surgical procedures. is more commonly used to induce hypnosis and anesthesia prior to the use of other anesthetic agents. is useful in preventing nausea and vomiting. decreases client anxiety.

(2) Because of the rapid onset of action (less than 60 seconds), this agent is used to induce hypnosis and anesthesia prior to the administration of long-acting anesthetic drugs. Choice 1 is incorrect because the short duration of action (10–30 minutes) and the slight analgesia it induces render this agent useful for brief procedures only. Choice 3 is incorrect because this drug does not prevent nausea and vomiting. Choice 4 is incorrect because this is not an anxiolytic agent. 169. When caring for a client receiving amphoteracin B (Fungizone, Amphocin), which laboratory values should be monitored closely? 1. 2. 3. 4.

serum electrolytes albumin values fibrinogen levels arterial blood gases

(1) Significant electrolyte abnormalities can occur with amphoteracin B administration. Choices 2, 3, and 4 are incorrect because amphoteracin does not affect these parameters. 170. A client is prescribed simvastatin (Zocor) to treat high cholesterol. The client asks which side effects may occur. The nurse should tell this client that simvastatin might cause all of the following. Which symptom(s) should be immediately reported to the physician? 1. 2. 3. 4.

GI distress (nausea, diarrhea, dyspepsia). muscle pain or muscle tenderness. flushing or itching of the skin. a decrease the absorption of other drugs (warfarin, digoxin, levothyroxine).

(2) The HMG-CoA reductase inhibitors (such as Simvastatin, Lovastatin, Pravastatin, Atorvastatin and Fluvastatin) can cause myalgia and rhabdomyolysis. Clients should be counseled to report any sign of unusual, diffuse or persistent muscle tenderness, pain, or weakness. Although choices 1, 3, and 4 may be distressing to the client, they are not indicative of life-threatening adverse effects of the drug. 171. A 14-year-old client with type I diabetes mellitus has responsibility for taking his own insulin. Because of afterschool activities today, this client takes his entire daily dose of insulin at breakfast. At school the client loses consciousness and has a seizure. The school nurse should administer which therapeutic agent while awaiting the arrival of Emergency Medical Services (EMS)? 1. 2. 3. 4.

rapid-acting regular insulin orange juice glucagon bicarbonate

(3) Glucagon activates glycogenolysis and gluconeogenesis and increases hepatic glucose production. It counteracts hypoglycemic reactions. Choice 1 makes hypoglycemia worse. Choice 2 is incorrect because the client cannot drink orange juice if he is unconscious. Choice 4 is incorrect because sodium bicarbonate is useful in treating ketoacidosis, but this client does not have ketoacidosis.

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172. Bovine and porcine preparations of insulin can result in: 1. 2. 3. 4.

diminished insulin antibody production. a significant reduction in insulin requirements. less chance of allergic reactions. lipodystrophy at injection sites.

(4) Bovine and porcine insulin preparations can cause significant atrophy or hypertrophy of subcutaneous adipose tissue at the injection site. This effect is considerably lessened when human insulin is used. Choice 1 is incorrect because insulin antibody production is triggered by the antigens in animal insulin. Choice 2 is incorrect because insulin requirements are higher when animal insulin is used because of insulin-insulin antibody binding. Choice 3 is incorrect because animal insulin can induce allergic responses to the product. 173. A 23-year-old woman with a prolonged history of seizures treated with phenobarbital (Luminal) and phenytoin (Dilantin) delivers a 38-week-gestation infant. On examination 4 hours after birth, the infant can be expected to exhibit: 1. 2. 3. 4.

digit and nail hypoplasia. seizures. omphalocele. drug withdrawal.

(1) Phenytoin is an antiepileptic drug in the hydantoin class. Infants with fetal hydantoin syndrome present with a variety of fetal abnormalities. Most notable are digit and nail hypoplasia, unusual faces, and growth and mental deficiencies. Additional craniofacial defects are common. In addition, hirsutism (short neck and rib anomalies) might be present. Similar craniofacial features are associated with prenatal exposure to carbamazepine (Tegretol), valproic acid (Depakote), primidone (Mysoline), and phenobarbital. Choice 2 is incorrect because the maternal seizure disorder does not put the infant at risk for seizures. Choice 3 is incorrect because neither of the drugs in the question cause omphalocele malformation. Choice 4 is incorrect because phenobarbital withdrawal symptoms (restlessness, hypertonicity, diarrhea, vomiting, poor suck) and seizures in clients with seizure disorder present three to seven days after birth, due to the long half-life of the drug. 174. The most common side effects of analgesic drugs include: 1. 2. 3. 4.

insomnia and somnambulance. constipation, nausea, and vomiting. seizures. nystagmus.

(2) The side effects in Choice 2 are the most frequent with analgesic medication administration. Narcotics are known to cause constipation. Analgesics relieve pain, which can promote restful sleep, but CNS effects can include insomnia, restlessness, and excitement. Choices 3 and 4 are not common with analgesic administration. 175. Which of the following negative effects can beta-adrenergic blockers have on a client with diabetes mellitus? 1. 2. 3. 4.

Beta blockers can induce hypoglycemia. None. Beta blockers are well tolerated by clients with diabetes mellitus. The sino-atrial node firing can be significantly slowed, resulting in a decreased heart rate. Beta blockers increase peripheral vascular disease in clients with diabetes mellitus.

(1) Beta-adrenergic blocking agents should be used with caution in diabetic clients. Diabetic clients must be assessed for symptoms of hypoglycemia, and their blood sugar must be monitored closely because hypoglycemia can result. Choice 2 is not true. Choice 3 is incorrect because it is the effect of the beta blocker; it happens regardless of whether the client has diabetes mellitus. Beta blockers do not have the effect described in Choice 4.

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176. Which of the following statements describes the effect of administering testosterone to boys before completion of bone growth? 1. 2. 3. 4.

Long bone growth is accelerated. Height increases by approximately 50%. Normal bone growth is inhibited. Puberty is delayed.

(3) Testosterone administration prior to completion of bone growth leads to premature closure of the epiphyseal plate, stopping growth in bone length. Choices 1 and 2 describe the opposite of the actual effect. Choice 4 is incorrect because testosterone is prescribed to treat delayed puberty. 177. A 62-year-old client with diabetes mellitus is started on the thiazide diuretic hydrochlorothiazide (Hydrodiuril) for mild hypertension. The nurse should educate this client about: 1. 2. 3. 4.

starting the administration of regular insulin. the low level of risk associated with thiazide diuretics. how hydrochlorothiazide can prevent diabetes complications. following his blood glucose values closely.

(4) Diuretic-induced hypokalemia can reduce insulin secretion resulting in elevated blood glucose levels. Blood sugar and potassium levels must be closely monitored in clients with diabetes mellitus who take thiazide diuretics. Choice 1 is incorrect because insulin requires a medical provider order. Choice 2 is incorrect because thiazide diuretics cause side effects, including electrolyte and acid-base disturbances, elevated blood glucose, uric acid, and lipid levels. Choice 3 is incorrect because thiazides are used in the treatment of mild hypertension and fluid overload; they do not prevent the complications of diabetes mellitus. 178. Metformin (Glucophage) is an oral biguinide antidiabetic medication. The most common side effect is: 1. 2. 3. 4.

gastrointestinal disturbance. hypoglycemia. sleepiness. visual disturbance.

(1) GI disturbance is the most common side effect of metformin administration. Common GI effects include diarrhea, nausea/vomiting, abdominal bloating, flatulence, anorexia, and unpleasant or metallic taste. Choice 2 is incorrect because metformin inhibits hepatic glucose production and increases glucose uptake by muscle cells; it does not induce pancreatic insulin release and hypoglycemia. Choices 3 and 4 are not side effects of metformin. Note: the nurse is much more likely to encounter a patient with GI side effects of metformin rather than lactic acidosis. With the removal of phenformin from the market, the incidence of lactic acidosis has decreased significantly. Lactic acidosis is rare with metformin and usually develops with comorbidities such as infection and renal failure. 179. A client is diagnosed with Reactive Airway Disease (Asthma) and started on inhaled glucocorticoids. Which side effect of glucocorticoid inhalation can be avoided by rinsing the mouth with water each time the medication is used? 1. 2. 3. 4.

dry mouth oral candidiasis halitosis gingivitis

(2) Excessive deposition of inhaled glucocorticoids in the mouth and upper airway can lead to oral candidiasis (thrush). Choices 1, 3, and 4 are not prevented by rinsing the mouth with water. (Dry mouth can be improved by rinsing.)

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180. A client’s blood work shows a low serum albumin level. The client is receiving a medication that is highly protein bound. The nurse should monitor the client for signs of: 1. 2. 3. 4.

hypokalemia. CNS depression. drug toxicity. hyperalbuminemia.

(3) Having a low serum albumin level allows more unbound (free) drug to circulate. The client might show drug toxicity signs and symptoms. Choices 1, 2, and 4 are not side effects of a low serum albumin level. 181. Side effects of corticosteroids that might be seen in clients being treated for arthritis include all the following except: 1. 2. 3. 4.

cutaneous atrophy. osteoporosis. cataracts. hypoglycemia.

(4) Prolonged administration of corticosteroids can result in cutaneous atrophy, osteoporosis, cataracts, and hyperglycemia. Hypoglycemia is not a side effect of corticosteroid administration. 182. The most common side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) affect which system? 1. 2. 3. 4.

gastrointestinal (GI) central nervous system (CNS) respiratory cardiovascular

(1) NSAIDs are associated with a high incidence of GI side effects. The most common effects are nausea, vomiting, dyspepsia, abdominal pain, and diarrhea. The less common, but more clinically significant effects are gastric ulcers and GI-tract bleeding. CNS effects include headaches, confusion, and tinnitus. Respiratory effects include bronchoconstriction in approximately 20% of the population. Some NSAIDs can aggravate congestive heart failure and hypertension.

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Reduction of Risk Potential This chapter contains questions and answers from the following topic areas: ■ ■ ■

Diagnostic Tests Laboratory Values Potential for Alterations in Body Systems

■

■ ■

Potential for Complications of Diagnostic Tests/ Treatments/Procedures/Surgery, or Health Alterations Therapeutic Procedures Vital Signs

1. When a physician orders an arterial blood gas, which artery is the appropriate one to use to obtain the specimen? 1. 2. 3. 4.

cerebral artery radial artery carotid artery ulnar artery

(2) The radial artery is the vessel that is appropriate for drawing arterial blood gas because it is most easily accessible and safest to draw from. The other choices are not appropriate for drawing blood for an arterial blood gas or other blood specimen. 2. Which of the following sites is most commonly used to obtain a venipuncture specimen? 1. 2. 3. 4.

radial artery radial vein brachial artery brachial vein

(4) The brachial vein is most commonly used for venipuncture, as opposed to the more difficult-to-locate radial vein. Arteries are not used for venipuncture. 3. After obtaining an arterial blood sample, how long should the nurse hold pressure on the insertion site? 1. 2. 3. 4.

two minutes three minutes four minutes five minutes

(4) Pressure should be held at least five minutes after obtaining an arterial specimen. Less time can lead to hematoma formation or excessive bleeding. 4. The nurse should perform Allen’s test to prevent which potential complication? 1. 2. 3. 4.

impaired hand circulation impaired foot circulation impaired cerebral circulation impaired leg circulation

(1) Allen’s test is performed prior to drawing a radial arterial blood gas and tests the circulation in the ulnar artery. A positive Allen test occurs when patency of the ulnar artery is not demonstrated by adequate perfusion of the hand. Drawing an arterial blood gas specimen from a radial artery when the ulnar artery is not patent, and therefore does not provide adequate collateral blood circulation to the hand, can lead to impaired hand circulation. Allen’s test is not used for the other body parts mentioned.

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5. When teaching a client to perform fingerstick blood sugar tests at home, which of the following statements by the client indicates adequate understanding: 1. 2. 3. 4.

“I will check my fingerstick blood sugar from the same finger every time.” “I will check my fingerstick blood sugar in the middle of my meals.” “I will check my fingerstick blood sugar from different fingers each time.” “I will check my fingerstick blood sugar only when I feel sick.”

(3) Fingerstick blood sugar should be checked from various finger sites to allow punctures to heal. Blood sugars are usually checked 30 minutes before meals or 2 hours after meals. They are checked at regular intervals, not only when a client feels sick. 6. Which of the following statements by a client indicates that the nurse has adequately prepared the client for a venipuncture? 1. 2. 3. 4.

“I know I have to leave a bandage on for two days.” “I will hold pressure over the site with a gauze pad.” “I will release the tourniquet for you.” “I will not make a fist with my hand.”

(2) An alert client can hold pressure over the site with a gauze pad until bleeding stops. Choice 1 is incorrect because leaving a bandage in place for two days is not necessary or recommended. The bandage can be removed after blood has clotted. Choice 3 is incorrect because it is the nurse’s responsibility to release the tourniquet at the proper time. Choice 4 is incorrect because having the client make a fist several times helps increase venous distension. 7. What is the proper instruction for the nurse to provide a client undergoing a liver biopsy? 1. 2. 3. 4.

“Exhale and hold your breath.” “Breathe as you normally do.” “Take shallow, rapid breaths.” “Take deep, slow breaths.”

(1) The breath is held on end expiration during needle insertion to prevent movement of the chest wall. If the client breathes at all, there is a risk of accidental perforation of the lung. 8. What is the proper position for a client after a liver biopsy? 1. 2. 3. 4.

left-side lying right-side lying lithotomy Trendelenburg

(2) Positioning the client on the right side allows the client’s body weight to apply pressure on the side where the liver is located. The other positions do not provide pressure at the needle-insertion site. 9. During a renal biopsy, how should the client be positioned for needle puncture? 1. 2. 3. 4.

prone supine lithotomy Trendelenburg

(1) The client should be placed in a prone (face-down) position to provide access to the kidney. The other positions do not provide such access.

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10. In which position should a client be placed after a renal biopsy has been performed? 1. 2. 3. 4.

prone supine lithotomy Trendelenburg

(2) The client is placed in a supine (face-up) position after a renal biopsy in order to provide pressure from the client’s body weight at the renal biopsy puncture site. The other positions do not provide such pressure. 11. Which statement by a client indicates adequate understanding of care after a transbronchial biopsy? 1. 2. 3. 4.

“I can eat right after the procedure.” “I can drink right after the procedure.” “I have to wait two days before I can eat.” “I have to wait a while before I can eat.”

(4) The client needs to wait to eat or drink until his throat is no longer numb from the local anesthetic that is often used for the procedure and until any anesthesia administered during the procedure that might make the client less responsive has worn off. Otherwise, the client is at risk of aspirating food. This process generally takes two hours, but might be longer for some clients. 12. When a nurse who speaks only English is giving instructions to a Spanish-speaking client, who is an appropriate person to provide translation? 1. 2. 3. 4.

the client’s Spanish-speaking brother the client’s Spanish-speaking neighbor the nurse’s Spanish-speaking co-worker the nurse’s Spanish-speaking brother

(3) Due to privacy regulations, only a Spanish-speaking health care worker should provide translation. The other persons listed might violate the client’s right to privacy of medical information depending on client permissions. A family member might not be able to accurately assess a client’s understanding of instructions. 13. Which statement by the nurse is most therapeutic for a 20-year-old woman undergoing a breast biopsy? 1. 2. 3. 4.

“Look on the bright side, you have your husband to help you.” “Please tell me what concerns you have about the biopsy.” “You’ll be just fine; this only takes a short while.” “Don’t worry, women so young usually don’t have cancer.”

(2) This statement allows the client to express whatever concerns she might have and allows the nurse to respond to them in a therapeutic manner. The other statements do not elicit the client’s concerns and might provide false reassurance. 14. What is the appropriate nursing response to a Native-American client who requests a visit by the tribal medicine man prior to a biopsy? 1. 2. 3. 4.

“We don’t allow visits by medicine men.” “Do you really believe in that voodoo?” “I will assist you to arrange a visit.” “I will get permission from the doctor.”

(3) The Native-American client’s healing process might be facilitated by a traditional healer, especially when the client requests it. Choices 1 and 2 demonstrate a lack of cultural awareness and sensitivity. It is not necessary to have permission from the doctor, although it is appropriate to inform the doctor of the visit.

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15. Which of the following symptoms indicates an adverse complication of a cervical punch biopsy? 1. 2. 3. 4.

heavy vaginal bleeding neck pain with movement numbness of the arms foul-smelling discharge

(1) Heavy vaginal bleeding is an adverse complication of a punch biopsy of the cervix. Choice 2 refers to the cervical spine of the neck, which is not where a punch biopsy is performed; therefore, the complication described in Choice 3 cannot occur. Foul-smelling discharge is normal for several days (up to three weeks) after a biopsy. 16. Which of the following sites is not used for a bone marrow biopsy in adults? 1. 2. 3. 4.

sternum iliac spine spinous process tibia

(4) The tibia is used for bone marrow biopsy for infants under the age of one year. The other choices are appropriate sites for adults. 17. Which of the following represents a contraindication for a bone marrow biopsy? 1. 2. 3. 4.

bleeding disorder heart disease diabetes Crohn’s disease

(1) A bleeding disorder is a contraindication for a bone marrow biopsy because the biopsy involves a needle puncture that could cause severe bleeding. Heart disease, diabetes, and Crohn’s disease are not contraindications. 18. Which of the following statements reflects accurate understanding of the radioactive iodine uptake test by a client? 1. 2. 3. 4.

“I cannot eat for 24 hours before the test.” “This test may cause some pain.” “I cannot be near people for 24 hours after the test.” “I’ll need a scan 6 hours after taking my capsule.”

(4) A scan is done between 6 and 24 hours after ingesting a radioactive iodine capsule or liquid. The client does not eat or drink after midnight prior to the test. The test is painless, and the small amount of radiation from the test is considered by most physicians to be harmless. 19. Which of the following allergies indicates a possible allergy to iodine? 1. 2. 3. 4.

shellfish penicillin hay fever aspirin

(1) An allergy to shellfish is often related to an allergy to iodine, so it is important to get this information from a client undergoing diagnostic testing utilizing iodine as a contrast medium. The other allergies do not relate to an iodine allergy.

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20. What is the name of the diagnostic chart used to measure distance visual acuity? 1. 2. 3. 4.

Jaeger Snellen ocular Kirlian

(2) The Snellen chart is used to measure distance visual acuity. The Jaeger is used to measure near vision. Ocular refers to the eye, but is not a chart name. Kirlian photography is a way of measuring the human energy field. 21. What measure of distance visual acuity is a normal finding? 1. 2. 3. 4.

20/60 20/40 20/20 20/10

(3) Normal vision is 20/20. Choices 1 and 2 are lower than normal. Choice 4 is more acute than normal. 22. It is important for the nurse to obtain an accurate tonography reading to detect which of the following eye disorders? 1. 2. 3. 4.

presbyopia optic neuritis retinal detachment glaucoma

(4) Tonography is an indirect measurement of intraocular pressure, which is a test for glaucoma. The other problems are eye disorders, but are not detected by tonometry. 23. When the results of the Weber test show lateralization of tone to the right ear, what does this indicate? 1. 2. 3. 4.

conductive loss on the right side conductive loss on the left side conductive loss on both sides sensorineural loss on the right side

(1) The Weber test is performed with a vibrating tuning fork placed on the midline of the client’s head. If the tone lateralizes to the right ear, it indicates conductive loss on the right side. The other choices are incorrect. 24. The nurse should refrain from performing a pulmonary function test on clients who have which of the following medical diagnoses? 1. 2. 3. 4.

bronchitis angina cystic fibrosis asthma

(2) Clients with angina might become overexerted when doing the strenuous breathing necessary for the pulmonary function test, potentially worsening the angina or leading to a myocardial infarction. Clients who have the diagnoses in choices 1, 3, and 4 have indications for a pulmonary function test, as they might necessitate measures of pulmonary function.

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25. In which of the following positions should the nurse place a client who is preparing to undergo a thoracentesis? 1. 2. 3. 4.

lying on the affected side reverse Trendelenburg sitting on the edge of the bed lying down in bed

(3) Placing the client in a sitting position on the edge of the bed with his arms over an over-bed table provides visualization of the intercostal spaces and access to the pleural cavity. The other positions do not offer these benefits. 26. Which of the following is a post-test complication of a thoracentesis that the nurse must report to the physician? 1. 2. 3. 4.

a small amount of leakage an oxygen saturation of 98% periodic nonproductive cough difficulty breathing

(4) Difficulty breathing indicates a potentially life-threatening complication, such as pneumothorax or mediastinal shift, which must be reported to the physician. Choice 1 is an expected finding. Choice 2 is a normal oxygen saturation. Choice 3 might be present, but, in the absence of other signs and symptoms, does not need to be reported to the physician. 27. Which of the following statements by a client indicates understanding of post-test thoracentesis care? 1. 2. 3. 4.

“I will call the nurse if I have difficulty breathing.” “I will lay on my abdomen after the test.” “I will change my bandage if it gets wet.” “I will relax if I have difficulty breathing.”

(1) The client needs to notify the nurse immediately of any difficulty breathing because this could indicate a potentially life-threatening complication, such as pneumothorax or mediastinal shift; therefore, Choice 4 is incorrect. It is preferred that the client lie on the side of the puncture to place pressure on the area of the puncture, not the abdomen. If the dressing over the puncture site becomes saturated, the nurse needs to assess the amount of drainage and change the dressing using an aseptic technique to prevent infection. It is inappropriate for the client to change it. 28. A Chinese-American client is having some pain at the insertion site after a thoracentesis and requests an acupuncturist to treat her for pain reduction. Which statement by the nurse indicates cultural competency in this situation? 1. 2. 3. 4.

“Do you really believe that does any good?” “I have read research about effectiveness of acupuncture for pain relief.” “I cannot allow you to engage in such behavior.” “You must wait until you go home to have that done.”

(2) Acupuncture is an effective, integrative modality for pain relief that might be requested by a client. The statement in Choice 2 shows knowledge and cultural awareness by the nurse, who can arrange for a visit by an acupuncturist after consulting with the primary physician regarding any contraindications to the treatment. The other statements are derogatory and do not support the client’s healing process. 29. A Native-American client requests that a tissue specimen that was removed from his abdomen be returned to him after analysis. Which is the appropriate response by the nurse? 1. 2. 3. 4.

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“That is not allowed. It will be disposed of properly.” “Why would you want that? It could cause infection.” “I will obtain the specimen. You may take it home.” “I will let the physician know. But I don’t think it can be done.”

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(3) Some Native-American cultures believe that all a person’s body parts need to be buried. In the event of tissue loss, organ loss, or amputation, the request to return the specimen should be honored. The other responses do not indicate cultural sensitivity and destroy trust with the client. 30. Prior to a breast biopsy, a Mexican-American client wants all four of her family members in the room. Which response by the nurse indicates cultural competency? 1. 2. 3. 4.

“I realize how important family members are to you.” “I cannot allow so many people to visit you.” “You need rest, so I cannot let them in.” “It is better for you to have some privacy.”

(1) Family support is vital for some Mexican-American clients. The nurse should accommodate the needs of the client, within the guidelines of hospital policy. The other responses are not culturally sensitive and might alienate the client. 31. Which intervention by the nurse minimizes laryngeal edema after a laryngoscopy? 1. 2. 3. 4.

applying a heating pad applying a TENS unit applying pressure applying an ice collar

(4) Applying an ice collar provides cold therapy, thereby preventing edema formation. Heat and pressure do not prevent edema. A TENS unit is used for pain management. 32. What is the proper position in which to place a client after a laryngoscopy? 1. 2. 3. 4.

prone supine semi-Fowler’s Trendelenburg’s

(3) Semi-Fowler’s position, with the head of the bed slightly elevated, prevents aspiration and decreases the formation of edema. The other positions do not offer these benefits. 33. Which diagnostic test is most commonly used to diagnose pulmonary emboli? 1. 2. 3. 4.

Complete blood count Ventilation scan Ultrasound Chemistry profile

(2) The ventilation scan can reveal abnormal gas distribution, which is found with pulmonary emboli. The other tests are not used to diagnose pulmonary emboli. 34. Which statement by a client indicates understanding of post-test care after a knee arthroscopy? 1. 2. 3. 4.

“I should apply heat for the swelling.” “I should take ibuprofen for the pain.” “I should go for a long walk tonight.” “The swelling might last two weeks.”

(2) The client can take a mild analgesic, such as ibuprofen, for mild pain associated with an arthroscopy. Ice should be applied for swelling, not heat. The client should rest the joint for 6 to 12 hours, not go for a long walk. The swelling from the arthroscopy should last only one or two days, not two weeks.

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35. A client with a low hemoglobin level is receiving a unit of packed red blood cells. The client tells the nurse, “I am having trouble breathing.” Which of the following actions should the nurse perform first? 1. 2. 3. 4.

Notify the physician. Monitor the client’s breathing. Stop the blood transfusion. Document the event.

(3) The nurse should first stop the blood transfusion, as the client might be having a reaction to the blood, causing shortness of breath. The other choices can be performed after discontinuing the blood transfusion. 36. A client who needs to receive packed red blood cells for anemia tells the nurse, “I am afraid I will get hepatitis from the blood transfusion.” Which is an appropriate response by the nurse? 1. 2. 3. 4.

“It is not possible to contract hepatitis from a blood transfusion.” “The chance of contracting hepatitis is very slight.” “We check all our blood to prevent hepatitis transmission.” “No one ever contracted hepatitis from a blood transfusion at this hospital.”

(2) Despite testing blood for hepatitis, clients might still contract it from a transfusion. This is documented on standard transfusion consent forms, and the client needs to be made aware of it. For this reason, the other choices are incorrect. 37. Which of the following statements by a client who is receiving a blood transfusion indicates adequate understanding of the nurse’s teaching? 1. 2. 3. 4.

“If I get anxious, I should take a deep breath.” “I should let the nurse know if I start itching.” “If I get a fever, I should ask the nurse for Tylenol.” “If I start wheezing, I should use my inhaler.”

(2) Itching is a manifestation of a possible reaction to the transfusion, which needs to be communicated to the nurse. Anxiety, fever, and wheezing are also indications of possible reactions and need to be communicated immediately to the nurse. 38. Which of the following blood types is known as the universal donor? 1. 2. 3. 4.

A B AB O

(4) O is the universal donor. The other choices have incompatibilities. 39. Which of the following blood types is known as the universal recipient? 1. 2. 3. 4.

A B AB O

(3) AB is the universal recipient. Choices 1, 2, and 4 might have incompatibilities.

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40. A client who is blood type A needs an emergency blood transfusion, but it takes at least 15 minutes to type and cross-match the client for a transfusion. Which is the best action for the nurse to take? 1. 2. 3. 4.

Give type O blood. Increase intravenous fluids. Place the client in Trendelenburg’s position. Monitor the client for bleeding.

(1) In an emergency situation, the universal donor type, O, can be given with a physician’s order. The other choices might also be appropriate, but they are not the best responses. 41. For which of the following symptoms must the nurse be vigilant when assessing a client who has a low platelet count? 1. 2. 3. 4.

hypertension arrythmias petecchiae bradycardia

(3) Petecchiae is a sign of bleeding, which can indicate a dangerously low platelet count. The other signs do not directly indicate bleeding. 42. Which of the following statements by a client with thrombocytopenia indicates adequate self-care? 1. 2. 3. 4.

“I use a soft toothbrush.” “I use a hard toothbrush.” “I shave with my razor blade.” “I use dental floss.”

(1) Clients with thrombocytopenia are prone to bleeding. Using a soft toothbrush minimizes bleeding of the gums. The other choices put the client at risk for bleeding. 43. Which medication might be indicated for a client with an elevated prothrombin time (PT)? 1. 2. 3. 4.

vitamin C vitamin K protamine sulfate Protonix (Pantoprazole)

(2) Vitamin K is the antidote to an elevated PT. The other choices are not. 44. Which medication could cause an elevated PT? 1. 2. 3. 4.

Coumadin (warfarin) Heparin Lanoxin (digoxin) Morphine

(1) Coumadin is an anticoagulant that can cause an elevated PT. The other choices do not.

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45. Which medication might cause an elevated partial thromboplastin time (PTT)? 1. 2. 3. 4.

Coumadin (warfarin) Heparin Lanoxin (digoxin) Morphine

(2) Heparin is an anticoagulant that can cause an elevated PTT. The other choices do not. 46. Which medication should the nurse give to a client who has a dangerously elevated PTT from Heparin therapy? 1. 2. 3. 4.

vitamin C vitamin K protamine sulfate Protonix (pantoprazole)

(3) Protamine sulfate is the antidote to Heparin. The other choices are not. 47. Which statement by a client indicates adequate understanding of his recommended dietary intake while on Coumadin (warfarin)? 1. 2. 3. 4.

“I need to minimize my fluid intake.” “I need to minimize my use of salt.” “I need to minimize my sugar intake.” “I need to minimize my intake of broccoli.”

(4) Foods containing high amounts of vitamin K, such as broccoli, need to be limited. This is because they can counteract the effects of warfarin. Choices 1, 2, and 3 do not apply to warfarin therapy. 48. Which of the following indicates a therapeutic PTT for a client on Heparin therapy? 1. 2. 3. 4.

.5 times the control time level 1.0 times the control time level 1.2 times the control time level 2.0 times the control time level

(4) A therapeutic PTT is 1.5 to 2.5 times the control level. 49. For which of the following conditions is drawing a C-reactive protein (CRP) indicated? 1. 2. 3. 4.

rheumatoid arthritis scurvy protein deficiency cholecystitis

(1) CRP is present in 90% (or more) of clients with rheumatoid arthritis. This is not true of choices 2, 3, and 4. 50. Hepatitis A virus (HAV) can be transmitted by which of the following substances? 1. 2. 3. 4.

blood feces semen urine

(2) HAV can be transmitted through feces. Choices 1, 3, and 4 are substances through which Hepatitis B virus (HBV) can be transmitted.

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51. Which of the following clients should have blood drawn for Hepatitis C virus (HCV) testing? 1. 2. 3. 4.

an IV drug user an alcoholic a victim of food poisoning a bulimic

(1) IV drug abuse is the main cause of HCV, although it can also be transmitted by a blood transfusion. The other conditions are not associated with HCV. 52. Which of the following clients is at risk for human immunodeficiency virus (HIV)? 1. 2. 3. 4.

an alcoholic a diabetic a hemophiliac a client with cirrhosis

(3) Hemophiliacs are at risk for HIV, due to their need for frequent blood transfusions. HIV can be transmitted via the blood. The other conditions are not risks for HIV. 53. A female client comes to have blood drawn for HIV testing. Which statement by a client indicates adequate understanding of HIV? 1. 2. 3. 4.

“Women rarely test positive for HIV.” “I am at risk because I am sexually active.” “I won’t get HIV because I am married.” “Only homosexuals become HIV positive.”

(2) Those who are sexually active are at risk for HIV. HIV affects both sexes and can even affect those who are married, if one spouse becomes infected and transmits the disease to the other spouse. 54. A male client is informed by the physician that he is positive for HIV. He screams, “You can’t be right! I am not a homosexual!” What is the most appropriate response by the nurse? 1. 2. 3. 4.

Leave the room and allow the client to grieve. Remind the client that heterosexuals can get HIV. Reach out and hold the client’s hand. Put gloves on while in the room.

(3) Holding the client’s hand demonstrates support, caring, and willingness to be present during this painful, frightening time. This response provides space for listening. Leaving the room shows a lack of sensitivity. Reminding the client of facts does not provide consolation. It is not necessary to wear gloves unless contact with body fluids is possible. 55. Which of the following items does a nurse need to wear when drawing the blood of a client suspected of having HIV? 1. 2. 3. 4.

gloves gown goggles mask

(1) The nurse needs to assume that all clients might be HIV positive and wear garb appropriate to the situation. If no splashing of blood is expected, masks, gowns, and eye goggles are not required.

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56. What special medicolegal requirement might need to be met for a client who requires testing for HIV? 1. 2. 3. 4.

documentation by the nurse of the risks of drawing blood wearing a mask during a blood draw getting the signature of the client’s spouse on a consent form getting the signature of the client on a consent form

(4) Most agencies require that a consent form be signed before performing HIV testing, due to the sensitive nature of the test. The other choices are not necessary. 57. Which of the following values represents a normal blood glucose level for an adult? 1. 2. 3. 4.

50 mg/dl 55 mg/dl 90 mg/dl 130 mg/dl

(3) Depending on the laboratory, normal blood glucose levels fall in the range of 60–100 mg/dl. Choices 1 and 2 are below the normal range, and Choice 4 is above the normal range. 58. A diabetic client has taken her morning insulin dose but does not want to eat breakfast because she feels nauseous. Which is the best action the nurse can take? 1. 2. 3. 4.

Monitor the client for hypoglycemia. Administer an antiemetic. Notify the physician. Force the client to eat.

(2) Administering an antiemetic relieves nausea so that the client can eat. Simply monitoring for hypoglycemia can result in the client developing a dangerously low blood sugar. The physician should be notified, but that alone does not solve the problem. The client has the right to refuse to eat. Forcing the client to eat is likely to result in vomiting and/or choking; it constitutes client abuse and should never be done. 59. A nursing assistant reports to the nurse that a diabetic client has not been bathed today because he has been sleeping. Which is the best response by the nurse? 1. 2. 3. 4.

Notify the next shift that the client needs to be bathed. Document in the chart that the bath was not performed. Assess the diabetic client. Help the nursing assistant bathe the client.

(3) This is the best response because the diabetic client might be in a hypoglycemic or hyperglycemic coma, not merely sleeping, as the nursing assistant might think. The nurse has more advanced assessment skills to determine this. The other choices can be performed, but are not the best response. 60. Which of the following is not a symptom of hyperglycemia? 1. 2. 3. 4.

polydipsia polyphagia polydactyly polyuria

(3) Polydactyly is the presence of extra fingers and is not related to hyperglycemia. The other choices can be symptoms of hyperglycemia.

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61. A diabetic client becomes lethargic, so the nurse performs a finger-stick blood sugar test. The reading is 22 mg/dl. The client then becomes unresponsive. Which is the best response by the nurse? 1. 2. 3. 4.

Give dextrose intravenously as ordered. Give orange juice orally. Give a pack of sugar orally. Recheck the blood sugar.

(1) IV dextrose raises the life-threatening low blood sugar. Giving oral sugars to an unresponsive client is not effective because the client cannot swallow them and this can cause aspiration. The blood sugar can be rechecked at some point, but because the client has become unresponsive, the IV dextrose must be given first. 62. Which of the following statements by a client indicates adequate understanding of an oral glucose tolerance test? 1. 2. 3. 4.

“I can eat a light breakfast.” “I cannot drink water after midnight.” “Only one blood draw is necessary.” “I must drink a glucose solution.”

(4) The client is given an oral glucose solution to drink as part of the test. The client cannot eat after midnight, but is allowed to drink water. Several blood draws are performed at regular intervals after the glucose solution is given. 63. A newly diagnosed diabetic client says to the nurse, “I am so afraid I will eventually need dialysis.” Which is a therapeutic response by the nurse? 1. 2. 3. 4.

“Diabetics are not at risk for renal disease.” “Tell me more about your fears.” “You might never need dialysis.” “Not all diabetics need dialysis.”

(2) This response allows the client to ventilate fears and receive support from the nurse. Choice 1 is false. Choices 3 and 4 are true, but not therapeutic because they do not allow the client to share feelings. 64. Which condition is monitored by the use of the glycosylated hemoglobin (HgbA1C) test? 1. 2. 3. 4.

anemia diabetes glottitis hemophilia

(2) HgbA1C is used to monitor blood glucose control in diabetics. It is not used to monitor the other conditions. 65. Which condition can be diagnosed by blood urea nitrogen (BUN) and creatinine levels? 1. 2. 3. 4.

renal failure diabetes mellitus colitis Crohn’s disease

(1) Renal failure can be diagnosed by BUN and creatinine levels. The other conditions cannot.

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66. Which symptom is likely to be present in a client with a high BUN level? 1. 2. 3. 4.

polyuria confusion hypoxia paralysis

(2) Confusion is often seen in clients with a high BUN level. The other choices are not. 67. Which of the following foods should be restricted for a client who has high BUN and creatinine levels? 1. 2. 3. 4.

carbohydrates vegetables proteins fruits

(3) Proteins and fluids should be restricted for a client who has high BUN and creatinine levels. The other choices should not. 68. Which measurement should the nurse assess to determine the presence of glaucoma? 1. 2. 3. 4.

intraocular pressure pupillary response size of the pupils corneal reflex

(1) Intraocular pressure is assessed to diagnose possible glaucoma. The other choices are assessed to diagnose other potential eye or neurological problems. 69. A client complains to the nurse of eye pain after wearing new contact lenses. Which structure should the nurse assess first? 1. 2. 3. 4.

sclera lens cornea retina

(3) The cornea should be assessed first because new contact lenses that fit improperly can cause corneal abrasion. The remaining choices are other eye structures that can be checked later for other eye problems. 70. Which structure of the eye is affected when cataracts form? 1. 2. 3. 4.

sclera lens cornea retina

(2) The lens becomes opaque when cataracts form. The remaining answer options are other eye structures that may be checked later for other eye problems.

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71. Which of the following nursing diagnoses is most appropriate for an elderly client who has just become blind? 1. 2. 3. 4.

Imbalanced Nutrition Risk for Suicide Grieving Fatigue

(3) Grieving Due to Loss of Sight is the most appropriate nursing diagnosis for an elderly client who has just become blind. The other choices are not. 72. What is the normal color of the cornea? 1. 2. 3. 4.

white yellow opaque clear

(4) The cornea is normally clear. 73. In an ophthalmic exam, what is the normal color of the optic disc? 1. 2. 3. 4.

white yellow opaque clear

(2) The optic disc is normally yellow. 74. Which color is the sclera likely to become in elder clients with lipid deposits? 1. 2. 3. 4.

white yellow red clear

(2) The sclera can become yellow in elder clients due to lipid deposits. 75. What is the term used to describe hearing loss related to aging? 1. 2. 3. 4.

tinnitus ototoxicity audiometry presbyacusia

(4) Presbyacusia is the term used to describe progressive hearing loss related to normal aging. The other choices are incorrect but are related to the auditory system. 76. Which assessment tool is used to examine the ear? 1. 2. 3. 4.

otoscope ophthalmoscope stethoscope reflex hammer

(1) The otoscope is used to examine the ear. The remaining tools are used for other assessments.

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77. Which of the following medications can have an ototoxic effect when given in a high dose? 1. 2. 3. 4.

Vancocin Theobid (theophylline) Atenolol (tenormin) Isordil (isosorbide dinitrate)

(1) Vancocin may have an ototoxic effect if given at high doses. The other medications do not have such an effect. 78. During a physical exam, the nurse finds a client’s tympanic membrane to be red in color. What does this indicate? 1. 2. 3. 4.

a normal finding impacted cerumen acute otitis media exostosis

(3) A red tympanic membrane, with or without effusion, indicates acute otitis media. The other choices do not. 79. Which of the following is a test involving stimulation by irrigation with warm and cold water in the ear? 1. 2. 3. 4.

auditory brainstem response electronystagmography posturography the caloric test

(4) The caloric test assesses vestibular function by irrigating the ear canal with warm water followed by cold water. The remaining choices are other types of auditory tests. 80. Which of the following conditions is indicated by a client hearing a tuning fork louder in his right ear during the Weber test? 1. 2. 3. 4.

sensorineural loss in the right ear conductive hearing loss in the right ear conductive hearing loss in the left ear no hearing loss in either ear

(2) Hearing a tuning fork louder in the right ear during the Weber test is an indication of conductive hearing loss in the right ear. 81. Which of the following is a positive finding for the Rinne test? 1. 2. 3. 4.

Bone conduction is twice as long as air conduction. Air conduction is twice as long as bone conduction. Bone conduction is equal to air conduction. Air conduction is half as long as bone conduction.

(2) A positive finding for the Rinne test is a client hearing the sound of a tuning fork by air conduction twice as long as hearing it by bone conduction. 82. Which of the following racial groups has the highest incidence of age-related macular degeneration? 1. 2. 3. 4.

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(2) Caucasians have the highest incidence of age-related macular degeneration. 83. A client is able to read a book but cannot clearly see the television across the room. Which refractive error is this client likely to have? 1. 2. 3. 4.

myopia hyperopia presbyopia amblyopia

(1) A myopic client is said to be nearsighted. Hyperopia is is farsightedness. Presbyopia is loss of accomodation found in advancing age. Amblyopia is is reduced vision, not due to refractive errors of the eye; for example, diabetes. 84. Which of the following interventions should the nurse perform first for a client who has received a penetrating injury to the eye? 1. 2. 3. 4.

Assess for visual acuity. Irrigate the eye with saline. Cover the eye. Ensure an open airway.

(4) The nurse needs to ensure an open airway first. Remember the acronym ABC: airway, breathing, circulation. When stable, the client must be transported for care by an ophthalmologist. 85. Which is the best position for a client who has an object embedded in the left eye? 1. 2. 3. 4.

prone supine with the head of the bed flat side lying on the right side supine with the head of the bed up

(4) The best position for a client who has an object embedded in the left eye is supine with the head of the bed up to decrease intraocular pressure and minimize swelling. 86. Which of the following nursing diagnoses is most appropriate for a client with keratitis? 1. 2. 3. 4.

Dysreflexia Powerlessness Acute Pain Impaired Skin Integrity

(3) Acute Pain is the most appropriate nursing diagnosis for a client with keratitis (an inflammation or infection of the cornea). 87. Which of the following herbal remedies can be effective in enhancing microcirculation in the eyes? 1. 2. 3. 4.

garlic bilberry ginger red clover

(2) Bilberry can be effective in enhancing microcirculation in the eyes, as well as reducing hemorrhoids and growing hair.

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88. A client requests the use of goldenseal to help heal an ear infection. What is the most appropriate response by the nurse? 1. 2. 3. 4.

Tell the client herbs cannot be used for ear infections. Instruct the client that antibiotics need to be given. Check with the physician regarding the request. Document the request and address it in two weeks.

(3) When a client requests the use of herbal remedies, physician approval is required. Goldenseal might have antibacterial properties and is congruent with the practices of some Native-American cultures. 89. Which of the following racial groups has the highest incidence of skin cancer? 1. 2. 3. 4.

Native American African American Hispanic Caucasian

(4) Caucasians have the highest incidence of skin cancer. 90. Which of the following mnemonics is used in the recognition of melanoma? 1. 2. 3. 4.

ABCD HELP SOAR PAIN

(1) The acronym ABCD is a mnemonic device used to remember the primary features of melanoma (asymmetry, border irregularity, color, and diameter). 91. A 16-year-old client is distressed about having a large herpes blister on their lip. The client says to the nurse, “I look so ugly with this big blister.” Which is the most therapeutic response by the nurse? 1. 2. 3. 4.

“You do not look ugly to me.” “The physician will prescribe some medication.” “Tell me more about your feelings.” “What do your friends think about it?”

(3) This response is most therapeutic because it allows the client to ventilate feelings and enhances trust between the nurse and client. 92. Which of the following statements by a client who is being treated for candidiasis under her breasts shows adequate understanding of self-care? 1. 2. 3. 4.

“I should give it time to go away.” “I should dry thoroughly under my breasts.” “I should wear a tight bra all the time.” “I should bathe once a week.”

(2) Candidiasis is a yeast infection that flourishes in warm, moist environments. Therefore, drying thoroughly under breasts helps heal the infection. Giving it time to go away, without additional intervention, is not effective. Wearing a tight bra, especially all the time, makes the infection worse. Bathing once a week is not enough.

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93. Which type of burn refers to a superficial sunburn, without vesicles or blisters? 1. 2. 3. 4.

first degree second degree third degree fourth degree

(1) A first-degree burn is a superficial sunburn, without vesicles or blisters. The remaining choices refer to other burn types. 94. Which of the following actions should the nurse perform first for a client with an electrical burn? 1. 2. 3. 4.

Cover the burn sites. Administer oxygen. Begin fluid replacement. Establish IV access.

(2) The first step is to administer oxygen; then establish IV access, begin fluid replacement, and cover the burn sites. 95. Which of the following nursing diagnoses is most appropriate for a client with a fourth degree, full-thickness burn on the face? 1. 2. 3. 4.

Urinary Retention Impaired Mobility Disturbed Body Image Constipation

(3) Disturbed Body Image is the most appropriate nursing diagnosis for a client with a fourth degree, full-thickness burn of the face. 96. The mother of a three-year-old client who is severely burned says to the nurse, “I should not have left matches within reach of my child.” What is the most appropriate response by the nurse? 1. 2. 3. 4.

Leave the room and let the mother grieve. Scold the mother for leaving matches out. Tell the mother to learn from her mistake. Ask the mother how she feels about the event.

(4) Asking the mother how she feels facilitates therapeutic communication and ventilation of the mother’s feelings. The other responses are unprofessional and nontherapeutic. 97. Which respiratory condition is associated with an increased anterior-posterior diameter of the chest? 1. 2. 3. 4.

cystic fibrosis tuberculosis pneumonia pleurisy

(1) Cystic fibrosis is associated with an increased anterior-posterior diameter of the chest. The other conditions are not.

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98. Which of the following is a procedure that removes pleural fluid for analysis? 1. 2. 3. 4.

bronchoscopy thoracentesis pulmonary function test lung biopsy

(2) Thoracentesis is a procedure that removes pleural fluid for analysis. The other pulmonary procedures listed are not. 99. Which of the following is an appropriate nursing intervention for a client with epistaxis? 1. 2. 3. 4.

Apply heat to the nose. Have the client walk. Apply pressure to the nose. Have the client lie prone.

(3) Epistaxis is a nosebleed. Pressure is applied to the soft, lower portion of the nose. Ice can also be applied. The client should remain still, preferably in the sitting position, leaning forward. The client can lie supine if necessary, with the head and shoulders elevated. 100. A Mexican client has an upper-respiratory infection and wishes to take echinacea to aid healing. Which is the most appropriate response by the nurse? 1. 2. 3. 4.

Tell the client that only antibiotics work. Let the client know a prescription is needed. Instruct the client that this is an inappropriate request. Notify the physician of the client’s request.

(4) The physician should be notified of a client’s request for an herbal remedy. Echinacea might have antibacterial properties and might stimulate the immune system. For many Mexican-American clients, herbal remedies are part of cultural traditions. Echinacea can be purchased over the counter. It is necessary for the physician to determine whether an herbal remedy is likely to interact with other medications and whether it is safe and effective for the client’s condition. 101. Which of the following medications is commonly given to treat tuberculosis? 1. 2. 3. 4.

Isoniazid (INH) Cisplatin (CDDP) Carvedilol (Coreg) Floxuridine (FUDR)

(1) INH is commonly given to treat tuberculosis. The other medications listed are not. 102. Which potential complication should the nurse monitor for in a client who has had a radical mastectomy? 1. 2. 3. 4.

lymphedema cerebral edema peripheral edema pedal edema

(1) Lymphedema is a potential complication of a radical mastectomy and should be monitored for by the nurse. Lymphedema can result when lymph nodes are excised in a radical mastectomy. Mastectomies and lumpectomies, which do not disturb lymph nodes, are much more commonly performed.

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103. Why is it important for diabetic clients to visually inspect their feet daily? 1. 2. 3. 4.

to monitor growth of the feet to check for skin breakdown to determine which lotion to use to determine which socks to wear

(2) It important for diabetic clients to visually inspect their feet daily to check for skin breakdown because many diabetics have peripheral neuropathy and cannot feel pain adequately. The other choices do not apply. 104. Which medication is given to women with a history of breast cancer to prevent recurrence of the cancer? 1. 2. 3. 4.

Mexitil (mexiletine) Tolinase (tolazamide) Nolvadex (tamoxifen) Welchol (colesevelam)

(3) Tamoxifen is given to women with a history of breast cancer to prevent recurrence of the cancer. The remaining medications have other indications. 105. Which of the following statements by a client who has had a right radical mastectomy performed indicates adequate understanding of self-care? 1. 2. 3. 4.

“I should have blood drawn from my right arm.” “I should have blood pressures taken on my right arm.” “I should keep my arm elevated on a pillow.” “I should keep my arm flat on the bed.”

(3) Keeping the arm elevated reduces lymphedema. The other responses might increase lymphedema. Blood draws in the affected arm can also predispose the woman to risk of infection, particularly in the immediate postoperative period. 106. A Native-American woman is diagnosed with breast cancer. She wishes to see a medicine woman before she decides whether to have a mastectomy. Which of the following is an appropriate response by the nurse? 1. 2. 3. 4.

“Your surgery must be performed immediately.” “Your cancer might spread if you wait.” “You need chemotherapy, not herbs.” “I will let the physician know about your request.”

(4) Notifying the physician is appropriate; the other responses do not respect the client’s wishes. A medicine woman might provide valuable psychological support that can help the client with her decision. 107. Which racial group of women has the lowest rate of breast cancer screening? 1. 2. 3. 4.

Asian Caucasian Hispanic African American

(3) Hispanic women have the lowest rate of breast cancer screening. The effectiveness of teaching in Hispanic communities regarding the importance of breast cancer screening needs to be improved.

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108. Which of the following actions by a client indicates adequate understanding of how to prevent lynphedema after breast reconstruction with implants? 1. 2. 3. 4.

binding the breast with an elastic bandage wearing a sling on the arm on the surgical side keeping the arm on the unaffected side elevated keeping the arm on the affected side elevated

(4) Keeping the arm on the affected side elevated will prevent lymphedema. The breasts should not be bound. The arm on the affected side should be exercised to prevent edema, not worn in a sling. 109. Why are women more prone to complications from gonorrhea infections than men? 1. 2. 3. 4.

They are usually asymptomatic. They do not usually contract gonorrhea. They ignore their symptoms. They are more likely to be in denial.

(1) Women are more prone to complications from gonorrhea infections than men because they are usually asymptomatic. Without symptoms, they tend not to seek medical assistance, which gives the infection time to spread and cause complications. The other statements are not true. 110. Which is a complication of Treponema pallidum infection? 1. 2. 3. 4.

genital herpes syphilis genital warts hepatitis B

(2) Syphilis is a complication of Treponema pallidum infection. Genital herpes results from an infection by the herpes simplex virus (HSV). Genital warts result from condylomata acuminata. Hepatitis B results from the hepatitis B virus. 111. Which of the following represents a complication that occurs during the secondary stage of syphilis? 1. 2. 3. 4.

appearance of chancres symmetric rash loss of vision locomotor ataxia

(2) A symmetric rash is present in the secondary stage of syphilis. The other symptoms are present during other stages of the disease. 112. Which of the following is not a risk factor for chlamydial infections in women? 1. 2. 3. 4.

multiple sex partners lack of barrier contraception history of cervical ectopy use of birth control pills

(4) Using a birth control pill neither puts at risk, nor protects a woman from a chlamydial infection. The other three choices place a woman at risk for such an infection.

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113. Which method is used to prevent a pregnant woman from transmitting herpes simplex virus (HSV) to her neonate? 1. 2. 3. 4.

performing a cesarean section giving the neonate antibiotics giving the mother antibiotics both 2 and 3

(1) Performing a cesarean section helps a pregnant woman prevent transmission of HSV to her neonate. Most HSV infections of neonates occur during birth. Because HSV is a virus, antibiotics do not have any effect. 114. Which of the following is a potential complication for a woman with a human papilloma virus (HPV) infection? 1. 2. 3. 4.

colon cancer skin cancer breast cancer cervical cancer

(4) Certain types of HPV infection predispose a woman to develop cervical cancer. The risk of colon, skin, or breast cancer is not increased. 115. Which of the following statements by a male client indicates adequate understanding of the prevention of sexually transmitted diseases (STDs)? 1. 2. 3. 4.

“I should use spermicidal jelly before intercourse.” “I should wear a condom during intercourse.” “I should wash my genitals after intercourse.” “I should limit my number of sexual partners.”

(2) Wearing a condom during intercourse has been shown to prevent STD infections. Spermicides have not been shown to reduce transmission of STDs. Washing after exposure to infection does not prevent transmission. Limiting the number of sexual partners is not effective protection. A monogamous relationship between uninfected partners is the only sexual relationship that prevents the spread of STDs. 116. Which of the following statements by a client indicates adequate understanding of how to prevent exacerbation of premenstrual syndrome (PMS)? 1. 2. 3. 4.

“I should practice relaxation therapy.” “I should drink lots of coffee each day.” “I should increase my intake of salt.” “I should stay on bed rest for three days.”

(1) Relaxation therapy has been shown to decrease exacerbation of PMS. To decrease PMS, clients should decrease coffee (caffeine) intake, decrease salt intake, and increase aerobic exercise. 117. Immediately after having a blood sample drawn, a client develops a hematoma at the venipuncture site. What should the nurse do first? 1. 2. 3. 4.

Apply a cold compress to the site. Apply pressure to the site. Notify the physician of the hematoma. Check the client’s medications.

(2) The nurse should apply pressure to the site first, to prevent further hematoma formation. The other steps can be performed afterward.

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118. Why should the nurse handle a blood specimen gently during and after venipuncture? 1. 2. 3. 4.

to keep it warm during handling to prevent hemolysis of the cells to ensure correct identification to prevent blood clotting

(2) A blood specimen should be handled gently during and after venipuncture in order to prevent hemolysis, or damage to the blood cells. Such damage can alter laboratory results. The other responses are not correct, as they have no relevance to handling the specimen gently. 119. A client who is on Coumadin (warfarin) therapy begins to have a nosebleed. What should the nurse do first? 1. 2. 3. 4.

Administer vitamin K. Administer protamine sulfate. Apply pressure to the nose. Check the prothrombin time (PT).

(3) Pressure should be applied first, while keeping the client in an upright position and leaning slightly forward to prevent further bleeding and aspiration of blood. The other interventions can be performed later, with the exception of administering protamine sulfate, which is an antidote for Heparin therapy. 120. A client on Heparin therapy has a partial thromboplastin time (PTT) of 200 seconds. What should the nurse do first? 1. 2. 3. 4.

Administer protamine sulfate. Recheck the laboratory result. Decrease the rate of Heparin. Turn off the Heparin infusion.

(4) A PTT of 200 seconds is dangerously high and could cause lethal bleeding. The nurse needs to turn off the Heparin infusion first. The other interventions can be performed afterward. The rate of Heparin should be decreased if the infusion is restarted. 121. Where is Chvostek’s sign checked? 1. 2. 3. 4.

foot chest face arm

(3) Chvostek’s sign is a check for hypocalcemia. It is checked by tapping the client’s facial nerve, and observing for contraction of the upper lip, nose, or side of the face. 122. Where is Trousseau’s sign checked? 1. 2. 3. 4.

foot chest face hand

(4) Trousseau’s sign is a test for hypocalcemia. It is checked by occluding the arterial flow to the client’s arm with a blood pressure cuff. After one to five minutes, carpopedal spasms indicate tetany, a sign of hypocalcemia.

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123. Which potential complication of diuretic therapy should the nurse monitor for? 1. 2. 3. 4.

hypokalemia hyperkalemia hypophosphatemia hyperphosphatemia

(1) Clients on diuretic therapy are at risk for hypokalemia, or low potassium levels, due to diuresis. Risk for an increased potassium level or change in phosphate level has not been shown, based on diuretic use alone. 124. Which of the following clients is not a candidate for magnetic resonance imaging (MRI)? 1. 2. 3. 4.

a client with an implanted pacemaker a client who has had a recent heart attack a client who has had a recent stroke a client wearing a cast

(1) A client with an implanted pacemaker is not a candidate for MRI. This is because the magnetic pull of the MRI could cause the pacemaker to malfunction, as well as causing safety hazards to the client. A client with metal objects is a safety hazard and not allowed in an MRI, as the the magnet will pull on the objects. This includes clients with a hip or knee replacement. The other responses are not contraindications to having an MRI. 125. Which of the following conditions might be a complication of cerebral spinal fluid removal from a lumbar puncture? 1. 2. 3. 4.

earache headache vomiting seizure

(2) Headache can be a complication following cerebral spinal fluid removal from a lumbar puncture. This is due to leaking of the cerebral spinal fluid (which normally cushions the brain and spinal cord) after the procedure, causing the brain to herniate downward and inducing pain. The other responses are not complications found with lumbar puncture. 126. Which of the following complications might result after a client has an esophagogastroduodenoscopy (EGD)? 1. 2. 3. 4.

aspiration seizure headache spasm

(1) Clients are at risk for aspiration after an EGD. This is due to the paralyzing effect of the anesthetic spray used on the throat. The nurse needs to monitor for the return of swallowing ability after the test to prevent aspiration. The other complications do not result from an EGD. 127. A client receiving morphine sulfate begins to breathe at a rate of six breaths/minute. What should the nurse do first? 1. 2. 3. 4.

Document the respirations. Monitor the respirations. Administer naloxone (Narcan). Administer flumazenil (Romazicon).

(3) Naloxone is an antagonist to morphine sulfate, so it should be administered first, causing the respirations to return to a normal rate. Choices 1 and 2 should be performed later. Choice 4 does not apply because flumazenil is an antidote for benzodiazepines.

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128. A client receiving midazolam (Versed) develops a respiratory rate of four breaths/minute. What should the nurse do first? 1. 2. 3. 4.

Document the respirations. Monitor the respirations. Administer naloxone (Narcan). Administer flumazenil (Romazicon).

(4) Flumazenil is an antagonist to Versed, so it should be administered first, causing the respirations to return to a normal rate. Choices 1 and 2 should be performed later. Choice 3 does not apply because naloxone is an antidote for narcotic analgesics. 129. Which of the following complications might arise in a client who has had a barium swallow? 1. 2. 3. 4.

constipation fever muscle spasms seizures

(1) Constipation is a common complication occurring in clients who have had a barium swallow. This is because the barium may be difficult to expel. It is helpful to have the client drink plenty of fluids after a barium swallow, to prevent constipation. A mild laxative is often prescribed following a barium enema. The other options do not apply to having a barium enema. 130. Which of the following clients is not a candidate for a treadmill stress test? 1. 2. 3. 4.

a client with arthritis in the knees a client with dysphagia a client with heart disease a client with hypertension

(1) A client with arthritis in the knees is not a candidate for a treadmill stress test because the client must walk briskly on a treadmill, which might be difficult or impossible for a client with arthritic knees. There are chemical options for stress tests available for the client who cannot undergo a treadmill stress test. The other choices are not contraindications. Clients with dysphagia have difficulty swallowing. A treadmill stress test is often ordered for clients with heart disease. Blood pressure is monitored during a treadmill stress test, so clients with hypertension are not excluded. 131. A client who has had a cardiac catheterization develops a hematoma on the right groin, the site of catheter insertion. What should the nurse do first? 1. 2. 3. 4.

Check the right pedal pulse. Apply pressure to the right groin. Document the hematoma formation. Monitor the hematoma formation.

(2) Pressure should be applied immediately to the right groin to prevent further hematoma formation. The other interventions should be performed afterward. 132. Which of the following nursing diagnoses is most appropriate for a client who has had a cerebrovascular accident with resulting right-sided hemiparesis? 1. 2. 3. 4.

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Impaired Mobility Impaired Tissue Integrity Risk for Loneliness Confusion

Reduction of Risk Potential

(1) Impaired mobility is the best of the above options. This is because hemiparesis is paralysis on one side of the body, which causes varying degrees of impairment of mobility. The other diagnoses might also apply, but Choice 1 is the most appropriate. 133. Which complication might occur as a result of menorrhagia? 1. 2. 3. 4.

diarrhea vomiting headache anemia

(4) Menorrhagia is excessive bleeding associated with menstruation. This blood loss may lead to anemia. The other complications are not directly associated with menorrhagia. 134. Which of the following statements by a client indicates adequate understanding of prevention of complications from PMS? 1. 2. 3. 4.

“I should eat more salty foods during PMS.” “I should sleep less when I have PMS.” “I should get more exercise during PMS.” “I should drink more coffee during PMS.”

(3) Exercise during PMS has been shown to decrease the complications that can arise. The other choices are not recommended activities during PMS. 135. Which of the following statements regarding weighing a client is not correct? 1. 2. 3. 4.

Clients should be weighed at the same time each day. Wet gowns should be changed before weighing. The scale should be balanced before weighing. A different scale should be used each day.

(4) The same scale should be used each day to assure accurate recording of weight changes. The remaining choices are correct statements regarding the procedure for weighing a client. 136. When a client is discharged against medical advice (AMA), what should the nurse do first? 1. 2. 3. 4.

Offer the client the AMA form to sign. Teach the client about necessary care. Notify the physician of the action. Explain the risks of leaving the hospital.

(3) The physician needs to be notified first. The nurse needs an order to discharge the client AMA. The physician might be able to convince the client to remain hospitalized. Choices 1, 2, and 4 can be performed later. 137. When a client is discharged AMA, what documentation is the most important legally? 1. 2. 3. 4.

documentation of the discharge in the progress notes documentation of the discharge on the discharge sheet an AMA form signed by the client an AMA form signed by the client’s spouse

(3) The most important legal documentation is the client’s signature on an AMA form, providing verification that the nurse explained the risks to the client. Having the discharge documented elsewhere does not provide such legal coverage. A spouse’s signature is not sufficient, unless the spouse has power of attorney for health care.

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138. Which of the following activities enhances the results of client-focused education? 1. 2. 3. 4.

planning follow-up to reassess learning utilizing complex language for teaching using goals for education determined by the nurse using only one teaching method

(1) Choice 1 is the only activity that enhances the results of client-focused education. For effective learning, simple language should be used, the client should determine the goals for education, and several methods of teaching should be used. 139. Which method of teaching has the greatest retention rate for clients? 1. 2. 3. 4.

reading performance writing observance

(2) Performance has been shown to provide a 75%–90% retention rate of new information. The other methods have a lower retention rate; therefore, it is important that the nurse have clients demonstrate new skills to improve retention and mastery. 140. Which of the following interventions should not be used when teaching a client? 1. 2. 3. 4.

Face the learner. Speed the pace. Bolster self-esteem. Decrease noise.

(2) For a learner, the pace needs to be slow, in order to facilitate learning. Choices 1, 3, and 4 should be used when teaching a client. 141. Which source provides the nurse with information regarding proper handling and care of potentially toxic materials? 1. 2. 3. 4.

nursing care plan material safety data sheets physician’s orders fire safety manual

(2) Material safety data sheets provide information about chemical makeup, health effects, exposure, and emergencycare procedures related to potentially toxic materials. The remaining choices do not provide such information. 142. Which of the following actions by the nurse is least likely to protect client privacy? 1. 2. 3. 4.

showing medical records to a spouse drawing the curtain in the room pulling the window shades knocking on the client’s door

(1) Choice 1 is least likely to protect client privacy. A spouse is allowed to see a client’s medical records only if the client has given permission. Choices 2, 3, and 4 protect client privacy.

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143. A nurse discovers a fire in a hallway closet. Which mnemonic device is used to recall the proper use of a common fire extinguisher? 1. 2. 3. 4.

PUSH RUSH PASS LAST

(3) The acronym PASS is the mnemonic device used to remember the following actions (and the order in which to perform them): Pull the pin (if one is present in the extinguisher), Aim the extinguisher at the base of the fire, Squeeze the trigger, Sweep from side to side. The other mnemonics are fictitious. 144. Which method of evacuating clients in case of a fire is usually performed first? 1. 2. 3. 4.

vertical horizontal diagonal perpendicular

(2) Horizontal movement is usually performed first when evacuating clients. This means the clients are moved to a different area on the same floor. Vertical movement, which means the clients are moved to a different floor, is usually performed later. Perpendicular and diagonal do not describe methods of evacuating clients. 145. What is the maximum amount of time per day a nurse can spend with a client under radiation precautions for an implant? 1. 2. 3. 4.

5 minutes 15 minutes 25 minutes 35 minutes

(2) The nurse can spend up to 15 minutes per day with a client under radiation precautions. This avoids overexposure to radiation. 146. Which of the following activities indicates that the nurse is not adequately observing radiation precautions for a client with an implant? 1. 2. 3. 4.

placing linens in a hamper outside the client’s room spending five minutes per day in the client’s room keeping pregnant women out of the client’s room flushing the client’s urine down the toilet

(1) Linens are kept in the client’s room until they are cleared by a radiation safety officer as safe for removal. Choices 2, 3, and 4 are correct procedures for radiation precautions. 147. How often does a physician’s order need to be written for a client who requires restraints? 1. 2. 3. 4.

once per admission once every 24 hours once every 48 hours once every 72 hours

(2) A physician’s order needs to be written for a client who requires restraints every 24 hours, by regulation. A physician’s order needs to be written for a client who requires restraints every 24 hours, by regulation.

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148. Which type of restraint is being used when the nurse holds a client’s hand in place? 1. 2. 3. 4.

physical chemical seclusion pharmaceutical

(1) Holding a client in place and preventing freedom of movement is physical restraint. An example of chemical or pharmaceutical restraint is psychotropic drugs. An example of seclusion is keeping the client confined in a locked room. 149. What is the maximum amount of time a nurse can leave restraints in place without releasing the client? 1. 2. 3. 4.

1 hour 2 hours 3 hours 4 hours

(2) The maximum amount of time a nurse can leave restraints in place without releasing the client is 2 hours. Clients must be checked every 30 minutes, and restraints must be released every 2 hours. The nurse should check the client’s skin, circulation, and provide for the client’s needs every 2 hours when the restraints are released. 150. Which type of knot should a nurse use to tie a restraint to a bed frame? 1. 2. 3. 4.

square knot full-bow knot half-bow knot double knot

(3) The nurse should use a half-bow knot to tie a restraint to a bed frame. This is a secure knot that can be loosened quickly in an emergency. A full-bow knot is not as secure. Choices 1 and 2 take too long to untie in an emergency. 151. Which of the following actions by the nurse indicates observation of medical asepsis while making a bed? 1. 2. 3. 4.

placing dirty linen on the floor transferring linen from one client area to another Holding a pillow under the chin to apply a pillowcase placing bagged, dirty linen in a hamper

(4) Placing bagged dirty linen in a hamper indicates observation of medical asepsis while making a bed. Linen should not be placed on the chair, transferred to another client area, or held under the chin, as this could cause spread of microorganisms. 152. A female Hispanic client refuses to have a male nurse give her a complete bed bath. Which is an appropriate response by the male nurse? 1. 2. 3. 4.

“I can give a bath as well as a female nurse.” “I’m a professional, so you shouldn’t feel embarrassed.” “I will get a female nurse to give your bath.” “You can’t discriminate against me.”

(3) The client has the right to refuse any treatment. Some cultures value privacy and modesty between genders, so getting a female nurse to perform the client’s bath is a culturally sensitive response. The other choices are nontherapeutic and/or unprofessional.

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Reduction of Risk Potential

153. What is the appropriate method for heating a disposable bath packet? 1. 2. 3. 4.

Place the package in boiling water for one minute. Heat the package in a microwave. Hold the package under hot water. Soak the package in warm water.

(2) Disposable bath packets should be heated in a microwave for the length of time recommended by the manufacturer (usually 45 seconds). Choices 1, 3, and 4 are not recommended by manufacturers of disposable bath packets. 154. When placing a client in a tub of water, what is the highest allowable temperature (to avoid burning the client)? 1. 2. 3. 4.

98.6° Fahrenheit 101° Fahrenheit 105° Fahrenheit 110° Fahrenheit

(3) The highest allowable temperature is 105° Fahrenheit. Higher temperatures can burn the client’s skin. A special thermometer can be placed in the water to measure the temperature of the bath water. 155. A client complains of dry, itchy skin following a complete bed bath. What should the nurse do first? 1. 2. 3. 4.

Monitor the itching. Document the itching. Apply lotion to the client’s skin. Assess the client’s skin.

(4) Assess the client’s skin first, to determine if there is an allergic reaction. Applying lotion to the skin may make the condition worse, particularly if the client also has a sensitivity to the lotion. Monitoring and documenting may also be done, but can be done later. 156. Which part of the hand should a nurse use to assess a client’s skin temperature? 1. 2. 3. 4.

palm of the hand pads of the fingers back of the hand both palms

(3) The back of the hand should be used to assess skin temperature in clients. This is because the back of the hand is more sensitive to changes in skin temperature than the palm of the hand or the pads of the fingers. 157. Which action by the nurse is inappropriate to protect a client’s skin from tears? 1. 2. 3. 4.

using foam tape using paper tape applying lotion using a lift sheet

(1) Use of foam tape does not protect a client’s skin from tears. Foam tape is highly adhesive, and removal of the tape can cause a skin tear. Choices 2, 3, and 4 are ways to prevent skin tears.

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158. A client on Heparin therapy requests to be shaved with a disposable razor. Which is an appropriate response by the nurse? 1. 2. 3. 4.

“I will get you a disposable razor.” “I will get an electric razor instead.” “I will have your spouse shave you with a disposable razor.” “I will shave you with a disposable razor.”

(2) The best action is to get an electric razor, which does not pose a bleeding risk. Clients on Heparin therapy are prone to bleeding, so using a disposable razor is a safety risk. 159. While providing foot care to a diabetic client, the nurse notices that the client’s toenails are too long. Which is an appropriate response by the nurse? 1. 2. 3. 4.

Clip the toenails with a clipper. Cut the toenails with scissors. Report the condition to the physician. Soak, and then file the toenails.

(3) The physician should be notified if a diabetic client needs foot care so that the client can be referred to a podiatrist. Diabetics are prone to infection and impaired circulation, so their toenails should be cared for by a podiatrist. 160. A European client refuses to have deodorant applied after a bath. Which is an appropriate response by the nurse? 1. 2. 3. 4.

Respect the wish of the client. Teach the client about body odor. Notify the charge nurse. Give an additional partial bath later.

(1) Some European clients accept body odor as natural and do not find it offensive. Some Europeans do not use deodorant regularly. Choice 1 is the most culturally sensitive choice. The client has the legal right to refuse any treatment or procedure. Notifying the charge nurse is not necessary, nor is giving a partial bath later. 161. Which of the following is not a symptom of a fever? 1. 2. 3. 4.

chills shivers perspiration cool skin

(4) Clients with a fever have warm or hot skin. Choices 1, 2, and 3 are symptoms of a fever. 162. Which Celsius temperature is equivalent to 98.6° Fahrenheit? 1. 2. 3. 4.

36° 37° 39° 40°

(2) A temperature of 98.6° Fahrenheit equals 37° Celsius. To convert Fahrenheit temperatures to Celsius, subtract 32, and then multiply by 1.8. To convert from Celsius to Fahrenheit, multiply by 1.8, and then add 32.

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Reduction of Risk Potential

163. Which of the following is the proper way to hold a child’s ear to get a correct tympanic temperature reading? 1. 2. 3. 4.

Pull the pinna up and back. Pull the pinna up and forward. Pull the pinna down and back. Pull the pinna down and forward.

(3) A child’s ear should be pulled down and back to straighten the ear canal and allow correct placement of the tympanic thermometer probe. An adult’s ear is pulled up and back. The pinna is not pulled forward for temperature readings. 164. Which digit(s) should be used to correctly palpate a client’s radial pulse? 1. 2. 3. 4.

thumb index finger middle three fingers index and middle finger

(3) The three middle fingers should be used to correctly palpate a client’s radial pulse. This allows for correct palpation of the pulse, unlike the remaining options. 165. When auscultating the apical pulse, which of the following anatomic landmarks is the proper location for the nurse to place the stethoscope? 1. 2. 3. 4.

fifth intercostal space at the midclavicular line second intercostal space at the left sternal border second intercostal space at the right sternal border fourth intercostal space at the left sternal border

(1) This is the proper location for auscultating the apical pulse. Choices 2, 3, and 4 describe positions for auscultating heart sounds other than the apical pulse. 166. When assessing a client’s abdomen, which of the following steps in the assessment process is performed last by the nurse? 1. 2. 3. 4.

inspection auscultation palpation percussion

(3) Palpation is performed last because palpation of the abdominal organs might stimulate the intestines and change the character of the bowel sounds. 167. Which of the following positions illustrates proper body mechanics when lifting? 1. 2. 3. 4.

knees locked straight twisting at the waist knees slightly bent feet close together

(3) For proper body mechanics when lifting, the knees should be slightly bent, not locked straight. The whole body should be turned, not just at the waist. The feet should be spread about shoulder-width apart for a firm base of support.

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Physiological Adaptation This chapter contains questions and answers from the following topic areas: ■ ■ ■

Alterations in Body Systems Basic Pathophysiology Fluid and Electrolyte Imbalances

■ ■ ■

Medical Emergencies Radiation Therapy Unexpected Response to Therapies

1. A client has suffered a massive hemorrhagic stroke. Upon assessment of his level of consciousness (LOC), the PN should expect to find that the client is: 1. 2. 3. 4.

awake, alert, and oriented. arousable to voice and oriented to person and place. arousable to light touch and oriented to person only. arousable to deep pain and incomprehensible sounds.

(3) A massive stroke deeply depresses the client’s LOC. Choice 1 indicates no neurologic insult. Choices 2 and 4 are signs of increasing neurologic insult, respectively. 2. A client presents to the Emergency Department with a 1-hour history of left-sided weakness, right-sided ptosis, and aphasia. Results of a computed tomography (CT) scan demonstrate no intracranial bleeding. The client should be considered for which therapy? 1. 2. 3. 4.

fibrinolytics antiplatelet agents and anticoagulants craniotomy and embolectomy intracranial pressure monitoring

(1) Fibrinolytics are the treatment of choice for embolic stroke, if started within 3 hours of symptoms. The purpose of the computed tomography (CT) scan is to rule out hemorrhagic stroke. Choice 2 can be used if fibrinolytics are ruled out because more than 3 hours have passed since symptoms began, the client has had recent major surgery or the client has uncontrollable hypertension. Choice 3 can be used to treat hemorrhagic stroke if the cause is an arterial-venous malformation or a ruptured aneurysm. Choice 4 might be used after an hemorrhagic stroke or a closed head injury (CHI). 3. A client has been diagnosed with a Glioblastoma. Which of the following statements indicates that the client has understood the medication teaching? 1. 2. 3. 4.

“I should take all the doses of this antibiotic.” “Pyridium (phenazopyridine HCl) turns my urine red-orange.” “Aspirin helps prevent blood clots in my brain.” “Decadron (dexamethasone) can cause ulcers.”

(4) Dexamethasone is used to reduce swelling in the brain, which is the cause of much of the symptomatology of brain cancer. Choice 1 is incorrect because antibiotics are not prescribed unless the client has an infection. Phenazopyridine is used to treat pain from a urinary tract infection (UTI). Choice 3 is incorrect because clots are not a critical concern in clients with brain cancer.

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4. The PN is teaching a client with a spinal cord injury at T-8 about intermittent self-catheterization. The PN should be sure to include which of the following in the teaching? 1. 2. 3. 4.

that the volume of urine returned should be at least 800ml how to recognize the signs and symptoms of a urinary tract infection (UTI) how to follow strict aseptic technique that fluids should be limited at meals

(2) UTI is a leading cause of illness in clients with urinary catheters. Choice 1 is incorrect because the goal is to keep less than 500ml of urine in the bladder to prevent overdistention. Choice 3 is incorrect because the RN uses aseptic technique, but the client should learn and use clean technique. Choice 4 is incorrect because fluid intake should be about 3000ml/24 hours, evenly distributed throughout the day. 5. The PN is caring for a client with migraine headaches. Discussion and teaching about the medication for migraine headaches is done. Which of the following statements indicates that the teaching has been effective? 1. 2. 3. 4.

“I should take Tylenol (acetaminophen) every day, even if I don’t have a headache.” “I should take Imitrex (sumatriptan) only if I have a headache.” “I should take Phenergan (promethazine) for the nausea only.” “I should take Cafergot (ergotamine) with caffeine.”

(2) Sumatriptan is used to relieve a migraine. Choice 1 is for pain relief, not prevention. Choice 3 is for treatment of the nausea associated with migraine. Choice 4 is used to prevent migraine and should be taken as prescribed. 6. The PN is caring for a client with a cervical fracture and quadriplegia. The care plan should include: 1. 2. 3. 4.

mandatory mechanical ventilation. assisted coughing. Trendelenburg’s position. suctioning every 2 hours.

(2) The client might have functional diaphragmatic breathing but no intercostal muscle movement, which is important for effective coughing. Choice 1 is incorrect because the phrenic nerve exits the spinal cord at C4-C5 and should not be damaged by a C6-C7 fracture. The client might need temporary ventilation during the period of acute swelling. Choice 3 is contraindicated because it allows abdominal contents to press against the diaphragm, making breathing more difficult. Choice 4 is incorrect because the client should be able to cough with assistance and should not require suctioning. 7. A client recovering from a closed head injury (CHI) is living with his parents after rehabilitation. The home health PN teaching the client and family about common sequelae from a CHI should be sure to include: 1. 2. 3. 4.

Schizophrenia commonly occurs after CHI. Depression is seldom seen after CHI. Alcohol abuse seldom worsens after CHI. Poor impulse control commonly occurs after CHI.

(4) Impulsivity is often a problem after CHI. Schizophrenia is not associated with CHI. Choices 2 and 3 both might occur or worsen after CHI. 8. The PN is selecting a nursing diagnosis for a client who states that he consumes 12 beers every day. Choose the best diagnosis: 1. 2. 3. 4.

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Potential for Injury (related to alcohol withdrawal) Potential for Injury (related to lower gastrointestinal bleeding) Alteration in Nutrition (related to excess calorie consumption) Fluid Volume Excess (related to intake of beer)

Physiological Adaptation

(1) A client who drinks every day is likely to need prophylaxis to prevent alcohol withdrawal syndrome. Choice 2 is incorrect because clients who abuse alcohol frequently have upper GI bleeding. Choice 3 is incorrect because clients who abuse alcohol frequently have malnutrition, not overnutrition. Choice 4 is incorrect because in the absence of renal failure, the beer is eliminated via urine output. 9. The PN is caring for a client with Guillain-Barré syndrome (GBS) who is being treated with plasmapheresis. Which of the following conditions indicates that the treatment is working? 1. 2. 3. 4.

The prothrombin time (PT) and partial thromboplastin time (PTT) return to normal. The platelet count normalizes. The vital capacity improves. The pulse oximeter reads 95% or greater.

(3) GBS is an autoimmune demyelinating disorder. Ventilation is the primary concern and is monitored with serial vital capacity or minute volume measurements. Plasmapheresis removes the offending antibodies. Choice 1 is incorrect because PTT replaces the client’s plasma, but clotting is not the problem. Choice 2 is incorrect because platelets are not involved. Choice 4 is incorrect because a pulse oximeter measures oxygenation, not ventilation. 10. The PN is caring for a client with a CHI. The client demonstrates Battle’s sign and bilateral periorbital ecchymoses (raccoon eyes) The PN should monitor for: 1. 2. 3. 4.

lack of pupillary light reflexes or accommodation. fluctuating level of consciousness. levels of agitation or restlessness. cerebrospinal fluid (CSF) leak from the ears or nose.

(4) Raccoon eyes and/or mastoid bruising (Battle’s sign) are associated with basilar skull fracture and cerebrospinal fluid (CSF) leak is a serious complication that makes the client vulnerable to central nervous system (CNS) infection. Choices 1, 2, and 3 are generic neurological assessments performed for any client with neuro dysfunction. 11. After an education session, the PN expects the client to be able to list modifiable risk factors for coronary artery disease (CAD). These include: 1. 2. 3. 4.

age, gender, diabetes. central obesity. active lifestyle. family history.

(2) Central obesity is a marker for metabolic syndrome (hyperlipidemia, hypertension, diabetes), which increases risk for CAD and can be affected by diet and exercise. Choices 1 and 4 are not modifiable risk factors. Choice 3 helps prevent CAD. A sedentary lifestyle is a modifiable risk factor. 12. The nurse is reviewing lab work on a 60-year-old client with a 10-year history of type II diabetes. Lipid targets for this client include: 1. 2. 3. 4.

total cholesterol less than 100 and LDLs less than 50. total cholesterol less than 200 and LDLs less than 100. total cholesterol less than 200 and LDLs less than 130. total cholesterol less than 250 and LDLs less than 180.

(2) Diabetes is regarded as a CAD risk-equivalent. If a person has diabetes, he or she is considered to have CAD, even if no symptoms currently exist. Therefore, the targets are Tchol less than 200 and LDL less than 100. Choice 1 is not achiveable for most people. Choice 3 gives appropriate targets for those without CAD or diabetes. The results in Choice 4 are too high.

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13. The PN is caring for a client who is 12 hours postop with an abdominal aneurysm repair. The nurse should be most concerned about which of the following findings? 1. 2. 3. 4.

pulse 102, temperature 99.5° F (37.5° C) pedal pulses present client needs oxygen at 4 liters/min to maintain pulse oxygen 96% urine output 100ml for 4 hours

(4) The nurse should be most concerned about a urine output less than 30ml/hr. The aorta is cross-clamped to perform the repair described, decreasing renal perfusion and increasing the risk of acute tubular necrosis. Low-grade fever (as in Choice 1) is common shortly after surgery and is most likely due to inflammatory response rather than infection. Mild tachycardia is probably due to fever. Choice 2 is an expected finding; most clients needing abdominal aneurysm repair also have peripheral vascular disease and pedal pulses might not be palpable. Choice 3 is incorrect. Many clients have slightly decreased ventilation due to incisional pain and might require oxygen support for a few days. 14. The recommended diet for clients diagnosed with Hypertension is: 1. 2. 3. 4.

low fat, low cholesterol. low fat and high carbohydrate. low sodium. low fiber and high fat.

(3) A high-sodium diet can cause water retention, resulting in water retention. Choice 1 is for clients with or who are at risk for CAD. 15. The PN auscultating a client’s heart sounds hears a holosystolic murmur most prominent at the fifth intercostal space, left mid-clavicular line. The most likely explanation is: 1. 2. 3. 4.

aortic stenosis. aortic regurgitation. mitral stenosis. mitral regurgitation.

(4) The fifth intercostal space at the left clavicular line is the correct spot to listen to the mitral valve. A systolic murmur at this site means the valve is at least partially open when it should be closed. Choice 1 is a systolic murmur heard best at the second intercostal space, right sternal border. Choice 2 is a diastolic murmur heard best at the second intercostal space, left sternal border. Choice 3 is a diastolic murmur heard best at the fifth intercostal space, left mid-clavicular line. 16. The nurse should include which of the following pieces of information when teaching a client about taking a beta blocker? 1. 2. 3. 4.

It can cause sexual dysfunction. It can cause palpitations. It should be taken as needed. It can be discontinued any time.

(1) If clients know that sexual dysfunction is a possible side effect, they’re more likely to discuss related problems with the prescriber. Choice 2 is incorrect because beta blockers slow the heart rate; they do not speed it up. Choice 3 is incorrect because a beta blocker must be taken every day to be effective. Choice 4 is incorrect because a beta blocker can cause rebound hypertension if stopped suddenly.

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Physiological Adaptation

17. A client with newly diagnosed Mild Hypertension is reluctant to take medications. What alternative intervention is appropriate? 1. 2. 3. 4.

herbal preparations acupuncture walking daily aromatherapy

(3) Walking for 30–60 minutes most days of the week can lower blood pressure (BP). Choices 1, 2, and 4 are not supported by research. 18. Clients with an implanted artificial valve are typically treated with: 1. 2. 3. 4.

aspirin (acetylsalicylic acid). antibiotics. Lanoxin (digoxin). Coumadin (warfarin).

(4) Mechanical valves are thrombogenic. The goal is to keep the International Normalized Ratio (INR) at 2 to 3 depending on the specific type of valve and the valve it replaces. Choice 1 might be used as an adjunct or alone for a biologic valve replacement, but is not enough for a mechanical valve alone. Choice 2 is prescribed prophylactically before dental or urogenital procedures. Choice 3 is used to treat clients with heart failure or atrial fibrillation, not clients with valve replacement. 19. The PN is caring for a client with a history of peripheral vascular disease who has just had an exploratory laparotomy. Interventions for this client include: 1. 2. 3. 4.

anti-embolism stockings. keeping legs elevated above the heart. low-dose Heparin. Heparin infusion.

(3) This client is at risk for deep vein thrombosis (DVT) because of major abdominal surgery. Choice 1 is not indicated because of peripheral vascular disease. Choice 2 is incorrect because the atherosclerotic plaques in the leg vessels decrease circulation to the lower extremities, and elevating the legs makes this worse. Choice 4 is incorrect because Heparin infusion is used to treat pulmonary embolus, not for prophylaxis of DVT. 20. Treatment for angina includes: 1. 2. 3. 4.

nitroglycerin and rest. beta blockers and exercise. ACE inhibitors and rest. angiotensin II (A2) blockers and exercise.

(1) Angina is due to an imbalance between oxygen supply and demand on the heart. Nitroglycerin dilates the coronary arteries, increasing supply, while rest decreases demand. Choice 2 is incorrect because beta blockers are sometimes used to prevent anginal attacks but not during an acute attack, and rest, not exercise, is indicated to decrease demand. Choices 3 and 4 are incorrect because ACE inhibitors and A2 blockers are used for heart failure and hypertension, not angina. 21. The PN is preparing a client with chronic bronchitis for discharge. One item to be sure to include in teaching is: 1. 2. 3. 4.

Consume 2–3 liters of fluid daily. Use a steroid inhaler whenever necessary for wheezing. Consume 2–3 cups of milk daily. Use a short-acting beta agonist inhaler to reduce inflammation.

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(1) Fluid intake of 2–3 liters a day helps thin secretions, which is a primary problem in chronic bronchitis. Choice 2 is incorrect because steroid inhalers should be used on a regular schedule to decrease inflammation. Choice 3 is incorrect because milk can cause more/thicker secretions in many clients. Choice 4 is incorrect because beta agonists cause bronchodialation and are used for wheezing. 22. People with chronic obstructive pulmonary disease (COPD) should be vaccinated with: 1. 2. 3. 4.

pneumococcal vaccine yearly and influenza vaccine once. influenza vaccine yearly and pneumococcal vaccine every five years. MMR and chicken pox. pertussis and diphtheria.

(2) COPD clients are at increased risk from respiratory infections and should be vaccinated. Choice 1 is incorrect because the frequencies are incorrect. Choices 3 and 4 are childhood vaccines. 23. A client complains of muscle weakness, leg cramps, fatigue, and lethargy. These symptoms might be related to: 1. 2. 3. 4.

hyponatremia. hypernatremia. hyperkalemia. hypokalemia.

(4) Hypokalemia is a state of extremely low potassium in the circulating blood. Symptoms include muscle weakness, leg cramps, fatigue, lethargy, anorexia, nausea, and vomiting, decreased bowel motility, cardiac dysrhythmias, and depressed deep-tendon reflexes. 24. In addition to being prescribed a potassium supplement, the nurse should advise the client described in Question 23 to eat foods rich in potassium. All the following foods are high in potassium except: 1. 2. 3. 4.

dry fruits. bananas and prunes. broccoli and peanut butter. eggs and whole-grain breads.

(4) The nurse should instruct the client to include potassium-rich foods (such as tomatoes, spinach, bananas, oranges, and other fruits and vegetables) in her diet. 25. The client asks why she has to take potassium. All the following responses are appropriate except: 1. 2. 3. 4.

“Your diuretic causes not only water and sodium to be excreted but also potassium.” “Your serum potassium level is low, and Slow K helps to prevent a potassium deficit.” “Your health care provider should discontinue the potassium supplement after a week.” “The potassium supplement should maintain a normal potassium level in your body while you are taking the potassium-wasting diuretic.”

(3) Treatment focuses on restoring normal potassium balance, preventing serious complications, and removing or treating the underlying causes of hypokalemia. Serum potassium levels should be monitored carefully. If a potassium supplement is given, serum potassium levels are monitored. (The physician is likely to order lab work.) The potassium supplement can be discontinued if the cause of the imbalance is corrected.

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Physiological Adaptation

26. Which of the following serum potassium levels indicates hyperkalemia? 1. 2. 3. 4.

5.9 mEq/L 4.6 mEq/L 3.8 mEq/L 2.9 mEq/L

(1) Hyperkalemia occurs when the serum potassium level rises above 5 mEq/L. The normal range is narrow (3.5 to 5 mEq/L), and a serum potassium above the normal range can be life threatening and include cardiac arrest or dysrhythmias, gastrointestinal hyperactivity, and muscle weakness. 27. Causes of hyperkalemia include all the following except: 1. 2. 3. 4.

renal insufficiency. administration of IV solutions with potassium chloride added. potassium-wasting diuretics. poor calcium and magnesium intake.

(3) Potassium-conserving diuretics can result in hyperkalemia. Other causes might be: ■ ■ ■

excessive use of salt substitutes or potassium-sparing diuretics such as Spironolactone. injury to cells (from burns, sepsis, trauma, crush injuries, and intravascular hemolysis). lysis of malignant cells from chemotherapy.

28. A client’s serum potassium level is 6.1 mEq/L. The nurse should observe for signs and symptoms of hyperkalemia, which include all the following except: 1. 2. 3. 4.

abdominal cramps. muscular weakness. cardiac dysrhythmia. oliguria.

(4) Oliguria (low volume of urine) is not a symptom of hyperkalemia. Abdominal cramps, muscle weakness, and cardiac dysrhythmia are symptoms of hyperkalemia. 29. Drugs commonly used to treat hyperkalemia include all the following except: 1. 2. 3. 4.

glucose. calcium gluconate. insulin. diuretics.

(1) IV calcium gluconate is administered to counter the myocardial depressant effects of hyperkalemia. Diuretics, glucose, and insulin might also be ordered. 30. A 68-year-old client has a calcium deficit. His serum calcium level is 3.6 mEq/L. The client’s serum calcium level is: 1. 2. 3. 4.

slightly low. severely low. low to average. normal.

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(2) The normal range for a calcium serum level is 4.5–5.5 mEq/L (8.9–10.1 mgm/dl) Calcium is the major cation involved in the structure and function of bones and teeth. Approximately 99% of this mineral is concentrated in bones and teeth; most of the remaining 1 % is in the extracellular fluid (ECF). 31. The physician orders calcium chloride in 5% dextrose and 0.45% sodium chloride (D5/1/2NSS). Which effect might saline solution have on calcium chloride? 1. 2. 3. 4.

It might increase the effects of calcium. It has little or no effect on the calcium additive. Calcium additives should always be added to IV solutions containing sodium chloride. Sodium encourages calcium loss; calcium should not be mixed with a saline solution.

(4) Dilute prescribed IV calcium preparations in dextrose 5% in water (D5W). Calcium should never be diluted in solutions containing bicarbonate because precipitation occurs. Clients with hypocalcemia should not be given calcium diluted in 0.9% sodium chloride because the sodium chloride might increase renal calcium loss. 32. The best response by the nurse to an order (calcium IV) of IV saline is: 1. 2. 3. 4.

explaining to the client that he or s he should not accept this intravenous fluid. suggesting that the health care provider change the IV order to D5W and explain why. doing nothing because this solution does not have any effect on the calcium chloride additive. reporting the health care provider to the chiefs of nursing and medicine.

(2) Always use IV D5W with calcium preparation. Calcium should never be diluted in solutions containing bicarbonate because precipitation occurs. If calcium is diluted in a 0.9% sodium chloride solution, it might increase renal calcium loss. 33. Ringer’s lactate IV solution is: 1. 2. 3. 4.

a fluid replacement only. a fluid and electrolyte replacement. a dextrose replacement. a sodium replacement.

(2) Ringer’s lactate solution is a sterile solution fluid and electrolyte replenisher. It is prescribed for correction of extracellular volume and electrolyte depletion. 34. IV solutions are classified as: 1. 2. 3. 4.

colloids. crystalloids. lipids. blood products.

(2) Crystalloids include dextrose, saline, and Ringer’s lactate solutions. This group of solutions is used for replacement and maintenance fluid therapy. 35. D5 1/2NS is which type of IV fluid? 1. 2. 3. 4.

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isotonic hypotonic hypertonic iso/hypo-osmolar

Physiological Adaptation

(3) Hypertonic solutions have a greater concentration of solutes than plasma. Hypertonic solutions draw fluid from the intracellular and interstitial compartments into the vascular compartment. They expand circulating volume. Hypotonic solutions have less concentration of solutes. Isotonic solutions have the same concentration of solutes as blood plasma. 36. If D5W is used continuously over several days, the IV solution becomes: 1. 2. 3. 4.

hypotonic. hypertonic. isotonic. iso-hyperosmolar.

(1) Hypotonic solutions have less concentration of solutes than plasma. D5W is isotonic on administration, but after the dextrose is metabolized it provides free water, expanding intra- and extracellular volume. 37. A client is taken to the Emergency Department following a car accident. The client is hemorrhaging. Which of the following is a reason to use crystalloids instead of colloids when there is an acute blood loss? 1. 2. 3. 4.

Colloids help stop bleeding. Crystalloids lower blood pressure (BP) rapidly. Crystalloids raise BP. Colloids replace packed cells.

(3) Crystalloids do not interfere with type and cross-match of blood; they raise BP. However, BP remains elevated longer with colloids than with crystalloids. Colloids provide protein and fluid for the body, prevent shock and promote wound healing. Crystalloids can be helpful in maintaining renal function. Crystalloids can restore extracellular volume and balance sodium chloride. 38. A client is admitted with seizure activity. Her electrolyte values are as follows: Na 115 mEq/L, K 3.0 mEq/L, Ca 8.0 mg/dL and Mg 1.0 mEq/L. Which imbalances must be controlled to reduce the client’s seizure activity? 1. 2. 3. 4.

K and Ca Na and Ca Na and K Mg and K

(2) Hyponatremia, hypomagnesemia, and hypocalcemia all might result in neuromuscular irritability with seizure activity. Choices 1, 3, and 4 are not associated with seizure activity. 39. Mr. Henry is admitted with altered level of consciousness (LOC). Laboratory results show pH 7.28, PaCO2 20 mmHg, PaO2 65 mmHg, and HCO3 18mEq/L. Which of the following nursing diagnoses is most appropriate for this client? 1. 2. 3. 4.

Pain Fluid Volume Excess Ineffective Breathing Pattern Ineffective Thermoregulation

(3) This client is in partially compensated metabolic acidosis. A pH below 7.35 indicates acidosis. Alteration in PaCO2 points to the regulatory mechanism of acid-base balance; carbon dioxide is being “blown off” by the lungs to compensate and minimize the acidosis. Decreased HCO3 supports metabolic acidosis; decreased PaCO2 supports compensation. Kussmaul’s respirations are a classic response to metabolic acidosis. Choices 1, 2 and 4 are not expected with metabolic acidosis.

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40. Laboratory data on Mr. Johnson show serum Na 128 mEq/L and K 3.0 mEq/L. The nurse should expect to see a return to normal values based on which of the following? 1. 2. 3. 4.

The client exhibits decreased diuresis. The client’s urine output increases to normal level. The client exhibits resolution of diabetic ketoacidosis. The client exhibits decreased renal function and acidosis.

(3) Decreased Na and K levels can result from gastrointestinal (GI) fluid loss, as occurs with diarrhea and vomiting. This can lead to cardiac dysrhythmias. Choices 1 and 2 are incorrect because increased fluid output results in a serum Na level depletion. Choice 4 is incorrect because decreased renal function and acidosis result in an increased serum K level. 41. Which of the following homeostatic mechanisms helps regulate fluid, electrolyte, and acid-base balance? 1. 2. 3. 4.

the cardiovascular system the pituitary gland chemical buffers the renal system

(4) Homeostatic mechanisms common to fluid, electrolyte, and acid-base balance are the kidneys and lungs. Choices 1 and 2 are involved in fluid and electrolyte balance only. Choice 3 is specific to acid-base balance. 42. Mr. Jones has a history of chronic obstructive pulmonary disease (COPD); laboratory tests reveal the following arterial blood gas (ABG) values: PO2 55 mmHg and PCO2 60 mmHg. When attempting to improve Mr. Jones’s oxygenation, and therefore improve his blood gas values, the nurse should understand that this client’s primary stimulus for breathing is: 1. 2. 3. 4.

high PCO2. low PO2. normal pH. low PCO2.

(1) Chronically elevated PCO2 (above 50 mmHg) is associated with inadequate response of the respiratory center to plasma CO02. The major stimulus for breathing then becomes hypoxia. Choices 2, 3, and 4 are not primary stimuli for breathing in this client. 43. A successful resolution of a fluid volume deficit can be demonstrated by which of the following? 1. 2. 3. 4.

an absence of postural hypotension and tachycardia adherence to prescribed dietary sodium restrictions maintenance of weight loss maintenance of a serum sodium level above 145 mEq/L

(1) The client exhibits signs of adequate hydration such as stable BP and pulse. Choices 2 and 3 are incorrect because sodium restrictions and weight loss apply if the client exhibits fluid volume excess. Choice 4 is incorrect because a serum sodium level above 145 mEq/L indicates hypermatremia. 44. When planning care for a client with severe hypocalcemia, the nurse should consider: 1. 2. 3. 4.

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the effects of hypoirritability. the effects of hyperirritability. the effects of bedrest. the effects of certain medications.

Physiological Adaptation

(2) Severe hypocalcemia is characterized by hyperirritability, tremors, and cramps that can progress to tetany if severe. Choice 1 is incorrect because hypercalcemia might result in contrasting mental status changes, such as lethargy and coma. Prolonged bedrest is associated with calcium loss from bones in hypercalcemia. Antacid and cathartic use might potentiate hypermagnesemia. 45. Which of the following actions should the nurse expect to perform after a client has a bone marrow biopsy taken from the iliac crest? 1. 2. 3. 4.

Apply pressure to the site for one minute. Administer a narcotic analgesic. Apply an adhesive bandage to the site. Place the client in a recumbent position.

(4) The client should lie in bed in a recumbent position on a pressure dressing that is removed after about one hour. Hemorrhage is a risk following this procedure. Choice 1 is incorrect because pressure is applied to the site for several minutes prior to applying the pressure dressing. Choice 2 is incorrect because an analgesic is ordered and administered prior to the procedure. Nonpharmacologic pain relief measures might also be effective because the site might ache for a few days. 46. A client with anemia is to receive 1 unit of packed red blood cells. The nurse administers the unit over which period of time? 1. 2. 3. 4.

30 minutes–1 hour 2–3 hours 4–5 hours 1–2 hours

(2) The unit of packed cells should be infused over a period of 2–3 hours. If it is infused over a shorter period, there is a chance of circulatory overload. The blood should run at about 2 ml per minute during the first 15 minutes. The duration of administration of a unit of packed cells should not exceed 4 hours. 47. Miriam Roth, a client with acute myelogenous leukemia (AML or ANLL: nonlymphocytic leukemia), had an bone marrow transplant three days ago. To monitor Ms. Roth for development of a graft-versus-host (GVH) reaction, the nurse should watch for: 1. 2. 3. 4.

a temperature change greater than 101° F. development of a skin rash. bleeding from the gums. a change in lung sounds.

(2) A skin rash is often the first sign of a GVH reaction. Other common sites of symptoms are the skin, GI tract, and liver. Any client who has received a myelogenous bone marrow transplant is at risk for a GVH reaction in which the donor marrow attacks the cells of the recipient. Assessing vitals signs (including temperature and lung sounds) is an important part of caring for any client at risk. 48. The assessment data for a female client with anorexia nervosa include hemoglobin 6.0 g/dl, weight 70 lb, height 5’9”, dyspnea on ambulation, and pale skin and mucous membranes. Based on this information, which of the following nursing diagnoses should have the highest priority in the nurse’s care plan? 1. 2. 3. 4.

High Risk for Impaired Skin Integrity (related to decreased tissue perfusion) Knowledge Deficit (related to dietary iron deficiency) Activity Intolerance (related to dyspnea and weakness) Altered Nutrition, Less than Body Requirements (related to anorexia)

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(4) Altered Nutrition is the highest priority diagnosis. Anorexia nervosa is a severe eating disorder in which very limited amounts of food and nutrients are consumed and absorbed by the body. Anorexia nervosa is a self-destructive behavior. Among many other complications, anorexia results in anemia, indicated in the assessment data. Inadequate intake of iron, vitamin B12, and folic acid leads to anemia. Decreased hemoglobin levels lead to decreased oxygenation of the body tissues. If adequate nutrients are taken in and absorbed by the body through diet or supplementation, the anemia and its symptoms should resolve. 49. The nurse writes, “Knowledge deficit: prevention of sickle cell crisis” as the problem statement beginning the nursing care plan of an 18-year-old male client with sickle cell anemia. After a client has been taught to avoid situations that can precipitate a crisis, which of the following actions indicates a need for follow-up education? 1. 2. 3. 4.

applying for a driver’s permit planning a vacation at a beach resort staying up until 3:00 a.m. to study for a test applying antiseptic to a cut on his finger

(3) Clients should avoid factors that might trigger sickle cell crisis (including fatigue, excessive alcohol consumption, dehydration, extreme heat, high altitudes, and emotional stress) The client needs to identify and change lifestyle patterns that can precipitate crises in an attempt to maintain well-being. Sickle cell anemia is an incurable hereditary blood disease found primarily in black populations in which deformed sickle-shaped red blood cells (RBCs) cause a chronic form of anemia. Deformed RBCs block small blood vessels, reducing blood flow. 50. In a client suspected of having aplastic anemia, the nurse should plan to: 1. 2. 3. 4.

Take a thorough history of medication and chemical exposures. Assess for renal disease, and administer prescribed folic acid. Teach the client which foods have high iron content, and administer prescribed iron. Assess the client for signs of infection, and administer ordered prophylactic antibiotics.

(1) The underlying cause of aplastic anemia is unknown, but exposure to certain drugs, chemicals, radiation, and infections has been linked to the disorder. It is believed that these agents cause depressed bone marrow activity and lead to the replacement of marrow by fat cells. Aplastic anemia is defined as depressed bone marrow activity with low productions of erythrocytes, leukocytes, and platelets. If the client receives dialysis, folic acid should be given to replace what passes into the dialysate (this is ordered by the physician). The client with aplastic anemia is at risk for development of infection as a result of the development of granulocytopenia. Treatment includes bone marrow transplants, administration of immunosuppressant therapy with antithymocyte globulin (ATG), blood transfusions, antibiotics for the treatment of infections, and high dosages of corticosteroids. 51. Which of the following observations reported by a client with acute myelogenous leukemia (AML) should the nurse first assess? 1. 2. 3. 4.

weakness and fatigue bruising on the arm drainage from a small finger cut mild abdominal pain

(3) Because of the granulocytopenia associated with AML (or ANLL: nonlymphocytic leukemia), these clients are at high risk for development of infection. Infection is the major cause of death in clients with leukemia, and therefore any indications of infection are of concern. Signs of infection include purulent wound drainage, redness surrounding a wound and fever. Weakness and fatigue occur in clients with AML as a result of anemia. Bruising occurs in clients with AML as a result of thrombocytopenia.

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52. The nurse has reviewed a discharge teaching checklist with a 65-year-old male client who has chronic lymphocytic leukemia (CLL) Which of the following statements by the client indicates to the nurse that further review is necessary? 1. 2. 3. 4.

“I’m retired, so I can sleep whenever I want.” “I’ve got season tickets for all the basketball games.” “I’ll call the physician if I have a fever higher than 99° F.” “I’m going to teach my grandson how to fish.”

(2) Leukemia is any of several types of cancer in which there is a disorganized proliferation of white blood cells (WBCs) in the bone marrow. The symptoms of acute lymphatic leukemia (ALL) are fever, bleeding, enlarged lymph nodes, fatigue, and weakness. Treatment includes chemotherapy. Appropriate nursing interventions include encouraging the client to walk, maintain proper hydration (measure fluid intake and output), rest, and maintain close medical care; teaching; and emotional support. 53. A client with multiple myeloma is admitted to the hospital with a pathologic fracture of the tibia and is ordered to be on bed rest. Which of the following nursing actions is appropriate? 1. 2. 3. 4.

raising the head of the bed to a 10° angle turning the client on his or her side once per shift having the client fast before a scheduled X-ray recording fluid intake and output accurately

(4) Multiple myeloma is a malignant disorder in which immature plasma cells proliferate in bone marrow, forming single or multiple osteolytic tumors. The symptoms include vague pain in the pelvis, spine, and/or ribs (eventually becoming more severe and localized), pathological fractures (with decreased resistance to infection), anemia, and eventually renal problems. Clients with multiple myeloma must be well hydrated to prevent renal damage. Because clients with multiple myeloma are at risk for developing bacterial infections, especially pneumonia, preventive measures must be taken. Turning the client to prevent skin breakdown and improve lung expansion should be performed every 2–3 hours. 54. The nurse should give immediate consideration to which of the following assessment findings in a female client with auto-immune thrombocytopenic purpura? 1. 2. 3. 4.

petechiae on the chest cold, moist skin bruising on the arms heavy menstrual flow

(2) Cold, moist skin is one of the signs of shock. This finding indicates possible internal bleeding, which is a complication of auto-immune thrombocytopenic purpura. Choices 1, 3, and 4 are all symptoms of this disease. Antiplatelet antibodies are produced in the body; these attack the platelets, causing a decreased platelet count and increased risk of bleeding. This disease is a deficient number of platelets circulating in the blood; antibodies are directed to and coat the surface of the body’s own platelets, making them more susceptible to destruction by phagocytic leukocytes. 55. During the past 3 months, a 13-year-old boy with hemophilia A has suddenly had an increased number of admissions for bleeding episodes. In planning for his discharge, the nurse should: 1. 2. 3. 4.

Advise the client to stop going to school. Encourage him to depend on his parents to provide his care. Question him and his parents about possible exposure to trauma. Instruct his parents to give him aspirin for joint discomfort.

(3) The client and his parents should be questioned about the possible reasons for the increased number of bleeding episodes. They might need further education or counseling to prevent trauma exposure and reduce the number of bleeding episodes. Hemophilia is a hereditary clotting factor disorder characterized by prolonged coagulation time, which can

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result in persistent and severe bleeding. The nurse should suggest ways for the boy to perform the activities of daily living without incurring further joint damage. Non-aspirin based analgesics should be given to this boy for the discomfort. Clients with hemophilia should be encouraged to accept themselves and their disease. They should also be encouraged to be self-sufficient and to maintain their independence. 56. A client newly diagnosed with Hodgkin’s disease most often reports which of the following symptoms to the nurse when providing a history? 1. 2. 3. 4.

generalized pruritus petechiae across the back nausea and vomiting weight gain

(1) Generalized pruritus might be present in some clients. Painless enlargement of lymph nodes, especially the cervical, axillary, inguinal, mediastinal, and mesenteric. Hodgkin’s disease is a malignant disorder characterized by solid tumors of the lymphoreticular system. 57. The most common sign of thrombocytopenia is: 1. 2. 3. 4.

petechiae. hemostasis. melena. hemarthosis.

(1) Petechiae are characteristic of platelet defects because platelets are primarily responsible for clotting in small vessels. Thrombocytopenia causes bleeding into muscles and joints with even minor trauma (this refers to extravasation of blood into skin and mucous membranes). Platelet defects produce petechiae, bruising, and bleeding. As the condition worsens, other systems are affected. 58. Transfusion of which of the following blood components therapeutically provides all the coagulation factors? 1. 2. 3. 4.

cryoprecipitate random donor platelets fresh frozen plasma stored whole blood

(3) Fresh frozen plasma contains all the coagulation factors. Plasma, the liquid portion of whole blood, constitutes 55% of blood volume and contains large quantities of organic and inorganic substances. Platelets help to control bleeding and activate biochemical substances that will activate coagulation factors in plasma to form a stable fibrin clot. Coagulation of fibrin clot formation results from a complex series of reactions, where inert plasma proteins are activated or transformed into enzymes in a sequential manner, ending with thrombin-induced conversion of fibrinogen to fibrin (cascade theory). 59. Which of the following clinical symptoms suggests anemia secondary to vitamin deficiency? 1. 2. 3. 4.

smooth, sore tongue palpitations paresthesias dizziness

(3) Vitamin B12 is essential for nervous system function, and the neurologic manifestations of B12 deficiency are not seen in folic acid deficiency. Anemia is a clinical condition (not a laboratory result) and is defined as a decrease in hemoglobin content or red cell mass that impairs oxygen transport. Management is directed toward the cause of the

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anemia and replacing blood loss as needed to sustain adequate oxygenation. The nurse should educate clients as to nutrition and nutrition supplements (iron, vitamin B12, folic acid, and ascorbic acid), rest, exercise, adequate nutrition, and support. 60. A client has a diagnosis of Idiopathic Thrombocytopenic Purpura (ITP). A CBC from today shows WBC 5,000/mm3, Hgb 12.9 g/dl, and platelet count 7,000/mm3. Which of the following measures should be implemented in caring for this client? 1. 2. 3. 4.

coughing and deep breathing every 4 hours to prevent infection platelet transfusions to maintain platelet count above 20,000/mm3 aspirin as needed to control temperature or chills stool softeners as needed to prevent constipation

(4) This client is at risk of spontaneous bleeding. Preventing constipation decreases the risk of intracerebral bleeding, which is secondary to increased intracranial pressure with Valsalva maneuvers (always avoided because of increased risk of cerebral bleeding). Symptoms that should be treated are cough, constipation, chills, nausea, and vomiting. The nurse should educate the client to avoid alcohol, aspirin, and other substances that interfere with platelet function. The client should be encouraged to rest, provided with emotional support, taught about primary prevention (for example, accidents, falls), and provided with counseling if needed. 61. Which of the following conditions is most likely to be a contributing factor in the development of infection in a client with acute leukemia? 1. 2. 3. 4.

myelosuppressive effects of chemotherapy granulocytopenia immature WBCs neutrophilia

(4) Neutrophilia, an increase in circulating mature neutrophils, occurs in healthy persons as a compensatory response to the onset of bacterial infection. Neutrophils are phagocytic cells that arrive early at the site of inflammatory reaction but have a relatively short life span of only several days. Increased numbers (neutrophilia) occur with the onset of infection, especially with pyogenic bacteria that augment the body’s resistance. Infection might also produce a shift to the left (appearance of more immature forms of neutrophils in circulation, such as bands and metamyelocytes). Awareness of the classic signs of infection is important because they might not be apparent in a client with leukemia. The nurse should maintain a protective environment, maintain integrity of skin and mucous membranes, and teach the client the symptoms of infection and preventive techniques. 62. Ms. James, age 36, has been diagnosed with Iron Deficiency Anemia and started on a prescribed iron supplement, ferrous sulfate. Which of the following statements by Ms. James might lead the nurse to include the nursing diagnosis Knowledge Deficit on the client problem list? 1. 2. 3. 4.

“I take my iron supplements with food to enhance their absorption.” “I know that the gastrointestinal side effects I’m experiencing are common with ferrous sulfate.” “I eat organ meats weekly because they are a good dietary source of iron.” “I take vitamin C tablets to enhance iron absorption.”

(1) Adequate iron absorption requires an acid environment; therefore, supplements should be taken between meals. Foods high in protein and calories should be included in the diet (for example, fruits, vegetables, and organ meats). Vitamin C enhances iron absorption and is included in several iron preparations.

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63. A 26-year-old client is receiving one unit of packed RBCs. Her baseline vitals before transfusion were temperature 98° F, BP 136/72 mmHg, pulse rate 100 beats per minute, and respiratory rate 22 breaths per minute. A routine check of her vital signs 15 minutes into the transfusion reveals the following changes: temperature 101° F, BP 140/76 mmHg, pulse rate and respiratory rate 20 breaths per minute. Based on these findings, which of the following is the most appropriate initial nursing intervention? 1. 2. 3. 4.

Continue the transfusion and monitor every 15 minutes for development of further symptoms. Report to the RN immediately. Continue the infusion, and administer aspirin for fever. Slow the rate of transfusion, and continue monitoring.

(2) Temperature elevation might indicate a hemolytic transfusion reaction; therefore, the PN must report vital sign data to the RN who stops the transfusion and contacts the physician. Hemolytic transfusion reaction is a life-threatening complication caused by the transfusion of donor blood that is incompatible with the recipient’s blood. In hemolytic transfusion reaction, the severity of complications correlates with the amount of incompatible blood transfused. Chances of fatal reaction are decreased if less that 100 mL of incompatible blood is infused. 64. The Masons have an infant son who has been newly diagnosed with Hemophilia A. Which of the following parental actions indicates an ineffective adjustment to their son’s illness? 1. 2. 3. 4.

They request counseling regarding family planning. They request teaching on the procedure for IV administration of factor VIII. They verbalize feelings of guilt. They discourage their child’s participation in sports.

(4) Contact sports should be avoided, but noncontact sports (for example, swimming) are therapeutic activities that improve the general health of the child and contribute to independence and heightened self-esteem. Preventing the child from engaging in safe physical activity is an indication of overprotective behavior. Hemophilia A and B are caused by a defect in the clotting factor. Symptoms include petechiae, respiratory distress, hemoptysis, cyanosis, hypotension, tachypnea, chest pain, and pallor. The nurse should instruct the parents in preventive measures, tell them to monitor any blood loss, and tell them to seek medical help when needed. 65. A 40-year-old client has been diagnosed with Multiple Myeloma. Which of the following actions might indicate a knowledge deficit regarding the disease? 1. 2. 3. 4.

The client decreases ambulation with bone pain. The client increases fluid intake. The client avoids heavy lifting. The client monitors his or her serum calcium levels.

(1) Immobilization should be avoided because ambulation prevents further bone resorption and hypercalcemia. Analgesics must be administered per physician’s orders to relieve pain and help maintain mobility. Multiple myeloma is a neoplastic disease characterized by infiltration of the bone and bone marrow by myeloma cells forming multiple tumor masses that lead to pathologic fractures. Symptoms include anemia, renal lesions, and high globulin levels in the blood. The nurse should educate the client about protection from infection and injury; the client should also be taught about pain relief and hydration and provided with emotional support. 66. Laboratory findings for a 60-year-old client include WBC count 10,800/mm3, Hgb 11.2 g/dL, platelet count 100,000/uL, and differential showing neutrophils 4%, bands 0, lymphocytes 94%, monocytes 1%, and eonsinophils 1%. Based on these data, the priority nursing diagnosis for the client should be High Risk for: 1. 2. 3. 4.

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Fluid Volume Deficit (related to bleeding with thrombocytopenia). Infection (related to neutropenia). Injury (related to anemia). Injury (related to leukocytosis).

Physiological Adaptation

(2) Although the client’s total WBC count is 10,800, only 4% of these cells are neutrophils, placing the client at grave risk of infection (that is, absolute neutrophil count less than 500/mm3). 67. The nurse discovers a sputum sample at a client’s bedside. The sample is dated with today’s date, along with the client’s name and identification number, but there is no time marked on it. What should the nurse do in this situation? 1. 2. 3. 4.

Send the sample to the clinical laboratory immediately. Discard the sample, and collect another one as soon as possible. Send the sample to the clinical laboratory immediately, but call the laboratory to tell it that the collection time is unknown. Refrigerate the sample, and call the clinical laboratory to pick up the specimen as soon as possible.

(2) Prompt delivery and analysis of microbiologic specimens is essential. Because the collection time of the specimen is unknown, it must be discarded. Choices 1, 3, and 4 are inappropriate; another sample must be obtained. 68. Because of the impact of sexually transmitted disease (STD) transmission in clients, the nurse must proceed carefully when assessing for suspected STDs, covering all the following topics except: 1. 2. 3. 4.

previous history of STDs. names of sexual partners. presence of dysuria. sexual history.

(2) It is inappropriate to ask for names in the assessment phase. Should the client be found to have an STD, he or she should be instructed to notify his or her sex partners and encourage them to be assessed and treated, if necessary. Choices 1 and 4 describe important information used to assess the current and future risk of contracting STDs. Choice 3 is a common symptom of STDs. 69. When planning care for a client in a health care facility, the nurse must be aware that a nosocomial infection: 1. 2. 3. 4.

occurs only in immunocompromised hosts. occurs in at least 30% of clients in a given hospital. is usually present within a community but is not always clinically apparent. is acquired in a health care facility.

(4) Nosocomial infections are associated with health care, which means that exposure to the causative organism occurs while a person is hospitalized. Nosocomial infections are not present or incubating on admission to the health care facility. A hospital is one of the most likely places to acquire an infection. Microorganisms might be present in the hospital environment that are antibiotic resistant and more virulent than microorganisms normally found in the community. Health care–associated infections (HAIs) affect over 2 million clients each year in the United States, or approximately 6% of all people admitted to acute care facilities. Surgical clients have the highest incidence of infection. Nearly 70% of all nosocomial infections develop in postoperative clients. Factors that predispose individuals to acquiring a nosocomial infection include extremes of age, compromised body defenses, exposure to invasive procedures, and long-term hospitalization. The major sites affected by nosocomial infections are the urinary tract, surgical wounds, the respiratory system, and the bloodstream. 70. All the following interventions are recommended to prevent nosocomial wound infections except: 1. 2. 3. 4.

avoiding hair removal when possible. changing dressings on closed wounds only when they become wet or if signs of infection occur. using a clean, sharp-edged razor if hair removal is necessary. Maintaining asepsis during surgery by limiting personnel movement in and out of the operating room.

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(3) If hair removal is necessary, depilatories, or clippers are suggested. Choices 1, 2, and 4 are all appropriate interventions. 71. Mr. Gordon, age 80, has come to a health maintenance organization for an annual physical examination during a regional flu epidemic. The nurse’s evaluation that Mr. Gordon’s preventive health measures are appropriate should be based on which of the following behaviors? 1. 2. 3. 4.

He covers his nose and mouth with a handkerchief when he sneezes or coughs. He takes prophylactic antibiotics. He receives the flu vaccine each year. He asks to have a throat culture performed to detect infection.

(3) Mr. Gordon receiving the flu vaccine each year is a behavior that demonstrates appropriate preventive health measures. Since 1957, there have been at least 19 influenza epidemics in the United States in which more than 10,000 people have died. Influenza vaccine is prepared each year in an attempt to anticipate antigenic variation among influenza viruses. Two strains of influenza A and one strain of influenza B are selected based on circulating strains. These vaccines provide moderate antibody protection against influenza viruses with the same antigenic characteristics. Protective efficacy is estimated to be 65%–80% in young adults but only 30%–40% in elder adults, who account for 80%–90% of influenza deaths. The vaccine is estimated to have higher efficacy (50%–60%) in preventing hospitalization and pneumonia in elder adults. The vaccines do not protect against infection with antigenically dissimilar influenza strains. 72. While on a trip to a malarious tropical region, the nurse determines that her traveling companions are at risk for malaria because they: 1. 2. 3. 4.

take prophylactic chloroquine. wear long-sleeved shirts and pants. seem to nap often. take frequent evening walks.

(4) Because mosquitoes feed at night, being out after dusk increases the risk of acquiring the disease. Malaria is a parasitic disease; infections with the four human malarias can present sufficiently similar symptoms to make species differentiation generally impossible without laboratory studies. Furthermore, the fever pattern of the first few days of infection resembles that seen in early stages of many other illnesses (bacterial, viral, and parasitic). Malaria can present a quite varied clinical picture (including fever, chills, sweats, cough, diarrhea, respiratory distress, and headache) and might progress to iceterus, coagulation defects, shock, renal and liver failure, acute encephalopathy, pulmonary and cerebral edema, coma, and death. It is a possible cause of coma and other CNS symptoms, such as disorientation and delirium, in any nonimmune person recently returned from a tropical area. Prompt treatment is essential, even in mild cases, because irreversible complications can appear suddenly; case-fatality rates among untreated children and nonimmune adults can be 10%–40% or higher. Travelers to malarious areas need to realize that protection from biting mosquitoes continues to be of paramount importance. No antimalarial prophylactic regimen gives complete protection, but mefloquine or chloroquine might be effective, depending on the region. Prophylaxis with antimalarial drugs should not automatically be prescribed for all travelers to malarious areas. Standby or emergency self-treatment is recommended when a febrile illness occurs in a falciparum malaria area where professional medical care is not readily available. 73. Ms. Roberts, a 23-year-old single mother of two young children, comes sporadically to the infectious disease clinic for follow-up treatment of tuberculosis. The nurse knows that she is on antidepressive medication because last week at the clinic she dropped her pills and the nurse happened to pick them up. To ensure proper treatment and follow-up, all the following interventions are appropriate except: 1. 2. 3. 4.

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arranging to have Ms. Roberts meet with the social worker to discuss insurance benefits. scheduling Ms. Roberts’s appointments during her lunch break from work. telling Ms. Roberts that you understand how hard it is to comply with treatment when she is feeling blue. keeping crayons and paper in the waiting room so that her children can occupy themselves while they wait.

Physiological Adaptation

(3) If Ms. Roberts does not volunteer information about her depression, it is inappropriate to discuss it with her and is an invasion of her privacy. 74. In 1900, communicable diseases were the leading causes of death in the United States. By the year 2000, epidemics that once ravaged entire populations ended. Which of the following is not a reason for the decrease in communicable diseases in the past century? 1. 2. 3. 4.

improved nutrition vaccines improved access to health care antibiotics

(3) Access to health care is still a problem in the United States. Infectious diseases account for 25% of all physician visits annually. Although many of the previously deadly communicable diseases have been conquered, new ones have emerged to take their place. 75. Which of the following is not an outcome of infectious diseases? 1. 2. 3. 4.

increased mortality increased morbidity economic burden leading cause of death

(4) Today, infectious diseases are not the leading cause of death, even though some individuals die of these diseases. The cost of research and development of new, effective therapies is high. 76. The epidemiological triad is: 1. 2. 3. 4.

the interaction of an infectious agent, a host, and the environment. a natural history of disease model. a primary prevention model. primary, secondary, and tertiary prevention.

(1) The transmission of communicable diseases depends on the successful interaction of the infectious agent with the host and the environment. Changes in the characteristics of any of these three factors might result in disease transmission. There are four main categories of infectious agents that might cause infection or disease: bacteria, fungi, parasites, and viruses. Four factors influence the spread of disease: host resistance, immunity, herd immunity, and infectiousness. A human or animal can harbor an infectious agent. 77. The transference of antibodies from mother to infant is known as: 1. 2. 3. 4.

active immunity. passive immunity. natural immunity. horizontal transmission.

(2) Passive immunity is immunization by a transfer of a specific antibody from an immunized person to one who is not immunized. It is not permanent and does not last as long as active immunity. Choice 1 protects the body against a new infection, as the result of antibodies that develop naturally after an initial infection or artificially after a vaccination. Choice 3 is a usually innate and permanent form of immunity to a specific disease. Choice 4 is the spread of an infectious agent form one person or group to another, usually through contact with contaminated material, such as sputum or feces.

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78. The constant presence of a disease within a population is referred to as: 1. 2. 3. 4.

an epidemic. a pandemic. an endemic. herd immunity.

(3) Endemic disease is indigenous to a geographic area or population. Choice 1 affects a significantly large number of people at the same time and is a widespread disease that tends to occur periodically. Choice 2 occurs in a large region or when epidemics of the same disease occur concurrently in many different places in the world. Choice 4 is immune protection of part of a population that might reduce the spread of disease by limiting the number of potential hosts for the pathogen. 79. The term used to describe the occurrence of one case of smallpox in a population in which it was considered to be previously eliminated is: 1. 2. 3. 4.

endemic. epidemic. pandemic. infectivity.

(2) An epidemic affects many people at the same time. One case of smallpox is considered an epidemic because of the life-threatening nature of the disease in a population that has little immunity. 80. The role of the community health nurse in surveillance includes: 1. 2. 3. 4.

investigating sources and contacts in outbreaks of diseases. collecting and reporting data pertaining to notifiable diseases. providing morbidity and mortality statistics to those who request them. all of the above.

(4) Surveillance is a system of close observation of all aspects of the occurrence and distribution of a communicable disease through systematic collection, orderly consolidation and analysis, and prompt dissemination of all relevant data. 81. Requirements for disease reporting in the United States are mandated by: 1. 2. 3. 4.

the Centers for Disease Control and Prevention (CDC). federal laws. state laws and regulations. county health departments.

(3) Requirements for disease reporting in the United States are mandated by state, rather than federal laws and regulations. State health departments, on a voluntary basis, report cases of selected diseases to the CDC. There are 52 diseases presently included in the National Notifiable Diseases Surveillance System (NNDSS), in which data are collected and published weekly in the Morbidity and Mortality Weekly Report (MMWR). 82. Adoption of universal precautions by health care workers is an example of: 1. 2. 3. 4.

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primary prevention. secondary prevention. tertiary prevention. specific protection.

Physiological Adaptation

(1) Primary prevention seeks to prevent disease before it develops. Other methods include health promotion and education. Examples include immunization against communicable diseases, malaria chemoprophylaxis, the adoption of universal precautions by health care workers, the promotion of safer sex, and making water and the environment safe. 83. The nurse performs intradermal testing on clients to identify cases of tuberculosis. This is an example of: 1. 2. 3. 4.

primary prevention. secondary prevention. tertiary prevention. primary health care prevention.

(2) Secondary prevention targets the reduction of the incidence and morbidity of a disease through early diagnosis and treatment. Examples are skin testing for tuberculosis, serological screening for HIV and other STDs, contact investigation in tuberculosis-control programs, and partner notification in AIDS and STD programs. 84. Infection with the human papilloma virus (HPV) is associated with: 1. 2. 3. 4.

neurological damage. cervical cancer. blindness. stillbirths and miscarriages.

(2) HPV causes three types of cutaneous wart infections. A fourth type, genital warts, is a common viral STD that is strongly linked to cancer of the cervix. Direct sexual contact is the mode of transmission. 85. Appropriate measures to prevent STDs include all the following except: 1. 2. 3. 4.

prophylactic antibiotics. condom use. mutually monogamous relationships. sexual abstinence.

(1) Prophylactic antibiotics are not effective for prevention of STDs. Nearly all STDs are acquired through behaviors that can be avoided or changed. Intervention efforts by nurses have focused on disease prevention. 86. Which of the following statements about genital herpes is true? 1. 2. 3. 4.

The virus cannot be spread during the asymptomatic period. Herpes is easily cured with antibiotics. Neonatal infection might result in neurologic damage and death. The typical lesions are warts located in the genital areas.

(3) If genital herpes lesions present in the mother during the last 2–3 weeks of pregnancy, a caesarean section is preformed to prevent the infant from passing through the infected areas of the birth canal. Neonatal infection might result in neurologic damage and death. Symptoms of genital herpes include painful vesicles and ulcerations of the penis, vagina, labia, perineum, or anus. The lesions can last 5–6 weeks, and recurrence is common. There is no cure. 87. Which of the following statements about hepatitis B (HBV) is inaccurate? 1. 2. 3. 4.

Like HIV, HBV is spread through blood and body fluids. HBV is prevalent in immigrants, health care workers, and persons with multiple sex partners. HBV has lower infectivity than HIV. Strategies for prevention include immunization and prevention of exposure.

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(3) The groups with the highest prevalence of HBV are users of injection drugs, persons with STDs or multiple sex partners, immigrants, refugees and their descendants (who come from areas where there is high endemic presence of HBV), health care workers, hemodialysis clients, and inmates of long-term correctional institutions. HBV is spread through blood and body fluids, like HIV. 88. Which of the following statements about contact tracing is inaccurate? 1. 2. 3. 4.

Clients are required to notify their partners. The community health nurse contacts health providers to verify examination of exposed partners. Contact tracing is carried out by the health department in conjunction with reportable disease requirements. Confidentiality is maintained in identifying and notifying partners.

(1) Contact tracing or partner notification can be performed by the infected client or by the health professional. It is accomplished by identifying, contacting, and encouraging evaluation and treatment, if needed, of the client’s partners. 89. The highest priority for the nurse in caring for a client who has been injured in an accident and has just been brought into the Emergency Department (ED) is: 1. 2. 3. 4.

immediately assessing ABC. hunting for a room for the client. avoiding worsening any injuries that have been caused by the accident. immediately notifying the police department.

(1) The immediate assessment of ABC (airway, breathing, and circulation) is the highest priority in this situation. If the client is having difficulty with a clear airway or breathing problems, the breathing assessment should be first. 90. Which of the following is a likely major nursing diagnosis for a person in decompensated septic shock? 1. 2. 3. 4.

Ineffective Individual Coping Altered Patterns of Urinary Elimination Decreased Cardiac Output High Risk for Infection

(3) The decompensated phase of shock is characterized by the inability of the body’s compensatory mechanisms to maintain tissue perfusion. The septicemia might have begun as a urinary tract infection (UTI), but at the decompensated stage, the UTI is not a high-priority problem. Oliguria is the probable alteration in urinary elimination. Although the septic client is at risk for potential additional infections, the highest-priority problem is the sequelae from the existing infections. Choices 1, 2, and 4, although possibly pertinent, are not as high a priority as decreased cardiac output for this client. 91. A client with septicemia is at risk for coagulopathy. Thus, one goal of nursing intervention is to minimize the client’s blood loss. Specific indicators of successful attainment of this goal include all the following except: 1. 2. 3. 4.

The client displays blood pressure of 130/78 mmHG. The client exhibits a hematocrit level of 37. The client exhibits central venous pressure (CVP) of 8 cm H2O. The client demonstrates a heart rate of 135 beats per minute.

(4) Tachycardia is the first sign of hemorrhage. The heart rate increases in an attempt to maintain cardiac output. Septicemia is a systemic infection in which pathogens are present in the circulating bloodstream, having spread from the primary site of infection. It is diagnosed by blood culture and treated with antibiotics. Characteristics include chills, fever, prostration, pain, headache, nausea, or diarrhea. Choices 1, 2, and 3 represent normal values, indicating stable cardiovascular and hematologic status.

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Physiological Adaptation

92. Shock is most accurately defined as a/an: 1. 2. 3. 4.

decreased circulating blood volume. inability of the heart to pump blood. inadequate oxygen supply to vital organs. hemorrhage as a result of trauma.

(3) Shock is the inability of the body’s compensatory mechanisms to maintain tissue perfusion. 93. Cellular dysfunctions that occur during shock and can lead to pathophysiologic alterations include: 1. 2. 3. 4.

increased cellular permeability. aerobic metabolism of glucose. increased activity of the sodium-potassium pump. an alkalotic intracellular environment.

(1) In shock, the cells lack adequate blood supply and are deprived of oxygen and nutrients; therefore, they produce energy through anaerobic metabolism. This results in low energy fields and an acidotic intracellular environment. The cell membrane becomes more permeable. 94. Which of the following terms is used to describe the level of care requiring first-aid intervention for minor injuries or illnesses? 1. 2. 3. 4.

triage urgent emergent immediate

(2) Urgent care is appropriate for individuals who require first aid, but not immediate treatment. Fast track or urgent care centers are less expensive than hospital EDs. Urgent care sites require less equipment and health care staff. 95. When field triage has occurred and the client is admitted to the ED with a yellow tag, the tag indicates that the client requires which type of care? 1. 2. 3. 4.

emergent immediate urgent psychological support

(2) A yellow tag from field triage indicates that the client has a nonacute, non-life-threatening injury or illness requiring attention and management without significant delay. These victims can wait for transportation after they receive initial emergency treatment. They include victims with immobilized closed fractures, soft-tissue injuries without hemorrhage, and burns over less than 40% of the body. 96. When a client arrives at the ED and is unconscious, which of the following actions by the nurse is most important regarding obtaining consent to examine and treat? 1. 2. 3. 4.

asking the physician to sign the consent form contacting the nearest relative seeking a court order for treatment documenting the client’s critical status in his or her medical record

(4) Although the consent to examine and treat is required, if a client is unconscious and brought to the ED without family or friends, the information is documented and treatment is not delayed. Time-tracking of clients and recording of the status of the clients are essential areas for the nurse.

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97. When family members arrive at the ED and are informed that a family member has died, the nurse should respond with which of the following actions? 1. 2. 3. 4.

Offer to obtain a physician order for sedation. Volunteer details of the event leading to the death. Inform the family member that the client has passed on. Show acceptance of the deceased’s body by touching it when family members view the body.

(4) The nurse must have effective communication skills to help family members begin the grieving process. Remaining calm and supportive is very important. Contact with the family is very important. The family must be able to view the body if desired. When the nurse touches the body, it gives the family permission to touch the body also and might help the family to begin to integrate the loss. 98. The single most important factor in determining survival of cardiac arrest is: 1. 2. 3. 4.

nitroglycerin administration. training middle-aged and elder people in CPT. early CPR. early defibrillation.

(4) Early defibrillation is the single most important factor in determining survival of a cardiac arrest. If the time between the call for and the arrival of the defibrillator is longer than 8 minutes, survival is unlikely. 99. The nurse suspects that an elder client admitted to the ED with injuries at various stages of healing might be a victim of maltreatment. Which of the following questions is phrased appropriately? 1. 2. 3. 4.

“Who has been hitting you?” “Where did you get those bruises?” “Has anyone failed to help you when you needed help?” “Do you have a balance problem?”

(3) Questions must be open-ended, nonaccusatory, and nonconfrontational. The nurse should encourage the client to confide in the nurse and indicate that the nurse is in a position to protect the client’s safety. 100. An unconscious client is admitted to the ED with poisoning, and the nurse is assisting with gastric lavage. The nurse should: 1. 2. 3. 4.

Place the client in a left-lateral position with the head elevated 30°. Instill the antidote, and then aspirate gastric contents. Inform the conscious client that an endotracheal tube must be placed prior to lavage. Lubricate the tube with a water-soluble lubricant.

(4) The client’s head is lowered 15°, and gastric contents are aspirated and sent for analysis prior to instillation of any substance. The unconscious client undergoes endotracheal intubation, using a water-soluble lubricant to lubricate the tube. 101. Nitroglycerin is sometimes administered to a client with chest pain. Why? 1. 2. 3. 4.

Blood flow to the brain is increased. Nitroglycerin dilates the blood vessels and decreases the work of the heart. Blood vessels constrict, and blood pressure is raised. It is easy to administer to unconscious clients.

(2) Nitroglycerin is administered to a client with anginal chest pain because it dilates the blood vessels and decreases the work of the heart. A drop in blood pressure is an expected side effect of nitroglycerin. This medication is not administered to unconscious clients.

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Physiological Adaptation

102. All the following are likely causes of cardiovascular emergencies, directly or indirectly, except: 1. 2. 3. 4.

changes in the inner walls of arteries. problems with the heart’s electrical function. problems with the heart’s mechanical function. complications that result from cardiovascular surgery.

(4) The majority of cardiovascular emergencies are not the result of complications of cardiovascular surgery. Instead, they are a result of changes in the inner walls of arteries, or problems with the heart’s electrical and mechanical functions. 103. The primary cause of most cardiac-related medical emergencies is: 1. 2. 3. 4.

reduced blood flow to the myocardium. cardiac arrest. loss of consciousness. breathing difficulty.

(1) The reason for most cardiac-related medical emergencies is reduced blood flow to the myocardium that can cause breathing difficulty, loss of consciousness, and cardiac arrest. 104. The definition of angina pectoris is: 1. 2. 3. 4.

a small heart attack. a pain in the chest. paralyzed chest muscles. breathing difficulty.

(2) Angina pectoris means, literally, a pain in the chest. Angina is a paroxysmal thoracic pain caused most often by myocardial anoxia as a result of atherosclerosis of the coronary arteries. The pain usually radiates down the inner aspect or the left arm and is frequently accompanied by a feeling of suffocation and impending death. Attacks of angina pectoris are often related to exertion, emotional stress, and exposure to intense cold. The pain might be relieved by rest and vasodilatation of the coronary arteries by medication such as nitroglycerin. 105. The symptoms of cardiac compromise include all the following except: 1. 2. 3. 4.

difficulty breathing and abnormal pulse rate. sudden onset of sweating and nausea or vomiting. sharp lower-abdominal pain and a fever. pain in the chest or upper abdomen.

(3) Signs and symptoms of cardiac compromise do not include sharp pain in the lower abdomen combined with a fever. A cardiac arrest can manifest itself in the following ways: loss of consciousness, absence of palpable pulses and heart sounds, apnea or gasping respirations, and ashen-gray skin color. 106. R.L. has been taken to the ED. It is suspected he has taken an overdose of morphine. Which is the best medication to treat him? 1. 2. 3. 4.

Demerol Naprosyn Aspirin Narcan

(4) Narcan is a narcotic antagonist. The drug binds to specific receptor sites and causes the opposite effect of a narcotic. It reverses the associated respiratory depression, which can be life threatening.

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107. Which of the following interventions is indicated early in treatment of an overactive client who has been admitted to the ED after having a bad reaction to a hallucinogen? 1. 2. 3. 4.

applying restraints administering psychotropic medication seeking police protection informing the client that you are there to help

(4) Approaching the client with a calm, confident, and firm manner is therapeutic and can have (although not always) a calming effect. Restraints are used as a last resort. Police should be called if the client is potentially violent. 108. The nurse is caring for a seriously ill client in the ED. The nurse can help to alleviate the anxiety of the client’s family by: 1. 2. 3. 4.

offering reassurance that the client will survive. keeping the family members informed frequently. requesting that family members limit visitation to promote rest. informing the family that this type of condition has a high mortality rate.

(2) To alleviate the anxiety of the client’s family, the nurse should keep family members informed frequently and allow them to be with the client. 109. A client shows symptoms of diabetes mellitus when seen in the Emergency Department. How will this be diagnosed? 1. 2. 3. 4.

fasting plasma glucose greater than or equal to 126 mg/dL two-hour postload glucose greater than 126 mg/dL fasting plasma glucose greater than 200 mg/dL casual plasma glucose greater than 126 mg/dL

(1) Criteria for the diagnosis of Diabetes Mellitus include symptoms of diabetes plus glucose greater than or equal to 200 mg/dL, fasting glucose greater than or equal to 126 mg/dL, or 2-hour postload glucose greater than or equal to 200 mg/dL. 110. Which of the following types of insulin is the most rapid acting? 1. 2. 3. 4.

Humalog regular NPH Ultralente

(1) Humalog’s onset of action is 10–15 minutes, while regular insulin acts in 30 minutes–1 hour. NPH acts in 3–4 hours, and Ultralente acts in 6–8 hours. 111. Which of the following terms describes a decrease in organ or tissue size? 1. 2. 3. 4.

hypertrophy hyperplasia atrophy metaplasia

(3) Atrophy describes a decrease in organ or tissue size caused by death and resorption of cells, diminished proliferation of cells, pressure, ischemia, malnutrition, or decreased activity. The other terms describe different forms of cell adaptation.

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Physiological Adaptation

112. Which of the following terms describes an abnormal differentiation of dividing cells that results in changes in the shape of the cells? 1. 2. 3. 4.

atrophy dysplasia anaplasia metaplasia

(2) Dysplasia describes an abnormal differentiation of dividing cells that results in changes in the shape of the cells. The other terms describe different forms of cell adaptation. 113. Which term refers to the reversible transformation of one cell type into another? 1. 2. 3. 4.

metaplasia hypertrophy atrophy dysplasia

(1) Metaplasia refers to the reversible transformation of one cell type into another. The other terms describe different forms of cell adaptation. 114. Which term refers to an increase in cell size without cell division? 1. 2. 3. 4.

dysplasia hyperplasia hypertrophy metaplasia

(3) Hypertrophy refers to an increase in cell size without cell division. The other terms describe different forms of cell adaptation. 115. Which term describes an increase in the number of cells resulting from increased cellular division? 1. 2. 3. 4.

hypertrophy anaplasia dysplasia hyperplasia

(4) Hyperplasia describes an increase in the number of cells resulting from increased cellular division. The other terms describe different forms of cell adaptation. 116. Which term describes cell differentiation to a more immature form? 1. 2. 3. 4.

hyperplasia anaplasia metaplasia dysplasia

(2) Anaplasia describes cell differentiation to a more immature form. The other terms describe different forms of cell adaptation.

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117. Which term refers to cell death? 1. 2. 3. 4.

necrosis injury inflammation ischemia

(1) Necrosis refers to cell death. The other terms refer to different cell conditions. 118. When tissue injury occurs, which type of white blood cell is the first to arrive at the site of the injury? 1. 2. 3. 4.

basophils monocytes neutrophils lymphocytes

(3) Neutrophils are the first type of white blood cell to arrive at the site of injury. The other cell types arrive later. 119. Which direction describes an increase in the number of band neutrophils? 1. 2. 3. 4.

shift to the right shift to the left shift upward shift downward

(2) A shift to the left describes an increase in the number of band neutrophils. The other terms do not. 120. All the following symptoms indicate a local inflammatory response except: 1. 2. 3. 4.

pain. heat. cold. swelling.

(3) Pain, heat, and swelling all indicate a local inflammatory response. Cold does not. 121. Which type of inflammatory exudate is found in an abscess? 1. 2. 3. 4.

purulent hemorrhagic catarrhal fibrinous

(1) Purulent exudate is found in an abscess. The other exudates are found in different conditions. 122. A client with an upper-respiratory infection is most likely to have which type of exudate? 1. 2. 3. 4.

fibrinous hemorrhagic serous catarrhal

(4) Catarrhal exudates are most likely to be found in clients with upper-respiratory infections. The other exudates are found in different conditions.

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Physiological Adaptation

123. A client with a skin blister from a burn is most likely to have which type of exudate? 1. 2. 3. 4.

purulent serous hemorrhagic catarrhal

(2) A client with a skin blister from a burn is most likely to have serous exudate. The other exudates are found in different conditions. 124. Which of the following terms describes tissue healing that takes place when a wound is well approximated? 1. 2. 3. 4.

primary intention secondary intention tertiary intention quartic intention

(1) Primary intention describes tissue healing that takes place when a wound is well approximated. Secondary and tertiary intentions describe other types of healing, and quartic intention does not exist. 125. A client who has had a large, infected wound debrided and then packed has which type of wound healing? 1. 2. 3. 4.

primary intention secondary intention tertiary intention quartic intention

(2) Secondary intention occurs with wounds that do not have approximated edges. Primary and tertiary intentions describe other types of healing, and quartic intention does not exist. 126. A deficiency in which of the following vitamins is most likely to delay wound healing? 1. 2. 3. 4.

D C E K

(2) Vitamin C deficiency is most likely to delay wound healing because it aids in the formation of collagen fibers and capillary development. 127. Which term describes bands of scar tissue between organs? 1. 2. 3. 4.

contracture dehiscence adhesion keloid

(3) Adhesion describes bands of scar tissue between organs. The other terms describe different complications of wound healing.

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128. A client who has not moved his knee for six weeks due to injury is most likely to develop which type of woundhealing complication? 1. 2. 3. 4.

contracture dehiscence adhesion keloid

(1) A contracture is most likely to develop in a client who has not moved his knee for six weeks due to injury. The other terms describe different complications of wound healing. 129. A client who has had abdominal surgery coughs, causing the abdominal incision to tear open and intestines to protrude from the abdominal cavity. This client has experienced which type of wound-healing complication? 1. 2. 3. 4.

contracture dehiscence adhesion keloid

(2) Dehiscence describes the opening of a previously joined wound. The other terms describe different complications of wound healing. 130. What is the most important action a nurse can take to prevent the spread of methicillin-resistant staphylococcus aureus (MRSA)? 1. 2. 3. 4.

wearing a mask wearing gloves using isolation washing hands

(4) Hand washing is the most important action a nurse can take to prevent the spread of MRSA. The other actions can also be taken, but they are not as vital as hand washing. 131. Which cultural group is most prone to developing keloids? 1. 2. 3. 4.

Asian Hispanic African American Native American

(3) African Americans are most prone to developing keloids. The other groups are not. 132. A hospitalized Native-American client wishes to apply the herb goldenseal topically to an infected wound. Which is the most appropriate response by the nurse? 1. 2. 3. 4.

Tell the client that goldenseal makes an infection worse. Notify the physician of the request. Take the goldenseal to prevent the client from applying it. Let the client know that you think aloe works better.

(2) The physician should be notified. Goldenseal can be used topically when approved by the physician. Some NativeAmerican cultures use herbs to facilitate the healing process. The other responses are not appropriate.

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133. Which of the statements by a postoperative client with an abdominal wound indicates adequate understanding of wound healing? 1. 2. 3. 4.

“I need to decrease my protein intake.” “I need to limit my fluid intake.” “I need to eat more potato chips.” “I need to take a multivitamin.”

(4) There is an increased need for vitamins to promote wound healing. Protein and fluid intake need to be increased. Potato chips provide little nutritional value. 134. Which of the following responses by the nurse is most therapeutic when seeing a stage IV pressure sore on a client’s coccyx? 1. 2. 3. 4.

“I will do everything I can to help you heal this ulcer.” “You must have a poor caregiver to get this ulcer.” “This is the worst ulcer I have ever seen.” “Your doctor must not check you very often.”

(1) This statement provides hope and reassurance to the client. The other statements are completely unprofessional and are not appropriate. 135. Which of the following nursing entries in a client’s record is appropriate? 1. 2. 3. 4.

This is the largest ulcer I have ever seen in my life. Stage I decubitus on coccyx, 2 cm in diameter. Red spot on coccyx, approximately dime sized. Wound on coccyx, small and red.

(2) This entry is appropriate. Choices 3 and 4 are unprofessional. Choice 1 is completely inappropriate and should never be part of any documentation in a client record. 136. Which of the following statements by a client with a stage I pressure sore on the coccyx indicates adequate understanding of the nurse’s teaching? 1. 2. 3. 4.

“I need to lie on my back most of the time.” “I need to sit in a chair most of the day.” “I need to turn from side to side in bed.” “I need to keep the head of the bed elevated 90°.”

(3) The client needs to turn from side to side in bed to keep pressure off the affected area. Lying on the back, sitting in a chair or elevating the head of the bed 90° increases pressure on the area and worsens the pressure sore. 137. Which factor can make assessment for infection in an elder client difficult? 1. 2. 3. 4.

Elder clients might not complain of illness. Elder clients might not show any change in lab results. Elder clients might have an increased febrile response. Elder clients might have a blunted febrile response.

(4) Elder clients might have a blunted febrile response to infection, making assessment difficult. Choices 1, 2, and 3 might also be true in certain circumstances but are not primary factors.

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138. What is the name of the scale used to predict pressure sore risk? 1. 2. 3. 4.

Glascow Braden Karnofsky Borg

(2) The Braden scale is used to predict pressure sore risk. The other scales provide other measures. 139. A 90-year-old client in a nursing home has an open pressure sore on the right hip. It measures 2 cm in diameter and .25 cm in depth. Pink tissue is visible. At which stage should the nurse document this decubitus? 1. 2. 3. 4.

stage I stage II stage III stage IV

(2) This shallow wound is stage II. The other stages refer to lesser or greater wound depth. 140. Maternal transmission of which of the following immunoglobins protects newborns from infection in early life? 1. 2. 3. 4.

IgA IgE IgG IgM

(3) IgG protects infants from infection and is the only immunoglobin that crosses the placenta. The other immunoglobins control different responses. 141. Which of the following symptoms is indicative of anaphylactic shock after a client receives an injection of penicillin? 1. 2. 3. 4.

wheal-and-flare reaction difficulty breathing nasal discharge sneezing

(2) Difficulty breathing is indicative of anaphylactic shock. The other signs are atopic reactions. 142. Which of the following actions should a nurse take first when a client goes into anaphylactic shock? 1. 2. 3. 4.

List penicillin as an allergy on the client’s chart. Elevate the client’s legs. Open the client’s airway. Administer epinephrine.

(3) The client’s airway must be opened first. The other interventions can be carried out after the airway is patent. Choice 4 is the next step. Remember the acronym ABC: airway, breathing, circulation, in that order. 143. Which of the following is a risk factor for latex allergy? 1. 2. 3. 4.

allergy to tomatoes allergy to peanuts allergy to penicillin allergy to aspirin

(1) Allergies to certain foods, including tomatoes, are risk factors for latex allergy. The other options are not risk factors.

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144. The steps in the process of emesis (in order) are as follows: 1. 2. 3. 4.

forceful diaphragm and abdominal muscle contractions, airway closure, esophageal sphincter relaxation, and deep inspiration. deep inspiration, airway closure, forceful diaphragm and abdominal muscle contractions, and esophageal sphincter relaxation. airway closure, forceful diaphragm and abdominal muscle contractions, deep inspiration, and esophageal sphincter relaxation. esophageal sphincter relaxation, forceful diaphragm and abdominal muscle contractions, deep inspiration, and airway closure.

(2) Vomiting (or emesis) is ejection through the mouth of the gastric contents. (Intestinal contents are ejected only in cases of bowel obstruction.) The vomiting reflex is stimulated by the presence of ipecac or copper salts in the duodenum, severe pain, or distention of the stomach or duodenum. Torsion or trauma affecting the ovaries, testes, uterus, bladder, or kidneys also elicits vomiting. Vomiting occurs when the stomach is full of gastric contents and the diaphragm is forced high into the thoracic cavity by strong abdominal muscle contractions. The higher intrathoracic pressure forces the upper-esophageal sphincter to open, and chyme is discharged from the mouth. 145. Gastroesophageal reflux is: 1. 2. 3. 4.

caused by rapid gastric emptying. excessive lower-esophageal sphincter functioning. associated with abdominal surgery. caused by spontaneous relaxation of the lower-esophageal sphincter.

(4) Gastroesophageal reflux is defined as the reflux of gastric contents into the esophagus. 146. Intestinal obstruction causes: 1. 2. 3. 4.

decreased intraluminal tension. hyperkalemia. decreased nutrient absorption. both 1 and 2.

(3) Intestinal obstruction; Hernia, telescoping of one part of intestine into another, twisting, inflamed diverticular, tumor growth, loss of peristaltic activity; colicky pain to severe and constant pain, vomiting, diarrhea, constipation, dehydration and hypovolemia, and acidosis with their complications. 147. In malabsorption syndrome, flatulence and abdominal distension are likely caused by: 1. 2. 3. 4.

protein deficiency and electrolyte imbalance. undigested lactose fermentation by bacteria. fat irritating the bowel. impaired absorption of amino acids and accompanying edema.

(2) Malabsorption syndrome interferes with nutrient absorption in the small intestine. The intestinal mucosa fails to absorb or transport the digested nutrients to the blood. Malabsorption is the result of mucosal disruption caused by gastric or intestinal resection, vascular disorders, or intestinal disease. 148. The characteristic lesion of Crohn’s disease is: 1. 2. 3. 4.

Found in the ileum. Precancerous. Granulomatous. Both 1 and 3 are correct.

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(4) Crohn’s disease is an inflammatory disease of the intestine that most frequently affects young adults (particularly females). The intestinal walls become thick and rigid. As the walls thicken with the formation of fibrous tissue, the lumen is narrowed and a chronic obstruction can develop. The client frequently alternates between diarrhea and constipation. Melena, dark stool containing blood pigments, is common. 149. Adult onset obesity is usually: 1. 2. 3. 4.

both hyperplastic and hypertrophic. distributed over the entire body. hypotrophic. unrelated to the genotype.

(3) Overnutrition or excessive caloric intake leads to obesity (or excessive body fat). It is classified by cause as either exogenous, resulting from an excess of ingested calories or endogenous, resulting from inherent metabolic problems. Physiologically, obesity can be hyperplastic, caused by a greater-than-normal number of fat cells, or hypertrophic, caused by greater-than-normal size of fat cells. 150. In pancreatitis: 1. 2. 3. 4.

The tissue damage likely results from release of pancreatic enzymes. High cholesterol intake is causative. Diabetes is uncommon. Bacterial infection is the etiological cause.

(1) Pancreatitis, or inflammation of the pancreas, is a potentially serious disorder. It develops because of an injury or disruption of the pancreatic ducts or acini that permits leakage of pancreatic enzymes into pancreatic tissue. The leaked enzymes initiate auto digestion and acute pancreatitis. Bile reflux into the pancreas occurs if gallstones obstruct the common bile duct. The refluxed bile also injures pancreatic tissue. Toxic enzymes are also released into the bloodstream and cause injury to vessels and other organs, such as the lungs and kidneys. 151. Symptoms of cholelithiasis include all the following except: 1. 2. 3. 4.

nausea and vomiting. right upper-quadrant tenderness. decreased serum bilirubin levels. abdominal distress.

(4) Cholelithiasis is gallstone formation. Obstruction is caused by gallstones, which aggrevates of substances in the bile. The gallstones might remain in the gallbladder or enter the cystic duct. They then obstruct the flow of bile into and out of the gallbladder. Supersaturation sets the stage for cholesterol crystal formation and aggregation into macrostones. The main symptom is pain. 152. Short-term starvation causes: 1. 2. 3. 4.

glycogenolysis. gluconeogenesis. proteolysis. both 1 and 2.

(4) Short-term starvation is several days of total dietary abstinence or deprivation. Glucose is the preferred energy for cells. After all available energy has been absorbed from the intestine, glycogen in the liver is converted to glucose through glycogenolysis, or the splitting of glycogen into glucose. This process peaks within 4–8 hours after glycogenolysis, and gluconeogenesis in the liver begins with the formation of glucose from noncarbohydrate molecules. Both processes deplete stored nutrients and, thus, cannot meet the body’s energy needs indefinitely. Proteins continue to be catabolized in gluconeogenesis to a minimal degree to provide carbon for the synthesis of glucose. Adequate ingestion

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of appropriate nutrients is the obvious treatment for starvation. Starvation caused by chronic disease, long-term illness, or malabsorption is treated by enteral or parenteral nutrition. 153. Which type of jaundice is due to increased destruction of erythocytes? 1. 2. 3. 4.

obstructive hemolytic hepatocellular both 2 and 3

(2) Jaundice is a yellow discoloration of the skin, mucous membranes, and sclera of the eyes, caused by greater than normal bilirubin in the blood. Symptoms include nausea/vomiting, abdominal pain, dark urine, liver diseases, biliary obstruction, hemolytic anemias, and hemolytic jaundice. The red blood cells hemolyze, and an excess of bilirubin results from the breakdown of released hemoglobin. 154. When assessing a client admitted with a bleeding gastric ulcer, the nurse should expect to find which of the following stool characteristics? 1. 2. 3. 4.

coffee-ground color and consistency clay color black color, tarry consistency bright red color

(3) Melena, or black, tarry stool, is a sign of bleeding high in the GI tract. The action of the digestive enzymes turns bright red blood black and tarry before defecation occurs. The ulceration is thought to be caused by hydrochloric acid and pepsin secretions of the stomach and by intestinal secretions, including bile, that is regurgitated through the pyloric sphincter. The gastric mucosa becomes irritated by this bile-containing secretion, and a lesion develops. Symptoms include nausea, vomiting, and abdominal pain. 155. Irritable bowel syndrome can best be described as: 1. 2. 3. 4.

an inflammatory process. the result of long-standing GI disease. a functional disorder. an inherited trait.

(3) Many of the symptoms described for diseases of the lower intestinal tract are characteristic of a spastic colon or irritable bowel. The symptoms include diarrhea, constipation, abdominal pain, and gas. The difference between a spastic colon and an irritable colon is that the spastic colon has no lesion; there is no tumor or ulceration. Irritable bowel syndrome is a functional disorder of the movement of the colon (motility). The pain is probably caused by muscle spasms in the wall of the intestine. Emotional stress and upset are disruptive in this disease. 156. Which of the following nursing actions demonstrates the nurse’s understanding of one of the primary complications of peritonitis? 1. 2. 3. 4.

providing small, frequent meals frequently assessing respiratory status assessing skin integrity regularly evaluating stools for color and consistency

(2) The infectious process can progress to respiratory complications (in general). Inflammation of the lining of the abdominal cavity usually results when the digestive contents enter the cavity, as this material contains numerous bacteria. The fibrous tissue of adhesions can serve to localize the inflammation. Peritonitis complications can occur after perforation of intestinal diverticule peptic ulcers, gangrenous, gallbladders, others. The bacteria most frequently identified as the causative agent in peritonitis is Escherichia coli. The client who is acutely ill with peritonitis is usually very apprehensive and needs constant care.

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157. A client has just been diagnosed with closed-angle (narrow-angle or acute angle-closure) glaucoma. The nurse should assess the client for which of the following most-common presenting symptoms of this disorder? 1. 2. 3. 4.

halo vision dull eye pain severe eye and face pain impaired night vision

(3) Narrow-angle glaucoma develops abruptly and manifests with acute face and eye pain and is a medical emergency. Halo vision, dull eye pain, and impaired night vision are symptoms commonly associated with open-angle glaucoma, which is caused by the alteration in the circulation and reabsorption of aqueous humor. This might occur because of an abnormality of the trabecular meshwork (network) that impairs flow of aqueous humor into the canal of Schlemm. The result causes increased pressure in the posterior chamber. 158. The nurse notes a cloudy appearance to the lens of an 80-year-old client’s eye. Which of the following additional assessment findings helps confirm the diagnosis of Cataracts? 1. 2. 3. 4.

the sense of a curtain falling over the visual field persistent, dull eye pain loss of red reflex double vision

(3) A cloudy-appearing lens is symptomatic of cataract development (a progressive clouding or opacity of the lens of the eye that interferes with the transmission of light to the retina, leading to painless loss of vision). As the cataract matures, the red reflex is lost. The sense that a curtain is falling over the visual field is associated with a detached retina. Eye pain and double vision are not associated with cataracts. Cellular debris from the deteriorating lens escapes through the degenerating lens capsule into the aqueous humor and can contribute to obstruction or overflow of aqueous humor, resulting in increased interocular pressure. 159. The priority nursing measure for the client with a penetrating eye injury from a visible foreign body is to: 1. 2. 3. 4.

Patch both eyes. Immobilize the foreign body, and cover the eye. Irrigate the eye with copious amounts of water. Administer carbonic anhydrase inhibitors as prescribed.

(2) The foreign body should not be removed or manipulated. It should be immobilized if possible, and the eye should be covered to protect it from further injury. A paper cup can be used in place of an eye patch. Patching both eyes is an appropriate intervention to prevent ocular movement but should follow immobilization of the foreign body. Irrigation with water is an intervention for chemical burns to the eyes. Carbonic anhydrase inhibitors are used to decrease intraocular pressure following blunt trauma. 160. A client is diagnosed with conductive hearing loss and asks how this occurred. The nurse should respond by stating that conductive hearing loss: 1. 2. 3. 4.

has an unknown etiology. occurs as a result of damage to the hair cells of the organ of Corti in the inner ear. usually results from chronic exposure to loud sounds. occurs as a result of damage to the ear structure.

(4) Conductive hearing loss results from changes that occur in the external or middle ear. Hearing aids, assistive listening devices (also known as pocket talkers), and reconstructive surgeries can improve or correct hearing loss. Exposure to high levels of noise on an intermittent or constant basis damages the hair cells of the organ of Corti, resulting in sensorineural hearing loss.

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161. The nurse developing a teaching plan for a client with atrophic macular degeneration should include which of the following pieces of information? 1. 2. 3. 4.

surgical treatment options the availability of aids to enhance vision and promote safety the risks associated with the loss of peripheral vision a description of antibiotic therapy

(2) Atrophic macular degeneration causes loss of central vision. Magnification devices and enhanced lighting help to promote safety. Peripheral vision remains intact. Although laser photocoagulation is effective for exudation macular degeneration, there is no treatment for the atrophic form. Because macular degeneration is not an infectious process, antibiotic therapy is not indicated. 162. A client with Meniére’s disease is likely to complain of which of the following? 1. 2. 3. 4.

bilateral hearing impairment vertigo and nausea pain when the tragus is touched tenderness over the mastoid area

(2) Meniére’s disease is associated with vertigo that can last for hours, as well as fluctuating hearing loss, nausea, and vomiting. The disorder is unilateral, but because hearing is bilateral, the client often does not realize the extent of the hearing loss. Disorder of the inner ear is characterized by a triad of symptoms, including vertigo, tinnitus, and sensorineural hearing loss (known as endololymphatic hydrops). 163. Which of the following clients is at highest risk for laryngeal cancer? A client who: 1. 2. 3. 4.

has an injury to the larynx. is 85-years old. has chewed tobacco for 20 years. suffers from chronic sinusitis.

(3) The two major risk factors for laryngeal cancer are use of any form of tobacco and the use of alcohol. Although the majority of cases occur in men between the ages of 50 and 75, advancing age does not significantly increase risk. Injury to the larynx and chronic sinusitis are not risk factors. 164. Ovulation occurs at the midpoint of the menstrual cycle as a direct result of secretion of which hormone? 1. 2. 3. 4.

estrogen progesterone GnRH (gonadotropin-releasing hormone) LH (luteninizing hormone)

(4) LH surges at midcycle, after estrogen levels have peaked and stimulated a buildup of the endometrium. Choice 1 is incorrect because during the menstrual phase, comprising the first five days of the cycle, low estrogen and progesterone levels stimulate hypothalamic GnRH and primary FSH (follicle-stimulating hormone) and LH secretion. Choice 2 is incorrect because estrogen and progesterone secretion causes endometrial buildup during the proliferation phase. Ovulation occurs at midcycle due to an LH surge. Choice 3 is incorrect because, during the luteal phase, the corpus luteum secretes estrogen and progesterone to maintain the endometrium. When conception does not occur, the corpus luteum degenerates, hormone levels decrease, and the cycle begins again.

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165. A client who has been on Antabuse (disulfiram) therapy for three months has been off the therapy for two days. He decides to go out with friends to have a beer. Which effect might this client experience? 1. 2. 3. 4.

no ill effects diarrhea vomiting euphoria

(3) Antabuse produces severe hypersensitivity to alcohol and inhibits liver enzymes that participate in the normal degradation of alcohol. This results in accumulation of acetaldehyde in the blood. This medication should be given only to cooperating clients who are fully aware of the consequences of alcohol ingestion. In the presence of alcohol, the symptoms that might be manifested are flushing, chest pain, palpitations, syncope, tachycardia, nausea, severe vomiting, thirst, and dyspnea. 166. Which of the following statements is true about chronic lead poisoning? 1. 2. 3. 4.

A child suffering from acute lead intoxication presents a medical emergency. It is hard to detect because lead is normally present in the blood. It is a silent disease because there are no warning signs or chronic symptoms. None of the preceding statements are true.

(1) Lead poisoning is a toxic condition caused by ingestion or inhalation of lead or lead compounds. The acute form of intoxication is characterized by a burning sensation in the mouth and esophagus, colic, constipation or diarrhea, mental disturbances, and paralysis of the extremities, followed in severe cases by convulsions and vascular collapse. If ingested, treatment commences with gastric lavage with magnesium or sodium sulfate fluid therapy followed by chelation with IM injection of calcium disodium edentate (or, for severe cases, British antilewisite). Encephalopathy must be anticipated in children with lead poisoning. 167. The diagnostic investigation of a congenital heart defect might include: 1. 2. 3. 4.

physical examination and client history. chest X-ray and blood tests. heart catheterization and electrocardiogram. all of the above.

(4) A congenital heart defect can be defined as a structural or functional abnormality or defect of the heart or great vessels existing from birth. General physical symptoms of these patho-physiologic alterations are growth retardation, decreased activity, recurrent respiratory infections, dysprea, tachycardia, cyanosis, and murmurs. It is diagnosed with physical exam and history, chest X-ray, and laboratory tests, such as echocardiogram, heart catheterization, and electrocardiogram. 168. What is the most definitive diagnostic test for tuberculosis (TB)? 1. 2. 3. 4.

hemoglobin electrophoresis chest radiography cardiac catheterization blood test

(2) Chest radiography is the definitive diagnostic evaluation for TB. Other tests include a PPD skin test, sputum, and other body fluid cultures revealing mycobacterium TB. TB is contracted from another person with the disease by inhalation of droplets from coughing, sneezing, or spitting.

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169. A causal relationship has been established between cancer of the lungs and which of the following? 1. 2. 3. 4.

airway atrisia hepatitis A cigarette smoking congenital defects

(3) Cancer is a malignant neoplasm marked by uncontrolled growth and spread of abnormal cells. Relationships have been established between lung cancer and cigarette smoking, air pollution, arsenic, asbestos, and radioactive dust. Diagnostic tests include computerized tomography (CT) and positron emission tomography (PET) scans, chest ultrasound, chest radiography, bronchoscopy, and tissue biopsy. 170. A nurse, teaching a client about medical treatment for lung cancer, should include information about which of the following? 1. 2. 3. 4.

surgery, bed rest, analgesics analgesics, lung gavages, nutrition surgery, radiation, chemotherapy chemotherapy, oxygen, exercise

(3) Medical treatment for lung cancer can include one or all the following: surgical removal of the tumor, radiation therapy, and chemotherapy. 171. The nurse’s responsibility in caring for a client receiving Radiation therapy is: 1. 2. 3. 4.

providing a special low-calorie diet. helping the client’s morale with cosmetics. providing a special outing during treatment. helping the client deal with fears and emotions.

(4) Radiation therapy as a procedure is painless; no cosmetics or underarm deodorants are permitted. Clients are taught to avoid exposure to respiratory irritants and avoid exposure to crowds. 172. Radiation therapy is instituted for treatment mainly to: 1. 2. 3. 4.

control the disease completely. control or arrest the disease. control the movements of the client. provide palliation.

(2) In many cases, radiation therapy can reduce the size and vascularity of tumors and/or control their growth for varying periods of time. 173. John, a 10-year-old boy, is scheduled for a bone biopsy and a bone scan. He asks the nurse, “Why do I need these tests?” The best response is: 1. 2. 3. 4.

“The tests help the physician determine the prognosis for your illness.” “Have your parents talked with you about your illness?” “Your blood tests indicated a need for these tests.” “What has your physician told you about the tests to be done?”

(4) The principles of therapeutic communication are best observed by ascertaining the client’s understanding of his condition before appropriate responses to his questions are given. The nurse needs to determine what the client understands about his illness before giving information. Answers should be truthful.

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174. A client is having diagnostic testing for possible bone cancer. Which lab results are most indicative of bone cancer? 1. 2. 3. 4.

elevated alkaline phosphatase and lactate dehydrogenase levels decreased serum calcium and phosphorus levels elevated potassium level and erythrocyte sedimentation rate (ESR) decreased hemoglobin and lymphocyte levels

(1) Alkaline phosphatase is an enzyme that originates in the bone. It is used as a tumor marker and an index of bone disease. Lactate dehydrogenase level also increases in bone cancer. 175. A 68-year-old client is scheduled for a cardiac catheterization. Which nursing intervention is essential as the client recovers from the diagnostic procedure? 1. 2. 3. 4.

encouraging frequent ambulation to prevent deep vein thrombosis limiting fluid intake to prevent fluid overload evaluating cardiac status via continuous ECG monitoring assessing the arterial puncture site when taking vital signs

(4) Following a cardiac catheterization in which an arterial site is used for access, the puncture site should be assessed at least as often as vital signs are monitored. The client is at risk for the development of bleeding, hematomas, and arterial insufficiency of the affected extremity. 176. A client is scheduled to have a barium enema in three days. Which meal choice indicates that the client understands the dietary instructions to be followed in preparation for the exam? 1. 2. 3. 4.

baked chicken, baked potato, applesauce, and skim milk tuna salad sandwich, apple, carrot sticks, and skim milk prime rib, leafy green salad, rice, and decaffeinated coffee oatmeal with fresh strawberries, wheat toast, and tea

(1) The client should follow a low-residue diet for the three days prior to a barium enema. Acceptable foods include milk (two glasses); juice; tea; coffee; eggs; cheese; broth; cream soups; cooked, strained vegetables and fruits; refined breads; cooked cereals; strained oatmeal; potatoes; pasta; rice; and roasted, baked, or broiled meats (except pork). Forbidden foods include raw vegetables and fruits, whole-grain cereals and breads, waffles, and pancakes. 177. A client is scheduled to undergo extracorporeal shock wave lithotripsy (ESWL) to crush renal calculi tomorrow morning and asks the nurse what the procedure involves. The nurse should explain that: 1. 2. 3. 4.

A special scope is passed through the urethra, into the bladder and up the ureters, where the stone can be captured and removed. Ultrasound waves are generated in water and are directed at the kidney at a frequency high enough to shatter the stone. A laser probe is inserted into the renal pelvis via a nephrostomy tube. The stone is visualized and dissolved with a single laser beam. A probe is inserted into the renal pelvis via cystoscopy, and sound waves are directed at the stone to shatter it.

(2) ESWL uses ultrasound to shatter the renal calculi. The client is placed in a tub of water, and a sensor directed at the kidney generates sound waves that cause the stone to vibrate and break apart.

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178. A 42-year-old male client is admitted with a diagnosis of Dehydration Secondary to Acquired ImmuneDeficiency Syndrome (AIDS). The client states that he has difficulty eating and swallowing just about anything. Assessment reveals a 10-pound weight loss over a 3-week period. What could be the most likely etiology for the client’s chief complaint? 1. 2. 3. 4.

The client has been unable to go food shopping. The client’s medication profile is causing him to develop anorexia. The client could be developing an opportunistic infection. The client has not been compliant with the medication regimen.

(3) A client complaining of difficulty eating and swallowing just about anything might have an opportunistic fungal infection of the mouth and/or esophagus. A clinical diagnosis of AIDS suggests that the client is at high risk for developing an opportunistic infection. AIDS symptoms include weight loss, diarrhea, enlarged lymph nodes, decline in body mass with vitamin and mineral deficiency, and severe infections. Treatment includes adequate hydration and nutrition as well as a medication regimen. 179. Which of the following statements about cachexia is true? 1. 2. 3. 4.

It is no different from simple starvation because the metabolic rate declines in response to tumor growth. Cancer cachexia occurs as a result of chemotherapy but not radiation therapy. Cancer cachexia occurs as a result of tumor-induced changes. Cancer cachexia is only seen in clients who have limited caloric intake.

(3) Cancer cachexia is a syndrome that occurs in clients with cancer (malignancy) that leads to a loss of muscle, fat, and body weight. It is thought to occur due to tumor-induced changes that cause profound effects on metabolism, nutrient losses, and anorexia. A cycle of wasting is established because alterations in nutrient requirements and intake lead to high cell turnover in body organs, affecting the GI tract and bone marrow. Alterations in digestion occur along with decreased immune response. In simple starvation the body adapts to a lower metabolic rate. The metabolic rate can be normal, decreased, or increased. Cachexia (general ill health and malnutrition, marked by weakness and emaciation) occurs in the presence of both chemotherapy and radiation. Cancer cachexia can be seen in clients who have adequate caloric intake because it is not calorie dependent. It is usually associated with serious diseases such as cancer. 180. A 52-year-old male client being treated for cancer doesn’t understand why he is being given a female hormone, megesterol acetate (Megace), as part of the treatment regimen. He is afraid that it will alter his appearance. How should the nurse respond to the client’s concern of altered body image? 1. 2. 3. 4.

Tell the client that the physical changes are only temporary. Tell the client that this medication is used for its ability to stimulate appetite. Tell the client that you understand his concern and that he should not take it. Tell the client that the medication is used for a short time and any effects are self-limiting.

(2) Megesterol acetate (Megace) is oral progesterone that is used for both male and female clients to boost appetite and promote weight gain. It is important that all clients receive accurate information about prescribed medications and are aware of the indication for the drug, potential side effects, and expected response to treatment. The nurse should respond to the client’s concern initially with factual information because the client does not seem to understand the effect of the medication. Megace has an antieoplastic activity due to suppression of gonadotropine (antiluteinizing effect). The appetite-enhancing properties (mechanism unknown) provide palliative treatment of advanced endometrial or breast cancer (not used in place of chemotherapy, radiation, or surgery). It is also used for the treatment of anorexia, cachexia, or an unexplained, significant weight loss in clients with a diagnosis of AIDS.

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181. Which intervention is appropriate for a client admitted to an oncology unit for chemotherapy and radiation therapy who is experiencing dysgeusia? 1. 2. 3. 4.

Premedicate the client with an antiemetic. Observe the client for signs of dehydration. Use highly seasoned foods to stimulate taste buds. Obtain an order for zinc, and give it with food or milk to treat symptoms.

(4) Elemental zinc, taken with food or milk, helps correct alterations in taste (dysgeuisa). Dygeusia is an impairment or perversion of the gustatory sense so that normal tastes are interpreted. The taste can be unpleasant or completely different from the usual characteristic taste of a particular food or chemical compound. It can also be associated with nutritional problems. Clients receiving radiation therapy are at risk to develop muscositis of the oral cavity, xerostomia, nausea, vomiting, diarrhea, dental caries, esophagitis, dysphagia, and anorexia. Clients receiving chemotherapy are at risk to develop anorexia, nausea, vomiting, altered elimination patterns (diarrhea or constipation), mucositis, and altered liver function (jaundice) as a consequence of impaired drug clearance. Associated weight loss and accompanying malnutrition correlate with impaired immunity and affect response to therapy and survival. 182. What is the primary effect of radiation therapy for the head or neck on nutritional status? 1. 2. 3. 4.

none if given with an antiemetic weight gain increased appetite irritation and/or destruction of the upper GI region

(4) Effects of radiation therapy for the head or neck on the nutritional status of the client are irritation of the mouth, tongue and esophagus; dry mouth; tooth decay; gum destruction; altered taste and smell; and dysphagia. 183. A client receiving radiation therapy for a malignant tumor asks the nurse, “How is the radiation treatment performed?” Which is the most appropriate response by the nurse? 1. 2. 3. 4.

The agents act on inhibiting DNA synthesis. The therapy can be performed with either an internal or an external beam. The agents used kill all the cancer cells. The therapy of the beam of radiation is for the total body.

(2) Clients can receive external-beam radiation therapy (EBRT) or internal radiation therapy (brachytherapy) with implanted isotopes. Radiation damages rapidly replicating local normal host cells along with cancerous cells. It is used to treat tumors that cannot be surgically removed and are sensitive to radiation exposure. 184. A 67-year-old man is admitted to the hospital with a tentative diagnosis of Bronchogenic Carcinoma. His chief complaint is dyspnea and a chronic cough. The physician orders a sputum sample for cytologic testing. Important nursing implications involved with obtaining a sputum sample for cytology should include which of the following? 1. 2. 3. 4.

Obtain the specimen in the evening hours. Collect the specimen in the morning before the client eats and drinks. Have the client brush his teeth before collection of the specimen. Keep the client NPO for 24 hours before collection of the specimen.

(2) Sputum samples should be collected early in the morning before the client eats or drinks. The client is not required to be NPO for 24 hours before the procedure. The client needs to be well hydrated to facilitate coughing up tenacious secretions. Using toothpaste or mouthwash should be avoided because they can affect the sample. The sample should be coughed up from deep within the lungs. Saliva should not be collected.

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185. Which statement is incorrect regarding lung cancer? 1. 2. 3. 4.

The five-year survival rate depends on tumor histology and disease stage at the time treatment is initiated. Small-cell lung cancer has an excellent prognosis. The five-year survival rate for lung cancer is less than 15%. Lung cancer is usually widespread by the time it is detected on chest X-ray.

(2) Small-cell lung cancer has a poor prognosis because it is rarely diagnosed in a limited and localized state. Even with treatment, the client has only a 20% chance for two-year survival. At advanced stages most clients die within six months. The five-year survival rate depends on the type of lung cancer (non-small-cell cancer has a somewhat better five-year survival rate) and stage (cancer is easier to treat in an earlier stage when the cancer is localized). Usually by the time a lung tumor is detected on X-ray, about 75% of the disease course has elapsed. Eighty-seven percent of lung cancer clients die within five years. 186. A client is scheduled for external radiation treatment for laryngeal cancer. Of the following, which is not a common systemic side effect of this treatment? 1. 2. 3. 4.

nausea fatigue malaise dry desquamation of the skin

(4) External radiation therapy side effects are nausea, fatigue, malaise, skin irritation, wet desquamation, and diarrhea. 187. When teaching the client about upcoming external radiation treatments, the nurse should stress the importance of: 1. 2. 3. 4.

massaging the area daily. exposing the area to sunlight for 30 minutes each day. not using soap on the treatment area and ink markings. applying cosmetic creams to conceal reddened areas.

(3) Skin markings over the treatment area should not be washed off for the duration of the therapy because they are important reference marks for the radiation beams. The area should be left open to the air, but sunlight should be avoided. The skin should not be massaged, and lotions, cosmetics, and powders should not be applied. 188. Mr. Jake, a 34-year-old accountant, calls the nurse at an outpatient clinic and reports the following: He had a cold last week but was feeling better today, so he went jogging, as is his usual routine. After a short run, however, he became very short of breath and felt tightness in his chest. He reported no sore throat, fever, or productive cough. Based on this information, elicited by way of telephone assessment, the nurse could surmise that Mr. Jake’s symptoms are related to: 1. 2. 3. 4.

asthma. pneumoconioses. bronchitis. pneumonia.

(1) The reported symptoms and lack of symptoms are characteristic of asthma. The previous viral infection might have made the client more prone to bronchial spasms in response to exercise or cold temperatures. A complete assessment needs to be performed, including laboratory X-rays. The main factors that trigger asthma symptoms are exercise, allergens, fumes, dust, odors, colds, viruses, emotions, stress, climate, and pollution.

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189. An 18-year-old woman comes to her physician’s office complaining of general malaise, fever, and a cough. In completing a nursing assessment, which of the following should the nurse expect to find in a client who has pneumonia? 1. 2. 3. 4.

conjunctivitis and nasal swelling tonsillar exudates and pain on swallowing bronchial breath sounds over lung field with consolidation productive cough with excess mucous production

(3) Bronchial breath sounds are commonly found over lung fields with the infiltration and consolidation of pneumonia. The client’s cough or fever increases the probability of either bronchitis or pneumonia. Cough associated with pneumonia is typically labored and is not productive (meaning it is without exudate). 190. Ms. Jones, age 70, is being prepared for discharge after hospitalization for a pulmonary embolism. The nursing diagnosis Knowledge Deficit: Health Behaviors is identified as a primary concern by the nursing staff to improve Ms. Stone’s outcome at home. This diagnosis is based on the client’s need to know which of the following self-care activities? 1. 2. 3. 4.

Reduce walking to only necessary activities around the house. Maintain peripheral circulation with leg exercises. Soak feet nightly in warm water to increase circulation. Avoid bending to pick up objects.

(2) Leg exercises are important in reducing the risk of further thrombus development. Inactivity makes the body more prone to the development of a thrombus (blood clot) that might dislodge and become an embolism (moving blood clot), which can go to the heart and potentially cause death. 191. Mrs. Hill, age 64, has been diagnosed with chronic obstructive pulmonary disease (COPD). Although she was hospitalized several times in the last year for acute respiratory failure, she is presently in stable condition. The primary focus in the long-term nursing care of Mrs. Hill is to: 1. 2. 3. 4.

Decrease activity to conserve functional lung tissue. Increase the frequency of postural drainage to every 2 hours while awake. Increase the residual volume (RV) Improve and maintain pulmonary ventilation

(4) The underlying pathology of COPD decreases the lungs’ capability to ventilate and exchange O2 and CO2. Ventilation and gas exchange are directly dependent on each other. Treatment should aim to increase activity while implementing work modification techniques. The goal is to decrease rather than increase residual volume (RV), which usually is high in COPD. COPD (a group of disorders associated with persistent or recurrent obstruction of airflow) includes chronic bronchitis, emphysema, and asthma, often with overlap of these disorders. 192. Mrs. Hill’s condition changed over a period of days, and her arterial blood studies now indicate she is in acute respiratory failure. One important nursing intervention in the care of a client with COPD who is in acute respiratory failure is: 1. 2. 3. 4.

establishing an initial stage of activity. discouraging the client from sitting in Fowler’s position to reduce work performed by the heart. removing bronchial secretions and managing oxygen therapy. planning with the family for home care.

(3) Acute respiratory failure results from inadequate gas exchange in the lungs. Increasing the availability of oxygen and assisting with secretion removal improves ventilation. Conservation of energy is critical at this stage. The client is most likely to find that semi-Fowler’s or Fowler’s position facilitates breathing.

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193. Mrs. Hill has been treated aggressively for acute respiratory failure and has improved over the past week. She is experiencing anxiety about being prepared for discharge. The nurse who cares for her should help her develop ways to cope with her chronic obstructive lung disease by: 1. 2. 3. 4.

encouraging the family to take increased responsibility for the client’s care. discouraging the client from performing activities of daily living if they make her tired. teaching the client relaxation techniques and breathing retraining exercises. protecting the client from knowing the prognosis of her disease.

(3) Relaxation techniques and breathing retraining helps a client with COPD maximize energy supplies and effectively use available oxygen. A COPD client should be encouraged to be as independent as possible within his or her physiologic capabilities. Knowledge of disease process might help the client better understand how she can make the most of her life. 194. Mr. Ponder, age 60, is experiencing an episode of acute respiratory failure following an asthma attack. He has a cuffed endotracheal tube in place. For Mr. Ponder, the inflated pressure in the cuff should be checked and maintained at or less than: 1. 2. 3. 4.

42 cm H2O. 24 cm H2O. 20 cm H2O. 5 cm H2O.

(3) Proper cuff pressure ensures a tracheal seal for air while avoiding necrosis of the tracheal wall. Pressure should be kept at or below 20 cm H2O. An endotracheal tube provides an airway; a tube is passed through either the nose or the mouth into the trachea and affixed to the face with waterproof tape. 195. Mr. Perkins, a 46-year-old man employed in a steel plant, was referred to the outpatient clinic at the local hospital from work with a tentative diagnosis of Pneumonia. The nurse who initially examines Mr. Perkins should be aware of the clinical manifestations of pneumonia. Nursing diagnoses appropriate to care for this client include which of the following? 1. 2. 3. 4.

Fluid Volume Deficit (related to vomiting and diarrhea) Pain (related to chest pain radiating to the left shoulder and arm) Difficulty Breathing (related to the inflammation of the lung’s inner structures) Ineffective Breathing Patterns (related to slow, shallow respiration with point tenderness at a rib site)

(3) Chills, fever, and pain result from inflammation of the terminal airways and alveoli caused by bacterial, viral, or fungal infection. Pneumonia is an inflammatory process involving the respiratory bronchioles, alveolar space, and lobes. It is caused primarily by specific organisms (bacteria, viruses, fungi, parasites, mycoplasma, or chemical irritants). Symptoms include bronchial breath sounds, fever, shaking chills, chest pain, dyspnea, hacking cough, anxiety, and confusion. 196. Mr. Perkins was hospitalized for acute bacterial pneumonia and is now recovering after a course of therapy with Penicillin G. In evaluating the outcome of care, the nurse should expect which of the following outcomes? 1. 2. 3. 4.

The client displays PaO2 (partial pressure of oxygen dissolved in arterial blood plasma) of 85 mmHg or above. The client displays PaO2 of 80 mmHg or above. The client demonstrates decreased breath sounds. The client demonstrates signs of restlessness and confusion.

(1) As lung infection progresses, ventilation is impaired. PO2 (partial pressure of oxygen in a mixture of gases or in solution) usually decreases, and a degree of respiratory insufficiency occurs. As the infection subsides and lung function returns, PO2 should be between 85 to 100 mmHg.

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197. Mrs. Pearce has just undergone chest surgery for a right lower lobectomy. The nurse planning Mrs. Pearce’s postoperative care should include which of the following interventions? 1. 2. 3. 4.

Encourage coughing to mobilize secretions. Ensure that the thoracotomy tube is attached to open chest drainage. Restrict IV fluids for 24 hours. Prevent coughing to ensure incision integrity.

(1) The client should be encouraged to cough to raise and expectorate sputum. Splinting the incision during coughing is recommended to minimize discomfort. Coughing is indicated to mobilize secretions. Thoracotomy tubes are always attached to closed, sealed drainage to allow re-expansion of lung tissue and prevent pneumothorax. IV fluid infusion is standard care. 198. Mr. Pips, age 52, underwent a right lobectomy one day ago and is having difficulty expectorating mucous secretions. The nurse caring for Mr. Pips performs tracheobronchial suctioning whenever necessary. A potential complication of suctioning is lobar collapse. This can be avoided by: 1. 2. 3. 4.

using a large catheter the same diameter as the trachea. applying suction at high pressure to accomplish the procedure as quickly as possible. applying suction continuously for 30 seconds or more. using a catheter of a size that does not occlude the lumen of the airway during application of suction.

(4) Suctioning might produce lobar collapse if the suction catheter diameter is too large for the size of the airway. Lobar collapse can occur when air cannot enter the lung from around the catheter while suction is applied. Performing intermittent suctioning for no more than 8 seconds at a time and using low pressure reduce the risk of trauma or hypoxia. 199. The partial pressure of oxygen in arterial blood (PO2) is proportional to the concentration of O2 because it is mixed with other gases. Keeping this fact in mind, at discharge from a Denver hospital that is at an altitude of approximately 5,000 feet, which of the following is an expected acceptable discharge criterion for a person without COPD? 1. 2. 3. 4.

pH 7.3 PaO2 65 to 75 mmHg PaO2 45 to 55 mmHg PaO2 80 to 100 mmHg

(2) Atmospheric air is composed of oxygen, nitrogen, carbon dioxide, and water. Inhaled air is translated into partial pressure of its components. At an altitude of 5,000 feet, the partial pressure of arterial O2 is 65 to 75 mmHg. The pH remains the same regardless of altitude. 200. The neurocontrol of ventilation rests in several areas of the nervous system. The primary control of inspiration and expiration occurs in the: 1. 2. 3. 4.

baroreceptors. medulla oblongata. alveoli. pons.

(2) The rhythm of breathing is controlled by respiratory centers located in the medulla oblongata of the brain. These inspiratory and expiratory centers control the rate and depth of respiration to meet the body’s metabolic demands.

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201. Mr. Green is diagnosed with Respiratory Insufficiency Due to Longstanding Restrictive Lung Disease as a result of working in the coal mines for 35 years. He should be advised to prevent or control respiratory infections by: 1. 2. 3. 4.

taking penicillin for the rest of his life as prophylaxis. smoking low-tar cigarettes. taking influenza and pneumonia vaccines on a regular schedule. having periodic blood studies to determine his PO2.

(3) Taking influenza and pneumonia vaccines on a regular schedule is indicated under medical supervision as a prophylactic treatment against lung infections, particularly during winter months. Influenza and pneumonia vaccines are regularly recommended on a regular schedule for high-risk clients. Smoking is not recommended for any client. 202. Expiration is a(n): 1. 2. 3. 4.

active process that involves the relaxation of the intercostal muscles and the diaphragm. passive process that involves the relaxation of the intercostal muscles and the diaphragm. active process that involves the contraction of the intercostal muscles and the diaphragm. passive process that involves the contraction of the intercostal muscles and the diaphragm.

(2) Expiration is a passive process in which the intercostal muscles and the diaphragm relax, causing the chest cavity to decrease in size and forcing air from the lungs. 203. To determine the quality of breathing, check for all the following except: 1. 2. 3. 4.

presence of breath sounds. chest expansion. breathing rhythm. depth of respirations.

(3) Although rhythm must be observed, it is not included as a measure of breathing quality. Quality includes breath sounds (diminished, unequal, or absent), chest expansion (inadequate or unequal) and depth of respirations (labored, increased respiratory effort or use of accessory muscles). 204. An unresponsive client with shallow, gasping breaths and only a few breaths per minute requires: 1. 2. 3. 4.

oxygen given via nasal cannula. immediate transport to a medical facility. immediate artificial ventilation with supplemental oxygen. oxygen given via nonrebreather mask.

(3) An unresponsive client with shallow, gasping breaths and only a few breaths per minute (agonal respirations) is clearly breathing inadequately. Artificial ventilation with supplemental oxygen (preferably via a pocket face mask) is appropriate. 205. Because oxygenation of the body’s tissues is reduced in a client with impaired breathing, the skin might be _______ in color and feel _______. 1. 2. 3. 4.

pale; dry and cool red; clammy and hot yellow; dry and warm blue; clammy and cool

(4) Blue-colored skin (cyanosis) that feels clammy and cool is usually a sign of inadequate breathing.

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206. The muscles in the neck and abdomen that sometimes assist in breathing are called _____ muscles. 1. 2. 3. 4.

extra accessory subdiaphragmatic smooth

(2) Accessory muscles, such as those in the neck and abdomen, assist in breathing, especially when a client is having difficulty breathing. Subdiaphragmatic is a location below the diaphragm. Smooth muscles line blood vessels. Extra muscle is an inventive distracter. 207. If an unresponsive adult client makes ______ sounds, she might have a serious airway problem requiring immediate intervention. 1. 2. 3. 4.

snoring or gurgling slight wheezing sniffling whistling or grunting

(1) Snoring and gurgling sounds usually indicate a partially obstructed airway. Wheezing can be a sign of anything from airway obstruction to bronchoconstriction. Sniffling is usually from a runny nose. Whistling or grunting is a distracter. 208. The structure of an infant or child’s airway is different from an adult’s in each of the following ways except: 1. 2. 3. 4.

All airway structures are smaller and more easily obstructed. Their tongues are proportionally larger than an adult’s. The trachea is softer and more flexible. For the close proximithy of the trachea to the bronchi.

(4) The proximity of the trachea to the bronchi of infants and children is less developed than an adult’s. The short, straight Eustachian tube closely communicates with the ear, allowing infection to ascend from the pharynx to the middle ear. In the adult, the proximity is lengthier and not in a straight line to the ear. 209. Because the chest wall is softer in infants and children, they: 1. 2. 3. 4.

must inhale twice the amount of air to breathe. depend more heavily on the diaphragm for breathing. grunt and gurgle whenever they breathe. expend less energy than adults do when breathing.

(2) Infants and children depend more heavily on the diaphragm for breathing because the chest wall is softer. 210. Prompt and complete treatment of acute tonsillitis caused by A Beta-hemolytic streptococci is necessary to prevent: 1. 2. 3. 4.

rheumatic fever. rheumatic heart disease. kidney complications. all the above.

(4) Untreated acute tonsillitis can lead to rheumatic fever, rheumatic heart disease, and kidney disease. Tonsillitis is an infection and inflammation of a tonsil. Rheumatic fever is an inflammatory disease that might develop as a delayed reaction to an inadequately treated Group A beta-hemolytic streptococcal infection of the upper respiratory tract. The affected individual might also develop leukocytosis, moderate anemia, and protenuria. Rheumatic heart disease causes damage to

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the muscle and heart valves and is caused by episodes of rheumatic fever. Death can result and is usually the result of heart failure or bacterial endocarditis. 211. Serious side effects of uncontrolled diarrhea in infants and children include: 1. 2. 3. 4.

intestinal obstruction and rhonchi. dehydration and electrolyte imbalance. diaper rash and Reye’s syndrome. all the above.

(2) Diarrhea is a change in normal bowel habits characterized by frequency and passage of loose, unformed stools and is generally the result of increased motility in the colon. In infants and young children, untreated diarrhea can lead to rapid dehydration and electrolyte imbalance. It should be treated symptomatically. Diarrhea is usually self-limiting but has more serious implications the younger the client. Infants and young children should be seen by their care provider. 212. Down syndrome is: 1. 2. 3. 4.

a congenital form of mild to severe mental retardation. associated with distinctive physical abnormalities and heart defects. caused by a chromosomal abnormality. all the above.

(4) Down syndrome is a congenital condition characterized by varying degrees of mental retardation and other defects. Clients with Down syndrome have an extra chromosome, most commonly number 21. 213. Cerebral palsy is: 1. 2. 3. 4.

a result of damage to the central nervous system. a condition that can be cured with treatment. a condition that primarily affects intelligence. all the above.

(1) Cerebral palsy is classified by the extremities involved and the type of neurological dysfunction: spastic, hypotonic, dystonic, athetotic, or a combination of these. Associated defects might include mental retardation or epilepsy. 214. The nurse is providing postoperative care to a client who has had a craniotomy. Which of the following observations require immediate attention? 1. 2. 3. 4.

continued unresponsiveness to verbal stimuli negative glucose reading in nasal mucus increased blood pressure and decreased pulse rate pale, warm skin and a temperature of 99° F

(3) Increased blood pressure and decreased pulse rate might indicate increasing intracranial pressure (ICP). The RN must be notified, who should contact the physician. Changes in responsiveness are significant. Decreased responsiveness might indicate increased ICP. A positive glucose reading indicates the presence of cerebrospinal fluid (CSF) and a possible leak. If the skin is pale and cool or moist, there might be active bleeding and development of shock. The temperature might be normal in this client. Although the nurse should monitor for an increase in temperature, it does not require immediate attention. 215. Upon assessment of a client, the nurse notes hepatomegaly, ascites, dependent edema, and jugular neck vein distention. Which of the following mechanisms accounts for these symptoms? 1. 2. 3. 4.

end-stage cirrhosis of the liver backward effects of right ventricular failure end-stage left ventricular failure backward effects of lymphatic obstruction

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(2) When the right ventricle fails, venous stasis and congestion result because the right ventricle cannot adequately pump the returning blood volume to the lungs. 216. The primary causes of obstruction in long-standing Crohn’s disease are: 1. 2. 3. 4.

volvulus and intussusception. slowed peristalsis and strictures. adhesions and narrowing of the lumen. ulcerations and incarcerated bowel segments.

(3) Crohn’s disease is characterized by periods of remission and exacerbation. During the active phase, inflammation and ulceration are the main physiologic events. They result in narrowing of the lumen and formation of adhesions. The primary complications of Crohn’s disease that must be monitored are sepsis, peritonitis, hemorrhage, and mechanical obstruction. The ulcerations associated with Crohn’s disease cause adhesions to form. 217. The nurse suspects that a client with diabetes is experiencing ketoacidosis. Which manifestations might the nurse be observing? 1. 2. 3. 4.

tachycardia and pale, moist skin hypertension and dry mucous membranes hypotension and dry, hot, flushed skin bradycardia and dry, pale mucous membranes

(3) Diabetic ketoacidosis (DKA) develops gradually but, untreated, can become an emergency in clients with Type I diabetes. The nurse must recognize the signs of DKA in its early stages to prevent complications that might lead to coma: blood glucose level greater than 200mg/dl; nausea; vomiting; abdominal pain; rapid, thready pulse; headache; hypotension; and dry, hot, flushed skin. 218. A client, age 64, has chronic renal failure (CRF). The nurse observes the following measurements: BUN 64, hemoglobin 8.8, creatinine 2.4, and a urine output of 250 ml over the past 24 hours compared with a 1000ml intake. An appropriate nursing diagnosis for this client is: 1. 2. 3. 4.

High Risk for Injury (related to possible seizure activity). Fluid Volume Excess (related to inability of the kidney to maintain body fluid balance). Anemia (related to impaired renal function). Urinary Retention (related to intake greater than output).

(2) The data indicate impaired renal function, which is expected in CRF. Because the kidney does not filter or excrete water or waste products, these substances accumulate in the blood, and there is a high risk of fluid volume excess. 219. A male client is receiving gentamicin sulfate intravenously for a postsurgical wound infection. Which outcome should be included on his care plan for the nursing diagnosis Risk for Injury related to: 1. 2. 3. 4.

Wound remains clean and moist with healthy granulation. Client reports freedom from pain. Lung sounds remain clear. BUN remains between 10 and 20 mg/dl.

(4) Gentamicin is an aminoglycoside. Because this class of drugs is highly nephrotoxic, the nurse should monitor kidney function closely while the client is receiving gentamicin. Maintaining BUN, which is a direct measure of kidney function, within normal range is a desired outcome.

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220. A client, who has type I diabetes mellitus, is experiencing nausea and vomiting. Which action indicates that he understands the sick-day rules for diabetes management? 1. 2. 3. 4.

talking 2⁄3 of his normal insulin dose abandoning his normal meal timing in favor of getting an extended period of sleep drinking nondietetic ginger ale monitoring his blood glucose every 6 hours

(3) While experiencing vomiting, the client should consume small, frequent portions of carbohydrates, including juices and regular (nondietetic) sodas. The normal insulin dose should be given, unless medical professionals order differently. The client should try to get extra rest, and should follow their normal meal plan. If the client cannot follow this routine because of stomach upset, he should eat small portions of soft foods (such as regular gelatin or custard) 6–8 times a day. If vomiting or diarrhea persists, the client should take liquids every 30 minutes–1 hour and contact his physician. The client should monitor his blood glucose and urine ketone levels. 221. Nancy Kline, age 56, reports that she has felt fatigued and slow for the past month. She has gained 7 pounds in 3 weeks despite a report of not eating. Which question should the nurse consider asking the client next? 1. 2. 3. 4.

“Are you losing clumps of hair when you brush your hair?” “Do you frequently feel cold when other people in the same room are comfortable?” “Have you experienced any tremors of your arms or hands?” “Have you noticed any visual blurring or dizzy spells?”

(2) This could be a physical or a psychological problem. In performing an assessment, the nurse establishes a rapport with the client followed by a review of systems, gathering subjective and objective data. Symptoms of hypothyroidism include obesity, dry hair and skin, hypotension, slow pulse, and sluggishness of all functions. 222. A client who is recovering from a spinal cord injury has been referred for nutritional counseling due to weight loss. The client states, “If I eat too much, the weight will just stay on and I will become fat.” How should the nurse best respond to this statement? 1. 2. 3. 4.

“It is important to continue to eat a diet high in protein, carbohydrates, and fiber to maintain optimal body function.” “I know that you are concerned about weight gain, but you can always diet later.” “Let me know what your food preferences are, and I will provide additional portions of whatever you like.” “It is important to have extra nutrient stores to preserve skin integrity.”

(1) Even though a client has had a spinal cord injury, a diet high in protein, carbohydrates, and fiber is necessary to prevent both the catabolic process that occurs following the injury and potential problems of bowel function. Spinal cord injury is characterized by disrupted transmission of nerve impulses from brain to peripheral nerves. The degree of dysfunction depends on cause, degree of transaction, and level of cord injury. There is usually a loss of body weight attributed to loss of lean body mass. Metabolic changes can be dramatic; monitoring fluid and nutrition is a key factor. A high-protein, low-fat diet should be instituted, and education of the client and family is very important. 223. A client is to undergo a bone marrow transplant for treatment of leukemia and is receiving preprocedure teaching with regard to nutrition. Which of the flowing nutritional support options is most likely to be utilized for this client? 1. 2. 3. 4.

supplement with enteral feedings to prevent catabolism oral feedings as soon as possible following the procedure to prevent gastroparesis total parenteral nutrition for a period to maintain nutritional balance insertion of a tube following the procedure to maintain nutritional balance

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(3) A client undergoing a bone marrow transplant is probably fed by total parenteral nutrition in the post transplant period due to potential complications that might affect the mouth, esophagus, and intestines, and could lead to diarrhea and malabsorption. Supplemental feedings (enteral) are not given because the client’s GI tract has been affected by chemotherapy and other medical treatments. In addition, merely supplementing the client does not provide sufficient calories and nutrients. Oral intake is not used due to side effects from high-dose chemotherapy regimens that lead to anorexia, taste perception, nausea, vomiting, and inflammation of mucous membranes. 224. A client being treated for gout is being evaluated for compliance with diet therapy. Which of the following meal selections indicates that the client has adhered to the diet plan? 1. 2. 3. 4.

scrambled eggs, white toast, and coffee seafood casserole, wheat roll, and soda pizza with anchovies, and soda braised liver, lentils, green peas, and tea

(1) Scrambled eggs, white toast, and coffee are all foods that are low in purine content. A client who is being treated for gout should restrict dietary purine sources because they can lead to an exacerbation of the disease process. Gout disorder results from deposits of needlelike crystals of uric acid in connective tissue, joint spaces, or both. Results from hyperuricemia (increased levels of uric acid in the blood) occur as a result of overproduction or underexcretion; when a person eats too many high-protein foods that are high in purines, drinks alcohol, or eats foods high in fat content. 225. A client presenting with ascites secondary to liver failure is being evaluated for fluid balance. Which of the following measurements provides the best indicator of fluid status? 1. 2. 3. 4.

intake and output liver function tests caloric intake and serum protein levels dry weight calculation

(4) A client experiencing ascites due to liver failure has decreased protein levels (albumin) that lead to third spacing of fluids. The calculation of dry weight (total weight minus the weight of ascites) is critical to determining fluid status and medical management of the client. Ascites is an abnormal intraperitoneal accumulation of a fluid containing large amounts of protein and electrolytes. Ascites is a complication of cirrhosis. Ascites is detectable when more than 500 ml of fluid has accumulated. 226. A client previously diagnosed with Cirrhosis of the Liver is now diagnosed with Hepatic Encephalopathy. The dietician has been consulted to evaluate this client for appropriate nutritional therapy. What priority information should the nurse provide to the dietician to help formulate nutritional goals for the client? 1. 2. 3. 4.

Discuss the client’s usual weight pattern and caloric intake pattern prior to admission. Discuss the client’s strong preference for taking in snack foods and sodas. Inform the dietician that the client has advance directives on the chart concerning organ donation. Inform the dietician that the client has been compliant with medical treatment during this hospitalization.

(2) A client who is being treated for hepatic encephalopathy has increased ammonia levels and is likely to be experiencing mental status changes and fluid retention (ascites) It is important to note whether the client has a certain food preference (high in sodium) that might cause more fluid retention. 227. An 18-year-old male is brought into the Emergency Department. A barbiturate overdose is suspected. The nurse should observe him for: 1. 2. 3. 4.

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respiratory depression. electrolyte imbalance. impaired clotting. bone marrow depression.

Physiological Adaptation

(1) The nurse should assess the male for respiratory depression, the most serious side effect of barbiturates. 228. A client is being admitted with a diagnosis of Thrombophlebitis. Which symptom is the nurse most likely to find at the initial assessment? 1. 2. 3. 4.

a negative Homans’ sign pallor of the legs shiny, atrophic skin on the legs unilateral leg swelling

(4) The nurse is most likely to find unilateral leg swelling at the initial assessment. Thrombophlebitis is the occlusion of a vein with inflammation and thrombus; it results in such findings as a positive Homans’ sign, history of leg pain, redness, and unilateral swelling. Pallor of the legs and shiny atrophic skin are signs of decreased arterial circulation to the extremity. 229. A student nurse is assigned to a client who has a diagnosis of Thrombophlebitis. Which action by this team member is most appropriate? 1. 2. 3. 4.

applying warm, dry packs to the involved site elevating the client’s legs 45° instructing the client about the need for bed rest for 10–14 days providing active range-of-motion exercises to both legs at least twice every shift

(2) The client’s legs should be elevated 45°. To prevent embolism (the dislodgement of a thrombus) in a client with thrombophlebitis, the therapeutic interventions are bed rest, leg elevation, applying warm moisture packs to the affected area, and exercising the unaffected extremity. 230. A client was admitted with complaints of sudden onset of chest pain and severe shortness of breath. Arterial blood gases on admission were pH 7.52, PCO2 27, HCO3 22, base excess 0, PO2 53, O2 saturation 91%. These arterial blood gas values suggest which acid-base disturbance? 1. 2. 3. 4.

respiratory alkalosis respiratory acidosis metabolic alkalosis metabolic acidosis

(1) Hyperventilation and lowered PCO2 are common after a pulmonary embolus. The bicarbonate is normal. O2 and O2 saturation are not used to evaluate the acid-base status of a client. 231. The arterial blood gases of a client reflect respiratory alkalosis. The assessment of this client should include which findings? 1. 2. 3. 4.

respiratory rate of 10 and shallow breathing respiratory rate of 26 and deep breathing central neurogenic hyperventilation syndrome cluster respiratory pattern

(1) The assessment should include a respiratory rate of 10 and shallow breathing. Signs and symptoms of respiratory acidosis include slow, shallow breathing; congestion in the lung; pneumonia; and/or noncardiogenic pulmonary edema, also known as adult respiratory distress syndrome (ARDS). The initial nursing action should be to provide airway, O2, and have the client take deep breaths.

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N C LEX-PN PR ACTI C E TE STS There is one additional practice test on the CD-ROM.

NCLEX-PN Practice Test 1 For each of the following questions, select the choice that best answers the question or completes the statement. 1. A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of: 1. 2. 3. 4.

climacteric. menopause. perimenopause. postmenopause.

2. When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy? 1. 2. 3. 4.

family history of stroke ovaries removed before age 45 frequent hot flashes and/or night sweats unexplained vaginal bleeding

3. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care? 1. 2. 3. 4.

“I should put alcohol on my baby’s cord 3–4 times a day.” “I should put the baby’s diaper on so that it covers the cord.” “I should call the physician if the cord becomes dark.” “I should wash my hands before and after I take care of the cord.”

4. The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include? 1. 2. 3. 4.

Use the defrost setting on microwave ovens to warm bottles. When refrigerating formula, don’t feed the baby partially used bottles after 24 hours. When using formula concentrate, mix two parts water and one part concentrate. If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it.

5. The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine? 1. 2. 3. 4.

6 8 12 16

6. Which of the following physical findings indicates that an 11–12-month-old child is at risk for developmental dysplasia of the hip? 1. 2. 3. 4.

refusal to walk not pulling to a standing position negative Trendelenburg sign negative Ortolani sign

7. When administering intravenous electrolyte solution, the nurse should take which of the following precautions? 1. 2. 3. 4.

Infuse hypertonic solutions rapidly. Mix no more than 80 mEq of potassium per liter of fluid. Prevent infiltration of calcium, which causes tissue necrosis and sloughing. As appropriate, reevaluate the client’s digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis’s action.

8. Teaching about the need to avoid foods high in potassium is most important for which client? 1. 2. 3. 4.

a client receiving diuretic therapy a client with an ileostomy a client with metabolic alkalosis a client with renal disease

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9. What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L? 1. 2. 3. 4.

metabolic alkalosis homeostasis respiratory acidosis respiratory alkalosis

10. The major electrolytes in the extracellular fluid are: 1. 2. 3. 4.

potassium and chloride. potassium and phosphate. sodium and chloride. sodium and phosphate.

11. A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image? 1. 2. 3. 4.

administering immune globulin intravenously assessing the extremities for edema, redness and desquamation every 8 hours explaining progression of the disease to the client and his or her family assessing heart sounds and rhythm

12. Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia? 1. 2. 3. 4.

immobility altered growth and development hemarthrosis altered family processes

13. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse? 1. 2. 3. 4.

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“I will assist you in arranging to have a medicine woman present.” “We do not allow medicine women in exam rooms.” “That does not make any difference in the outcome.” “It is old-fashioned to believe in that.”

14. All of the following should be performed when fetal heart monitoring indicates fetal distress except: 1. 2. 3. 4.

increase maternal fluids. administer oxygen. decrease maternal fluids. turn the mother.

15. Which fetal heart monitor pattern can indicate cord compression? 1. 2. 3. 4.

variable decelerations early decelerations bradycardia tachycardia

16. Which of the following conditions is mammography used to detect? 1. 2. 3. 4.

pain tumor edema epilepsy

17. Why might breast implants interfere with mammography? 1. 2. 3. 4.

They might cause additional discomfort. They are contraindications to mammography. They are likely to be dislodged. They might prevent detection of masses.

18. Which of the following instructions should the nurse give a client who will be undergoing mammography? 1. 2. 3. 4.

Be sure to use underarm deodorant. Do not use underarm deodorant. Do not eat or drink after midnight. Have a friend drive you home.

19. Which of the following diseases or conditions is least likely to be associated with increased potential for bleeding? 1. 2. 3. 4.

metastatic liver cancer gram-negative septicemia pernicious anemia iron-deficiency anemia

NCLEX-PN Practice Test 1

1. 2. 3. 4.

increased platelet count increased fibrinogen decreased fibrin split products decreased bleeding

21. A client, age 28, was recently diagnosed with Hodgkin’s disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP— nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image? 1. 2. 3. 4.

cushingoid appearance alopecia temporary or permanent sterility pathologic fractures

22. Which of the following is an inappropriate item to include in planning care for a severely neutropenic client? 1. 2. 3. 4.

Transfuse netrophils (granulocytes) to prevent infection. Exclude raw vegetables from the diet. Avoid administering rectal suppositories. Prohibit vases of fresh flowers and plants in the client’s room.

23. Which sign might the nurse see in a client with a high ammonia level? 1. 2. 3. 4.

coma edema hypoxia polyuria

24. A client with which of the following conditions is at risk for developing a high ammonia level? 1. 2. 3. 4.

renal failure psoriasis lupus cirrhosis

25. For which of the following conditions might blood be drawn for uric acid level? 1. 2. 3. 4.

asthma gout diverticulitis meningitis

26. Which of the following foods might a client with a hypercholesterolemia need to decrease his or her intake of? 1. 2. 3. 4.

broiled catfish hamburgers wheat bread fresh apples

27. Which of the following lab values is associated with a decreased risk of cardiovascular disease? 1. 2. 3. 4.

high HDL cholesterol low HDL cholesterol low total cholesterol low triglycerides

28. Which of the following organs of the digestive system has a primary function of absorption? 1. 2. 3. 4.

stomach pancreas small intestine gallbladder

29. For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant? 1. 2. 3. 4.

upper right upper left lower right lower left

30. A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, “I need this surgery because nothing else I have done has helped me to lose weight.” Which response by the nurse is most appropriate? 1. 2. 3. 4.

“If you eat less, you can save some money.” “Exercise is a healthier way to lose weight.” “You should try the Atkins diet first.” “I respect your decision to choose surgery.”

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20. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) subsequent to an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?

Part II: NCLEX-PN Practice Tests

31. A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate? 1. 2. 3. 4.

“I will call your physician to see if we can start some ginger.” “We don’t use home remedies in this clinic.” “Herbs are not as effective as regular medicines.” “Just eat some dry crackers instead.”

32. Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting? 1. 2. 3. 4.

metoclopramide (Reglan) onedansetron (Zofran) hydroxyzine (Vistaril) prochlorperazine (Compazine)

33. Which of the following is likely to increase the risk of sexually transmitted disease? 1. 2. 3. 4.

alcohol use certain types of sexual practices oral contraception use all of the above

34. Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of: 1. 2. 3. 4.

primary prevention. secondary prevention. tertiary prevention. primary health care prevention.

35. The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines: 1. 2. 3. 4.

human papilloma virus, genital herpes, measles. pneumonia, HIV, mumps. syphilis, gonorrhea, pneumonia. polio, pertussis, measles.

36. Acyclovir is the drug of choice for: 1. 2. 3. 4.

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HIV. HSV 1 and 2 and VZV. CMV. influenza A viruses.

37. A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is: 1. 2.

3.

4.

standing the client and walking him or her to the wheelchair. moving the wheelchair close to client’s bed and standing and pivoting the client on his unaffected extremity to the wheelchair. moving the wheelchair close to client’s bed and standing and pivoting the client on his affected extremity to the wheelchair. having the client stand and push his body to the wheelchair.

38. Assessment of a client with a cast should include: 1. 2. 3. 4.

capillary refill, warm toes, no discomfort. posterior tibial pulses, warm toes. moist skin essential, pain threshold. discomfort of the metacarpals.

39. In teaching clients with Buck’s Traction, the major areas of importance should be: 1. 2. 3. 4.

nutrition, ROM exercises. ROM exercises, transportation. nutrition, elimination, comfort, safety. elimination, safety, isotonic exercises.

40. When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing: 1. 2. 3. 4.

one commercially prepared glucose tablet. two hard candies. 4–6 ounces of fruit juice with 1 teaspoon of sugar added. 2–3 teaspoons of honey.

41. A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client’s weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as: 1. 2. 3. 4.

within normal limits, so a weight-reduction diet is unnecessary. lower than normal, so education about nutrient-dense foods is needed. indicating obesity because the BMI is 35. indicating overweight status because the BMI is 27.

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1. 2. 3. 4.

open leg fracture open head injury stab wound to the chest traumatic amputation of a thumb

43. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma? 1. 2. 3. 4.

The clothing is the property of another and must be treated with care. Such care facilitates repair and salvage of the clothing. The clothing of a trauma victim is potential evidence with legal implications. Such care decreases trauma to the family members receiving the clothing.

44. Which of the following terms refers to soft-tissue injury caused by blunt force? 1. 2. 3. 4.

contusion strain sprain dislocation

45. A client with dumping syndrome should ___________ while a client with GERD should ___________. 1. 2. 3. 4.

sit up 1 hour after meals; lie flat 30 minutes after meals lie down 1 hour after eating; sit up at least 30 minutes after eating sit up after meals; sit up after meals lie down after meals; lie down after meals

46. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction? 1. 2. 3. 4.

calcium magnesium potassium sodium chloride

47. Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to: 1. 2. 3. 4.

notify the physician of the drainage. change the dressing. reinforce the dressing. apply an abdominal binder.

48. A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered? 1. 2. 3. 4.

Advil Anasaid Clinocil Colace

49. A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as: 1. 2. 3. 4.

plantar fasciitis. hallux valgus. hammertoe. Morton’s neuroma.

50. A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a: 1. 2. 3. 4.

sprain. strain. subluxation. distoration.

51. To remove hard contact lenses from an unresponsive client, the nurse should: 1. 2. 3. 4.

gently irrigate the eye with an irrigating solution from the inner canthus outward. grasp the lens with a gentle pinching motion. don sterile gloves before attempting the procedure. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.

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42. Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?

Part II: NCLEX-PN Practice Tests

52. To remove a client’s gown when she has an intravenous line, the nurse should: 1.

2. 3. 4.

temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown. cut the gown with scissors. thread the bag and tubing through the gown sleeve, keeping the line intact. temporarily disconnect the tubing from the intravenous container and thread it through the gown.

53. When making an occupied bed, it is important for the nurse to: 1. 2. 3. 4.

keep the bed in the low position. use a bath blanket or top sheet for warmth and privacy. constantly keep side rails raised on both sides. move back and forth from one side to the other when adjusting the linens.

54. Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except: 1. 2. 3. 4.

terminating the pregnancy. preparing for the birth of a child with special needs. accessing support services before the birth. completing the grieving process before the birth.

55. A client who is experiencing infertility says to the nurse, “I feel I will be incomplete as a man/woman if I cannot have a child.” Which of the following nursing diagnoses is likely to be appropriate for this client? 1. 2. 3. 4.

Risk for Self Harm Body Image Disturbance Ineffective Role Performance Powerlessness

56. Which of the following foods is a complete protein? 1. 2. 3. 4.

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corn eggs peanuts sunflower seeds

57. Which condition is associated with inadequate intake of vitamin C? 1. 2. 3. 4.

rickets marasmus kwashiorkor scurvy

58. What is the primary nutritional deficiency of concern for a strict vegetarian? 1. 2. 3. 4.

vitamin C vitamin B12 vitamin E magnesium

59. How often should the nurse change the intravenous tubing on total parenteral nutrition solutions? 1. 2. 3. 4.

every 24 hours every 36 hours every 48 hours every 72 hours

60. Which of the following values should the nurse monitor closely while a client is on total parenteral nutrition? 1. 2. 3. 4.

calcium magnesium glucose cholesterol

61. A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs? 1. 2. 3. 4.

lungs liver kidneys adrenal glands

62. Light therapy can be effective for: 1. 2. 3. 4.

overcoming weight problems. helping with allergies. use in alternative medical treatments. working with sleep patterns.

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1. 2. 3. 4.

supplement vitamin pills. balance body molecules. cure many diseases. help improve body defenses.

69. The goals of palliative care include all of the following except: 1. 2. 3.

64. A diet high in fiber content can help an individual to: 1. 2. 3. 4.

lose body weight fast. reduce diabetic ketoacidosis. lower cholesterol. reduce the need for folate.

65. Which of the following is an appropriate nursing goal for a client at risk for nutritional problems? 1. 2. 3. 4.

provide oxygen promote healthy nutritional practices treat complications of malnutrition increase weight

66. The nurse explains to a client who underwent gastric resection that which of the following meals is most likely to cause rapid emptying of the stomach? 1. 2. 3. 4.

a high-protein meal a high-fat meal a large meal regardless of nutrient content a high-carbohydrate meal

67. Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)? 1. 2. 3. 4.

lettuce eggs chocolate butterscotch

68. Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except: 1. 2. 3. 4.

tolerance. constipation. sedation. addiction.

4.

giving clients with life-threatening illnesses the best quality of life possible. taking care of the whole person—body, mind, spirit, heart, and soul. no interventions are needed because the client is near death. support of needs of the family and client.

70. Major competencies for the nurse giving end-oflife care include: 1.

2. 3. 4.

demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client. assessing and intervening to support total management of the family and client. setting goals, expectations, and dynamic changes to care for the client. keeping all sad news away from the family and client.

71. Assessment of the client with an arteriovenous fistula for hemodialysis should include: 1. 2. 3. 4.

inspection for visible pulsation. palpation of thrill. percussion for dullness. auscultation of blood pressure.

72. A client with stress incontinence should be advised: 1. 2. 3. 4.

to purchase absorbent undergarments. that Kegel exercises might help. that effective surgical treatments are nonexistent. that behavioral therapy is ineffective.

73. An appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus is: 1. 2. 3. 4.

insertion of a Foley catheter. in and out catheter specimen for urinalysis. a voided urine specimen for urinalysis. a urologist consult.

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63. Broccoli, oranges, dark greens, and dark yellow vegetables can be eaten to:

Part II: NCLEX-PN Practice Tests

74. Erythropoietin used to treat anemia in clients with renal failure should be given in conjunction with: 1. 2. 3. 4.

iron, folic acid, and B12. an increase of protein in the diet. vitamins A and C. an increase of calcium in the diet.

75. The kind of man who beats a woman is: 1. 2. 3. 4.

from a minority culture in a low-income group. from a majority culture in a middle-income group. one who was never allowed to compete as a child. from any walk of life, race, income group, or profession.

76. A batterer is usually someone who: 1. 2. 3. 4.

grew up in a loving, secure home. was an only child. was physically or psychologically abused. admits he has a problem with anger.

77. When helping a client gain insight into anxiety, the nurse should: 1. 2. 3. 4.

help relate anxiety to specific behaviors. ask the client to describe events that precede increased anxiety. instruct the client to practice relaxation techniques. confront the client’s resistive behavior.

78. A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse’s teaching about discontinuing the medication? 1. 2. 3.

4.

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“I can drink alcohol now that I am decreasing my Xanax.” “I should not take another Xanax pill. Here is what is left of my last prescription.” “I should take three pills per day next week, then two pills for one week, then one pill for one week.” “I can expect to be sleepy for several days after stopping the medicine.”

79. A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with: 1. 2. 3. 4.

wearing clothing that is too small for the child. the child being shaken. falling while learning to walk. parents trying to awaken the child.

80. A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should: 1. 2. 3. 4.

immediately contact child protective services. provide the mother with literature about child care. consult a therapist to help the mother work out her fears. refer the mother to parenting classes.

81. Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs? 1. 2. 3. 4.

intrauterine device (IUD) Norplant oral contraceptives vaginal sponge

82. Which of the following is the primary force in sex education in a child’s life? 1. 2. 3. 4.

school nurse peers parents media

83. Which of the following nursing actions is most effective when evaluating a kinetic family drawing? 1. 2. 3. 4.

telling the child to draw their family doing something offering specific suggestions of what to include in the drawing discouraging the child from talking about the drawing noting the omission of any family members

NCLEX-PN Practice Test 1

1. 2. 3. 4.

high infant mortality rate. frequent use of Emergency Departments. consultation with folk healers. low incidence of dental problems.

85. A client is having a seizure; his blood oxygen saturation drops from 92% to 82%. What should the nurse do first? 1. 2. 3. 4.

Open the airway. Administer oxygen. Suction the client. Check for breathing.

86. Which of the following might be an appropriate nursing diagnosis for an epileptic client? 1. 2. 3. 4.

Dysreflexia Risk for Injury Urinary Retention Unbalanced Nutrition

87. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy’s mother indicates a need for further teaching by the nurse? 1. 2. 3. 4.

“I should make sure he gets plenty of rest.” “I should get him a medic alert bracelet.” “I should lay him on his back during a seizure.” “I should loosen his clothing during a seizure.”

88. Which of the following nursing diagnoses might be appropriate as Parkinson’s disease progresses and complications develop? 1. 2. 3. 4.

Impaired Physical Mobility Dysreflexia Hypothermia Impaired Dentition

89. Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs? 1. 2. 3. 4.

epilepsy Parkinson’s muscular sclerosis Huntington’s chorea

90. Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as: 1. 2. 3. 4.

mild. moderate. severe. panic.

91. What interpersonal relief behavior is Ashley using? 1. 2. 3. 4.

acting out somatizing withdrawal problem-solving

92. A primary belief of psychiatric mental health nursing is: 1. 2. 3. 4.

most people have the potential to change and grow. every person is worthy of dignity and respect. human needs are individual to each person. some behaviors have no meaning and cannot be understood.

93. James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as: 1. 2. 3. 4.

denial. suppression. displacement. fantasy.

94. A woman asks, “How much alcohol can I safely drink while pregnant?” The nurse’s best response is: 1. 2.

3.

4.

“The amount of alcohol that is safe during pregnancy is unknown.” “Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.” “Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.” “You can have a drink to help you relax and get to sleep at night.”

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84. All of the following factors, when identified in the history of a family, are correlated with poverty except:

Part II: NCLEX-PN Practice Tests

95. A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that: 1.

2.

3.

4.

the client’s body has developed tolerance, requiring more drug to produce the same effect. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence. addiction is the term used to describe physical dependence with withdrawal symptoms and tolerance. the client has a dual diagnosis of substance abuse and chronic back pain.

96. Which is the proper hand position for performing chest percussion? 1. 2. 3. 4.

cup the hands use the side of the hands flatten the hands spread the fingers of both hands

97. Which is the proper hand position for performing chest vibration? 1. 2. 3. 4.

cup the hands use the side of the hands flatten the hands spread the fingers of both hands

98. Which of the following indicates a hazard for a client on oxygen therapy? 1. 2. 3. 4.

A No Smoking sign is on the door. The client is wearing a synthetic gown. Electrical equipment is grounded. Matches are removed.

100. When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client’s body should she measure? 1. 2. 3. 4.

101. A nurse observes a client sitting alone and talking. When asked, the client reports that he is “talking to the voices.” The nurse’s next action should be: 1. 2. 3. 4.

1. 2. 3. 4.

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2 liters/minute 4 liters/minute 6 liters/minute 8 liters/minute

touching the client to help him return to reality. leaving the client alone until reality returns. asking the client to describe what is happening. telling the client there are no voices.

102. A client in an acute care psychiatric hospital asks, “Who are those two people by the door?” The nurse recognizes the client is having a hallucination. The best response is: 1. 2. 3. 4.

“I do not see anyone. Can you tell me more about what you are seeing?” “No one is there. You are seeing things again.” “Just ignore them. They will go away.” “I told you before that no one is there.”

103. A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, “Because there is no permanent physical damage, he does not need any more treatment.” The nurse’s response should be based on which of the following pieces of information? 1. 2.

99. When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?

corner of the mouth to the tragus of the ear corner of the eye to the top of the ear tip of the chin to the sternum tip of the nose to the earlobe

3. 4.

Male victims of sexual abuse seldom have long-term psychological problems. Survivors of male sexual abuse might become confused about their sexual identity. Unless treated, all male sex abuse survivors grow up to abuse other children. All children who have been sexually abused have the same needs, regardless of gender.

NCLEX-PN Practice Test 1

1. 2. 3. 4.

identify all psychosocial problems. eliminate the client’s enticing behaviors. resolve feelings of trauma and fear. verbalize feeling about the event.

105. The intent of the Patient Self Determination Act (PSDA) of 1990 is to: 1. 2. 3. 4.

enhance personal control over legal care decisions. encourage medical treatment decision making prior to need. give one federal standard for living wills and durable powers of attorney. emphasize client education.

106. Client self-determination is the primary focus of: 1. 2. 3. 4.

malpractice insurance. nursing’s advocacy for clients. confidentiality. health care.

110. Legal protection of confidentiality: 1. 2.

3. 4.

extends only to written documentation. extends to the electronic dissemination of information not identifiable to a specific client. is important only within the court system. extends to both written and verbal information.

111. A 65-year-old female client is experiencing postmenopausal bleeding. Which type of physician should this client be encouraged to see? 1. 2. 3. 4.

a radiologist a gynecologist a physiatrist an oncologist

112. People who live in poverty are most likely to obtain health care from: 1. 2. 3. 4.

their primary care physician (family doctor). a neighborhood clinic. specialists. Emergency Departments or urgent care centers.

107. The focus of a nurse case manager is: 1. 2. 3. 4.

nursing care needs at discharge. the comprehensive care needs of the client for continuity of care. client education needs upon discharge. financial resources for needed care.

108. Mr. H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except: 1. 2. 3. 4.

the right to examine and question the bill. the right to reasonable response to requests. the right to refuse treatment. the right to confidentiality.

113. Quality is defined as a combination of all of the following except: 1. 2. 3. 4.

conforming to standards. performing at the minimally acceptable level. meeting or exceeding customer requirements. exceeding customer expectations.

114. All of the following are common reasons that nurses are reluctant to delegate except: 1. 2. 3. 4.

lack of self-confidence. desire to maintain authority. confidence in subordinates. getting trapped in the “I can do it better myself” mindset.

109. On first meeting, a new nurse manager makes eye contact, smiles, initiates conversation about the previous work experience of nurses, and encourages active participation by nurses in the dialogue. Her behavior is an example of: 1. 2. 3. 4.

aggressiveness. passive aggressiveness. passiveness. assertiveness.

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104. A nurse is planning a brief treatment program for a client who was raped. A realistic, short-term goal is to:

Part II: NCLEX-PN Practice Tests

115. Following the change of shift report, the nurse should analyze the information and set priorities accordingly. When the plan has been formulated, at what point during the shift can or should the nurse’s plan be altered or modified? 1. 2. 3. 4.

halfway through the shift at the end of the shift before the nurse reports off when needs change after the top-priority tasks have been completed

116. A client states, “I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?” The nurse should respond with which of the following statements? 1. 2. 3. 4.

Sleep at least 6–8 hours a night. Practice monthly self-breast examination. Reduce stress. All of the above.

117. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, “I do not know how to make my diet work with the kind of foods that my family eats.” What should the nurse do first to help the client determine a suitable diet for disease prevention? 1.

2.

3. 4.

Provide her with copies of the approved dietary guidelines for the American Diabetic Association and the American Heart Association. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs. Provide a high-protein diet plan for the client. Provide the client with information related to risk factors for heart disease and diabetes.

118. According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to: 1. 2. 3. 4.

clients (patients). the profession of nursing. provide high-quality care. all of the above.

119. The role of the incident report in risk management is: 1. 2.

3. 4.

120. Which of the following individuals may legally give informed consent? 1. 2. 3. 4.

an 86-year-old male with advanced Alzheimer’s disease a 14-year-old girl needing an appendectomy who is not an emancipated minor a 72-year-old female scheduled for a heart transplant a 6-month-old baby needing bowel surgery

121. A wrong committed by one person against another (or against the property of another) that might result in a civil trial is: 1. 2. 3. 4.

a tort. a crime. a misdemeanor. a felony.

122. The family carries out its health care functions in which of the following ways? 1. 2. 3. 4.

Family provides very little preventive health care to its members at home. Family provides sick care to its members. Family pays for most health services. Family decides when and where to hospitalize its members.

123. What is the primary theory that explains a family’s concept of health and illness? 1. 2. 3. 4.

Health Belief Model Education-School-Completing Factor Family Health Expert Factor Disconnected Family Factor

124. Health promotion activities are designed to help clients: 1. 2. 3. 4.

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liability protection. to provide data for analysis by a risk manager to determine how future problems can be avoided. to discipline staff for errors. all of the above.

reduce the risk of illness. maintain maximal function. promote healthy habits related to health care. all of the above.

NCLEX-PN Practice Test 1

1. 2. 3. 4.

when the client enters the health care system. after the client requests rehabilitation services. after the client’s physical condition stabilizes. when the client is discharged from the hospital.

126. In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases? 1. 2. 3. 4.

measles, polio, pertussis, hepatitis B diptheria, pertussis, polio, tetanus rubella, polio, pertussis, hepatitis A measles, mumps, rubella, polio

130. Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep? 1. 2. 3. 4.

131. A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child? 1. 2. 3.

127. As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age? 1. 2. 3. 4.

builds towers with several blocks tries to color within the lines says “Mine!” when playing with toys tries to jump rope

exercising vigorously for 20 minutes each night beginning at 9:30 p.m. taking a cool shower and drinking a hot cup of tea watching TV nightly until midnight getting a back rub and drinking a glass of warm milk

4.

turning out the room light and closing the door tiring the child during the evening with play exercises identifying the child’s home bedtime rituals and following them encouraging visitation by friends during the evening

132. The 24-hour day-night cycle is known as: 1. 2. 3. 4.

circadian rhythm. infradium rhythm. ultradian rhythm. non-REM rhythm.

128. Vaccines provide what type of immunity? 1. 2. 3. 4.

active passive transplacental active and passive

129. A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the nurse expect to administer in addition to the scheduled vaccines? 1. 2. 3. 4.

pneumococcal vaccine hepatitis A vaccine Lyme disease vaccine typhoid vaccine

133. Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client? 1. 2. 3. 4.

0.9% sodium chloride 5% dextrose in water solution sterile water Heparin sodium

134. Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration? 1. 2. 3. 4.

CVADs are less expensive than a peripheral IV. Weekly administration is possible. Chemotherapeutic agents can be caustic to smaller veins. The client or family can administer the drug at home.

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125. Rehabilitation services begin:

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135. The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they: 1.

2. 3. 4.

cross-link DNA strands with covalent bonds between alkyl groups on the drug and guanine bases on DNA. have few, if any, side effects. are used to treat multiple types of cancer. are cell-cycle-specific agents.

136. Medication bound to protein can have which of the following effects? 1. 2. 3. 4.

enhancement of drug availability rapid distribution of the drug to receptor sites less availability to produce desired medicinal effects increased metabolism of the drug by the liver

137. The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should: 1. 2. 3.

4.

administer both medications simultaneously. give the medications sequentially, and flush well between them. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug. start one medication now and begin the other medication in 2–4 hours.

138. Fat emulsions are frequently administered as a part of total parenteral nutrition. Which statement is true regarding fat emulsions? 1. 2. 3. 4.

They have a high energy-to-fluid-volume ratio. Even though hypertonic, they are well tolerated. They are a basic solution secondary to the addition of sodium hydroxide (NaOH). The pH is alkaline, making them compatible with most medications.

139. The nurse wishes to decrease a client’s use of denial and increase the client’s expression of feelings. To do this the nurse should: 1. 2. 3. 4.

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tell the client to stop using the defense mechanism of denial. positively reinforce each expression of feelings. instruct the client to express feelings. challenge the client each time denial is used.

140. A 57-year-old woman is recently widowed. She states, “I will never be able to learn how to manage the finances. My husband did all of that.” Select the nurse’s response that could help raise the client’s self-esteem. 1. 2. 3. 4.

“You feel inadequate because you have never learned to balance a checkbook.” “You should have insisted your husband teach you about the finances.” “You are strong and will learn how to manage your finances after awhile.” “Why don’t you take a class in basic finance from the local college?”

141. An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim? 1. 2. 3. 4.

knowledge that elder abuse is rare personal belief that abuse is deserved lack of developmentally appropriate screening tools fear of reprisal or further violence if the incident is reported

142. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client? 1. 2. 3. 4.

“How did you get those bruises?” “Did someone grab you by your arms?” “Do you fall often?” “What did you bump against?”

143. Distribution of a drug to various tissues is dependent on the amount of cardiac output to each type of tissue. Which tissue would receive the highest amount of cardiac output and thus the highest amount of a drug? 1. 2. 3. 4.

skin adipose tissue skeletal muscle myocardium

144. A syringe pump is a type of electronic infusion pump used to infuse fluids or medications directly from a syringe. This device is commonly used for: 1. 2. 3. 4.

solutions administered in obstetrics. dilute antibiotics. large volumes of IV solution. the neonatal and pediatric populations.

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1.

2.

3.

4.

a declaration of wishes or documentation of wishes regarding organ donation by the donor is necessary for organ harvesting. the physician in charge of the case is the only person allowed to decide whether organ donation can occur. the client’s legally responsible party may make the decision for organ donation for the donor if the client is unable to do so. the organ procurement organization makes the decision regarding which organs to harvest.

146. A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service? 1. 2. 3. 4.

shopping for groceries house cleaning transportation to physician’s visits medication instruction

147. Narrow therapeutic index medications: 1. 2. 3.

4.

are drug formulations with limited pharmacokinetic variability. have limited value and require no monitoring of blood levels. have less than a twofold difference in minimum toxic levels and minimum effective concentration in the blood. have limited potency and side effects.

148. A client can receive the mumps, measles, rubella (MMR) vaccine if he or she: 1. 2. 3. 4.

is pregnant. is immunocompromised. is allergic to neomycin. has a cold.

149. A chemical reaction between drugs prior to their administration or absorption is known as: 1. 2. 3. 4.

a drug incompatibility. a side effect. an adverse event. an allergic response.

150. A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of: 1. 2. 3. 4.

naloxone (Narcan). labetalol (Normodyne). neostigmine (Prostigmin). thiothixene (Navane).

151. A narcotic analgesic, prescribed for chronic pain, is no longer effective for a client. The client asks the nurse why the analgesic is not effective any longer. Which common side effect of prolonged narcotic analgesic administration should the nurse teach this client about? 1. 2. 3. 4.

potency tolerance agonist efficacy

152. The greatest time savers when planning client care include all of the following except: 1. 2. 3. 4.

reacting to the crisis of the moment. setting goals. planning. specifying priorities.

153. Common problems for supervisors include all of the following except: 1. 2. 3.

4.

the supervisor facilitates development of staff members. the supervisor micromanages staff members. the supervisor wants to control the style in which a staff member correctly performs a task. the supervisor does not delegate.

154. What significant event occurs in the orientation phase of a nurse-client relationship? 1. 2. 3. 4.

establishment of roles identification of transference phenomenon placement of the client within the client’s family structure client agreement that the nurse has the authority in the relationship

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145. A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:

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155. At what point in the nurse-client relationship should termination first be addressed? 1. 2. 3. 4.

in the working phase in the termination phase in the orientation phase when the client initially brings up the topic

156. A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, “There must be some mistake in the diagnosis.” The nurse determines that the client is demonstrating which of the following? 1. 2. 3. 4.

denial anger bargaining acceptance

157. The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for: 1. 2. 3. 4.

elevated blood pressure. Cheyne-Stokes respiration. elevated pulse rate. decreased temperature.

158. A couple from the Philippines living in the United States is expecting their first child. In providing culturally competent care, the nurse must first: 1. 2.

3. 4.

review their own cultural beliefs and biases. respectfully request that the couple utilize only medically approved health care providers. realize that the clients have to learn their new country’s accepted medical practices. study family dynamics to understand the male and female gender roles in the clients’ culture.

159. Nursing considerations when caring for AfricanAmerican clients include that: 1. 2. 3. 4.

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families are generally distant and unsupportive. special hair, skin, and nail care might be required. fad diets are a cultural norm. clients are generally future-oriented.

160. Which of the following ethnic groups is at highest risk in the United States for pesticide-related injuries? 1. 2. 3. 4.

Native American Asian-Pacific Norwegian Hispanic

161. The nurse should teach parents of small children that the most common type of first-degree burn is: 1. 2. 3. 4.

scalding from hot bath water or spills. contact with hot surfaces such as stoves and fireplaces. contact with flammable liquids or gases resulting in flash burns. sunburn from lack of protection and overexposure.

162. The most common cause of injury from a house fire is: 1. 2. 3. 4.

explosion. falls from second-story windows. thermal damage to skin and body surfaces. inhalation injury.

163. The client’s lab culture report is negative for a suspected infection. A test that can correctly identify those who do not have a given disease is: 1. 2. 3. 4.

specific. sensitive. negative culture. marginal finding.

164. A client is told that his test is positive, but in fact, the client does not have the disease tested for. Which type of false report is this an example of? 1. 2. 3. 4.

positive false positive negative false negative

165. The vast majority of deaths resulting from unintentional poisoning occur in: 1. 2. 3. 4.

infants. toddlers. teens. adults.

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1. 2. 3. 4.

“Do not sit on toilet seats without protection.” “Oral sex does not transmit the virus.” “This infection can be transmitted via intercourse even when you do not feel ill.” “Try to drink lots of fluids after sex to flush the reproductive tract.”

167. A client is diagnosed with HIV. Which of the following are antiviral drug classes used in the treatment of HIV/AIDS? 1. 2. 3. 4.

nucleoside reverse transcriptase inhibitors protease inhibitors HIV fusion inhibitors all of the above.

171. The nurse is teaching a client about the use of Rifampin for prophylaxis after an exposure to meningitis. What change in bodily functions should the nurse advise the client about? 1. 2. 3. 4.

172. A concern regarding maternal and infant mortality and morbidity is that: 1. 2. 3.

168. Someone who has received a recent tattoo should be screened for: 1. 2. 3. 4.

tuberculosis. herpes. hepatitis. syphilis.

169. Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be: 1. 2. 3. 4.

outbreak of Asian flu. Chemical exposure. bacterial pneumonia. allergic reaction.

170. A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child’s scratching. Which of the following advisory comments should be given? 1. 2. 3. 4.

The history and presentation might indicate chickenpox, a highly contagious disease. The lesions might indicate a noncontagious infection that does not require isolation. The history and presentation might indicate an infectious illness called impetigo. The lesions are not contagious unless others have open wounds or lesions themselves.

The client’s urine might turn blue. The client remains infectious to others for 48 hours. The client’s contact lenses might be stained orange. The client’s skin might take on a crimson glow.

4.

a segment of the population is not receiving prenatal care. families appear unconcerned about quality health care. the personnel shortage in the maternity field will increase. maternal-child health workers are not adequately prepared.

173. The nurse teaching an obese client about nutritional needs and weight loss should include all of the following except: 1. 2. 3. 4.

knowledge of food and food products. development of a positive mental attitude. adequate exercise. starting a fast weight-loss diet.

174. An assessment of the skull of a normal 10-monthold baby should identify which of the following? 1. 2. 3. 4.

closure of the posterior fontanel. closure of the anterior fontanel. overlap of cranial bones. ossification of the sutures.

175. Which is the best way to position a client’s neck for palpation of the thyroid? 1. 2. 3. 4.

flexed toward the side being examined hyperextended directly backward flexed away from the side being examined flexed directly forward

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166. The nurse is teaching a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?

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176. Signs of impaired breathing in infants and children include all of the following except: 1. 2. 3. 4.

nasal flaring. grunting. seesaw breathing. quivering lips.

177. Which of the following observations is most important when assessing a client’s breathing? 1. 2. 3. 4.

presence of breathing and pulse rate breathing pattern and adequacy of breathing presence of breathing and adequacy of breathing patient position and adequacy of breathing

178. A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD). Oxygen is delivered at 1 L/min per nasal cannula. The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations? 1. 2. 3. 4.

COPD clients are stimulated to breathe by hypoxia. COPD clients depend on a low carbon dioxide level. COPD clients tend to retain hydrogen ions if they are given high doses of oxygen. COPD clients thrive on a high oxygen level.

179. A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63mmHg, HCO3 23, and oxygenation saturation ( SaO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs? 1. 2. 3. 4.

tuberculosis (TB) pneumonia pleural effusion hypoxia

180. The nurse is teaching a client about erythema infectiosum. Which of the following factors are not correct? 1. 2. 3. 4.

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There is no rash. The disorder is uncommon in adults. There is no fever. There is sometimes a “slapped face” appearance.

181. Which isolation procedure will be followed for secretions and blood? 1. 2. 3. 4.

Respiratory Standard Precautions Contact Isolation Droplet

182. A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents: 1. 2. 3. 4.

assessment. crisis intervention. empathetic concern. unwarranted intrusion.

183. The death of a beloved spouse places the surviving partner in which type of crisis? 1. 2. 3. 4.

maturational reactive nonreactive situational

184. A client with asthma develops respiratory acidosis. Based on this diagnosis, what should the nurse expect the client’s serum potassium level to be? 1. 2. 3. 4.

normal elevated low unrelated to the pH

185. A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage? 1. 2. 3. 4.

Test all excreta for occult blood. Use a soft toothbrush or foam cleaner for oral hygiene. Implement reverse isolation. Avoid IM injections.

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1. 2. 3. 4.

the inability of the kidneys to excrete the drug metabolites. rapid cell catabolism. toxic effects of the prophylactic antibiotics that are given concurrently. the altered blood pH from the acid medium of the drugs.

187. The drug of choice to decrease uric acid levels is: 1. 2. 3. 4.

prednisone (Colisone). allopurinol (Zyloprim). indomethacin (Indocin). hydrochlorothiazide (HydroDiuril).

188. A client recently lost a child due to poisoning. The client tells the nurse, “I don’t want to make any new friends right now.” This is an example of which of the following indicators of stress? 1. 2. 3. 4.

emotional behavioral indicator spiritual indicator sociocultural indicator intellectual indicator

189. A corporate executive works 60–80 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions? 1. 2. 3. 4.

structure relaxation technique time management regular exercise

190. In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess? 1. 2. 3. 4.

ability to speak ability to hear oxygen saturation adventitious breath sounds

191. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except: 1. 2. 3. 4.

diabetic signs and symptoms. nutritional status. bleeding problems. availability of insulin.

192. In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers? 1. 2. 3. 4.

Place extra padding under the mother to absorb blood from the delivery. Cut the umbilical cord using sterile scissors. Suction the baby’s mouth and nose. Wrap the baby in a clean blanket to preserve warmth.

193. Ethical and moral issues concerning restraints include all of the following except: 1. 2. 3. 4.

emotional impact on the client and family. dignity of the client. client’s quality of life. policies and procedures.

194. Attaching a restraint to a side rail or other movable part of the bed can: 1. 2. 3. 4.

do nothing to the client. injure the client if the rail or bed is moved. help the client stay in the bed without falling out. help the client with better posture.

195. How often must physical restraints be released? 1. 2. 3. 4.

every 2 hours between 1 and 3 hours every 30 minutes at least every 4 hours

196. Social support systems include of the following except: 1. 2. 3. 4.

call-in help lines. emotional assistance provided by others. community support groups. use of coping skills and verbalization for anger management.

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186. High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by:

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197. Support-system enhancement includes all of the following except: 1. 2. 3. 4.

determining the barriers to using support systems. discussing ways to help with others who are concerned. exploring life problems of the support-team members. involving spouse, family, and friends in the care and planning.

198. Using clichés in therapeutic communication leads the client toward: 1. 2. 3. 4.

viewing the nurse as human. accepting himself as human. self-disclosing. feeling discounted.

199. In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client’s: 1. 2. 3. 4.

feelings about what has been described. thoughts about what has been described. possible solutions to the problem. intent in sharing the description.

200. The most effective nursing strategy to assist a client in recognizing and using personal strength includes: 1. 2. 3. 4.

encouraging the client’s self-identification of strengths. promoting the client’s active external thinking. listening to the client and providing advice as needed. assisting the client in maintaining an external locus of control.

201. Appropriate nursing strategies to assist a client in maintaining a sense of self include: 1. 2. 3. 4.

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using the client’s first name when addressing the client. treating the client with dignity. explaining procedures only if the client is attentive. discouraging the use of personal items.

202. A client with Parkinson’s disease has difficulty performing voluntary movements. This is known as: 1. 2. 3. 4.

akinesia. dyskinesia. chorea. dystonia.

203. A client who is newly diagnosed with Parkinson’s disease and beginning medication therapy asks the nurse, “How soon will I see improvement ?” The nurse’s best response is: 1. 2. 3. 4.

“That varies from client to client.” “You should discuss that with your physician.” “You should notice a difference in a few days.” “It might take several weeks before you notice improvement.”

204. A client newly diagnosed with Diabetes Mellitus needs education. Which of the following statements should the nurse include in this education? 1. 2. 3. 4.

“You can eat anything you want, but no foods with sugar.” “You need to lose weight, so your diet must be a restricted one.” “You need a diet and exercise program.” “You must eliminate all salt, fat, and sugar from your diet.”

205. A client, age 28, is 8 1⁄2 months pregnant. She is most likely to display which normal skin-color variation? 1. 2. 3. 4.

vitiligo erythema cyanosis chloasma

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For your reference, the appropriate review chapter is listed at the end of each answer explanation below. 1. (3) Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric is a term applied to the period of life in which physiologic changes occur and result in cessation of a woman’s reproductive ability and lessened sexual activity in males. The term applies to both genders. Climacteric and menopause are interchangeable terms when used for females. Menopause is the period when permanent cessation of menses has occurred. Postmenopause refers to the period after the changes accompanying menopause are complete. Health Promotion and Maintenance 2. (4) Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy. Health Promotion and Maintenance 3. (4) Parents should be taught to wash their hands before and after providing cord care. This prevents transferring pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying. It also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include cleaning the area around the cord 3–4 times a day with a cotton swab but do not include putting alcohol or other antimicrobials on the cord. It is normal for the cord to turn dark as it dries. Health Promotion and Maintenance 4. (1) Parents must be careful when warming bottles in a microwave oven because the milk can become superheated. When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new formula. Health Promotion and Maintenance 5. (3) In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 – 6 = 12. An 18-month-old child should have approximately 12 teeth. Health Promotion and Maintenance 6. (2) The nurse might be concerned about developmental dysplasia of the hip if an 11–12-month-old child doesn’t pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11–15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants. Health Promotion and Maintenance 7. (3) Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L. Physiological Adaptation 8. (4) Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis are at risk for hypokalemia and should be encouraged to eat foods high in potassium. Physiological Adaptation 9. (2) These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values indicate none of these acid-base disturbances. Physiological Adaptation 10. (3) Sodium and chloride are the major electrolytes in the extracellular fluid. Physiological Adaptation

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Answers and Explanations for Practice Test 1

Part II: NCLEX-PN Practice Tests

11. (3) Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease. Health Promotion and Maintenance 12. (4) Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infant’s development of trust and how others relate to them because of their diagnosis. The longterm effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac. Health Promotion and Maintenance 13. (1) This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is important to the client. The other statements are culturally insensitive and unprofessional. Reduction of Risk Potential 14. (3) Decreasing maternal fluids is the only intervention that should not be performed when fetal distress is indicated. Reduction of Risk Potential 15. (1) Variable decelerations can be related to cord compression. The other patterns are not. Reduction of Risk Potential 16. (2) Mammography is used to detect tumors or cysts in the breasts, not the other conditions. Reduction of Risk Potential 17. (4) Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants interfere with mammography. Reduction of Risk Potential 18. (2) Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home. Reduction of Risk Potential 19. (3) Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result from inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic factor normally produced by gastric mucosal cells and certain disorders of the small intestine that impair absorption. The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as the need for folic acid, rest, diet, and support. Physiological Adaptation 20. (2) Effective Heparin therapy should stop the process of intravascular coagulation and result in increased availability of fibrinogen. Heparin administration interferes with thrombin-induced conversion of fibrinogen to fibrin. Bleeding should cease due to the increased availability of platelets and coagulation factors. Physiological Adaptation 21. (4) Pathologic fractures are not common to the disease process. Its treatment through osteoporosis is a potential complication of steroid use. Hodgkin’s disease most commonly affects young adults (males), is spread through lymphatic channels to contiguous nodes, and also might spread via the hematogenous route to extradal sites (GI, bone marrow, skin, and other organs). A working staging classification is performed for clinical use and care. Physiological Adaptation 22. (1) Granulocyte transfusion is not indicated to prevent infection. Produced in the bone marrow, granulocytes normally comprise 70% of all WBCs. They are subdivided into three types based on staining properties: neutrophils, eosinophils, and basophils. They can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production. Physiological Adaptation 23. (1) Coma might be seen in a client with a high ammonia level. Reduction of Risk Potential

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25. (2) Uric acid levels are indicated for clients with gout. Reduction of Risk Potential 26. (2) Due to the high cholesterol content of red meats, such as hamburger, intake needs to be decreased. The other options do not have high cholesterol content, so they do not need to be decreased. Reduction of Risk Potential 27. (1) High HDL cholesterol and low LDL cholesterol are associated with a decreased risk of cardiovascular disease. Reduction of Risk Potential 28. (3) The small intestine has a primary function of absorption. The remaining digestive organs have other primary functions. Physiological Adaptation 29. (3) The nurse should expect to find abdominal tenderness in the lower-right quadrant in a client with appendicitis. Physiological Adaptation 30. (4) This statement is most appropriate, as it shows respect and empathy. The other statements are both insensitive and unprofessional. Physiological Adaptation 31. (1) This statement reveals cultural sensitivity. Ginger is sometimes used to relieve nausea. The other statements are culturally insensitive and do not show an awareness of herbal pharmacology. Physiological Adaptation 32. (2) Zofran is a serotonin antagonist that can be used to relieve nausea and vomiting. The other medications can be used for nausea and vomiting, but they have different mechanisms of action. Physiological Adaptation 33. (4) STDs affect certain groups in groups in greater numbers. Factors associated with risk include being younger than 25 years of age, being a member of a minority group, residing in an urban setting, being impoverished, and using crack cocaine. Physiological Adaptation 34. (2) Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Physiological Adaptation 35. (4) Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases. The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the world’s population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine childhood immunization. They have not, however, been eradicated, so children need to be immunized against these diseases. Physiological Adaptation 36. (2) Acyclovir (Zovirax) is specific for treatment of herpes virus infections. There is no cure for herpes. Acyclovir is excreted unchanged in the urine and therefore must be used cautiously in the presence of renal impairment. Drugs that treat herpes inhibit viral DNA replication by competing with viral substrates to form shorter, ineffective DNA chains. Physiological Adaptation 37. (2) Moving the wheelchair close to client’s bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb. Basic Care and Comfort 38. (1) Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill, cool fingers or toes, and pain. Basic Care and Comfort 39. (3) Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids. Basic Care and Comfort 40. (4) The usual recommendation for treatment of hypoglycemia is 10–15 grams of a fast-acting simple carbohydrate, orally, if the client is conscious and able to swallow (for example, 3–4 commercially prepared glucose tablets or 4–6 oz of fruit juice). It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level. Addition of sugar might result in a sharp rise in blood sugar that could last for several hours. Physiological Adaptation 41. (3) Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client’s BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a client’s BMI, activity status, and energy requirements. Physiological Adaptation

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24. (4) A client with cirrhosis is at risk for developing a high ammonia level. Reduction of Risk Potential

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42. (3) A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions. Physiological Adaptation 43. (3) Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident. Physiological Adaptation 44. (1) A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact. Physiological Adaptation 45. (2) Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus. Basic Care and Comfort 46. (4) Duodenal intestinal fluid is rich in K+, NA+, and bicarbonate. Suctioning to remove excess fluids decreases the client’s K+ and NA+ levels. Basic Care and Comfort 47. (3) Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing. Basic Care and Comfort 48. (4) Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate. Basic Care and Comfort 49. (4) Morton’s neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as a bunion. Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot. Basic Care and Comfort 50. (2) A strain is excessive stretching of a ligament. A sprain involves a twisting motion involving muscles. Basic Care and Comfort 51. (4) To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present. Basic Care and Comfort 52. (3) Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available. Basic Care and Comfort 53. (2) Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse’s back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized. Basic Care and Comfort 54. (4) If findings are ominous, the grieving process will not be completed before birth. If the couple elects to terminate a pregnancy based on diagnostic tests, there will be grief and concerns for future pregnancies. Couples might choose to access support services and prepare for the birth of an infant with special needs. Some fetal conditions can be treated in utero. Health Promotion and Maintenance

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56. (2) Eggs are a complete protein. The remaining options are incomplete proteins. Health Promotion and Maintenance 57. (4) Scurvy is associated with inadequate intake of vitamin C. The remaining choices refer to other nutritional deficiencies. Health Promotion and Maintenance 58. (2) Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian. Health Promotion and Maintenance 59. (1) The nurse should change the intravenous tubing on total parenteral nutrition solutions every 24 hours, due to the high risk of bacterial growth. Health Promotion and Maintenance 60. (3) Glucose is monitored closely when a client is on total parenteral nutrition, due to high glucose concentration in the solutions. The other values are not monitored as closely. Health Promotion and Maintenance 61. (2) Acetaminophen is extensively metabolized in the liver. Choices 1, 3, and 4 are incorrect because prolonged use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands. Pharmacological Therapies 62. (4) Light therapy can be effective in treating problems associated with sleep patterns, stress, moods, jaundice in newborns, and seasonal affective disorders. Nonpharmacological Therapies 63. (4) Controversy over what types of food to eat and not eat is still under investigation. Certain foods can help improve body defenses to possibly prevent certain diseases. Nonpharmacological Therapies 64. (3) Fiber-rich foods (such as grains, apples, potatoes, and beans) can help lower cholesterol. Nonpharmacological Therapies 65. (2) Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems. Choice 1 is incorrect because it is a nursing intervention, not a goal statement. Choice 3 is incorrect because it is a therapeutic treatment. Choice 4 is incorrect because weight gain is an appropriate goal only if the client is underweight. Basic Care and Comfort 66. (4) Meals that are high in carbohydrates promote rapid gastric emptying. The other options are associated with decreased emptying time. Basic Care and Comfort 67. (3) Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. The other foods do not affect LES pressure. Basic Care and Comfort 68. (4) Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation. Basic Care and Comfort 69. (3) The goals of palliative care include choices 1, 2, and 4. Choice 3 is not part of palliative care. All aspects of medical, emotional, social, and spiritual needs of the dying client should be focused on until the end of life. Basic Care and Comfort 70. (1) There are many competencies that the nurse must have to care for families and clients at the end of life. Demonstration of respect and compassion as well as using knowledge and skills in the care of the client and family are major competencies. Basic Care and Comfort 71. (2) Thrill should be present. The client should be taught to check this daily at home. Pulsation is not typically visible. Percussion gives no information about the patency of a fistula. Blood pressure is not auscultated in a limb with an AVF. Auscultation of the AVF, for a bruit, is part of an assessment for patency. Physiological Adaptation

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55. (2) Of the nursing diagnoses listed, the client’s statement most represents Body Image Disturbance because it directly refers to loss of the function of having a child. Nothing in the statement indicates that the client is at risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the statement does not reflect a disruption of the parent’s role. Powerlessness could be an appropriate nursing diagnosis if the client described feeling powerless about the infertility. Health Promotion and Maintenance

Part II: NCLEX-PN Practice Tests

72. (2) Kegel exercises, tightening and releasing the pelvic floor muscles, might improve stress incontinence. Choice 1 is not an appropriate treatment for stress incontinence. Several effective surgical treatments exist. Lifestyle and dietary modifications can also be helpful. Physiological Adaptation 73. (4) A urologist consult is appropriate for a client with visible blood at the urethral meatus and suspected trauma. Choices 1 and 2 are contraindicated. A urinalysis might be ordered by the physician, but the question does not provide enough information to make Choice 3 the correct answer. Physiological Adaptation 74. (1) The kidneys of a client in renal failure produce no erythropoietin, a hormone necessary for RBC production. Erythropoietin can be given as replacement, but the client needs adequate iron, folate, and B12 to increase the effectiveness of EPO. Choice 2 is not necessary for RBC production and can increase uremia. Choices 3 and 4 are not necessary for RBC production. Physiological Adaptation 75. (4) Batterers cannot be predicted by demographic features related to age, ethnicity, race, religious denomination, education, socioeconomic status, or class. Ninety-five percent of domestic abuse cases involve male perpetrators and female victims. Psychosocial Integrity 76. (3) Many batterers report having been abused as children. Psychosocial Integrity 77. (2) To gain insight, the client needs to recognize causal events. The other activities focus on recognition of anxiety. Psychosocial Integrity 78. (3) Xanax, like other benzodiazepines, can cause withdrawal symptoms that include agitation, insomnia, hypertension, seizures, and abdominal pain. The drug must be slowly decreased to prevent withdrawal symptoms. Psychosocial Integrity 79. (2) Children who are shaken are frequently grasped by both upper arms. Symptoms of brain injury associated with shaking include decreased level of consciousness. Psychosocial Integrity 80. (4) Prevention of child abuse is centered on teaching the parents how to care for their child and cope with the demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents benefit by understanding the developmental needs of their children, while learning how to manage their home environment more effectively. The classes also increase the parents’ social contacts and teach about community resources. Psychosocial Integrity 81. (4) The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs as well as reducing the risk of pregnancy. IUDs, Norplant, and oral contraceptives can prevent pregnancy but not the transmission HIV and STDs. Clients using the contraceptive methods in Choices 1, 2, and 3 should be counseled to use a chemical or barrier contraceptive to decrease transmission of HIV or STDs. Health Promotion and Maintenance 82. (3) Parents are the primary force in sex education in a child’s life. The school nurse is involved with formal sex education and counseling. Peers become more important in sex education during adolescence but might lack correct information. The media play a powerful role in what children learn about sex through movies, TV, and video games. Health Promotion and Maintenance 83. (4) There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing actions include asking the child to explain what each family member is doing, encouraging him or her to tell as much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in the drawing, noting facial expressions of family members and noting if they are facing each other or turned away. Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting themes to the child. Health Promotion and Maintenance 84. (4) Dental problems are prevalent because of the lack of preventive care and access to care. High infant mortality is one of the most significant problems correlated with poverty. Pregnant women who do not have access to care might come to the Emergency Department when in labor. Those in poverty are likely to use Emergency Departments because they may not be turned away. Those in poverty might also turn to folk healers or other persons in their community for care who might be easier to access and might not demand payment. Health Promotion and Maintenance

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86. (2) The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question. Reduction of Risk Potential 87. (3) A client having a seizure should be turned to the side to prevent aspiration of secretions. The other statements are correct and indicate adequate understanding of teaching. Reduction of Risk Potential 88. (1) The client with Parkinson’s disease can develop a shuffling gait and rigidity, causing impaired physical mobility. The other diagnoses do not necessarily relate to a client with Parkinson’s disease. Reduction of Risk Potential 89. (4) Huntington’s chorea is characterized by writhing, twisting movements of the face and limbs. The remaining options are neurological disorders that do not have such movements as part of their disease process. Reduction of Risk Potential 90. (3) The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what’s happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present. Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and might even find performance enhanced. The individual with moderate anxiety grasps less information about the situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in panic demonstrates markedly disturbed behavior and might lose touch with reality. Psychosocial Integrity 91. (2) Somatizing means one experiences an emotional conflict as a physical symptom. Ashley manifests several physical symptoms associated with severe anxiety. Acting out refers to behaviors such as anger, crying, laughter, and physical or verbal abuse. Withdrawal is a reaction in which psychic energy is withdrawn from the environment and focused on the self in response to anxiety. Problem-solving takes place when anxiety is identified and the unmet need is met. Psychosocial Integrity 92. (2) Every person is worthy of dignity and respect. Every person has the potential to change and grow. All people have basic human needs in common with others. All behavior has meaning and can be understood from the client’s perspective. Psychosocial Integrity 93. (3) Displacement is the transference of anger to another. Anger is displaced on the dog as a convenient object. Psychosocial Integrity 94. (1) The amount of alcohol that is safe during pregnancy is unknown. Fetal alcohol syndrome is a combination of mental and physical abnormalities present in infants born to mothers who have consumed alcohol during pregnancy. Psychosocial Integrity 95. (1) Drug tolerance is characterized by the ability to ingest a larger dose without adverse effect and decreased sensitivity to the substance. Substance dependence is a severe condition indicating physical problems and disruption of the person’s social, family, and work life. The psychological behaviors related to substance use are termed addiction. Dual diagnosis is the coexistence of substance abuse and psychiatric disorders. Psychosocial Integrity 96. (1) The hands are cupped for performing percussion, producing a vibration that helps loosen respiratory secretions. The other hand positions do not accomplish this task. Reduction of Risk Potential 97. (3) The hands are flattened over the area of the body where chest percussion is used to conduct vibration through to the chest and loosen secretions. The other hand positions do not accomplish this task. Reduction of Risk Potential 98. (2) A synthetic gown might generate sparks of static electricity, which can be a fire hazard, particularly in the presence of oxygen. The client on oxygen therapy should wear a cotton gown. The remaining options are appropriate safety measures. Reduction of Risk Potential 99. (3) The highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by mask. Reduction of Risk Potential

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85. (1) The nurse needs to open the airway first when the oxygen saturation drops. The other actions might be appropriate, but the airway must be patent. Reduction of Risk Potential

Part II: NCLEX-PN Practice Tests

100. (1) An oropharyngeal airway is measured from the corner of the client’s mouth, to the tragus of the ear. Reduction of Risk Potential 101. (3) Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control. Psychosocial Integrity 102. (1) Nurses need to inform clients that there is a difference in perceptions and pay attention to the content of hallucinations. The other options are not therapeutic. Psychosocial Integrity 103. (2) Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts. Psychosocial Integrity 104. (4) A realistic short-term goal is for the client to verbalize feelings about the event. A brief treatment program is not designed to identify or resolve problems. The focus is on managing acute symptoms. If in-depth psychological problems are identified, the nurse might make referrals for treatment. Psychosocial Integrity 105. (2) The purpose of the PSDA is to promote decision-making prior to need. Choices 1, 3 and 4 are incorrect. The focus of the PSDA is individual health care decision-making. A federal standard for advance directives does not exist. Each state has jurisdiction regarding these policies and protocols. Coordinated Care 106. (2) Advocacy for clients by nurses is the primary focus of the client’s right to autonomy and self-determination. Confidentiality involves the maintenance of the privacy of the client and information regarding him or her. Malpractice insurance is a type of insurance for professionals. Coordinated Care 107. (2) By definition, case management is a process of providing for the comprehensive care needs of a client for continuity of care throughout the health care experience. Coordinated Care 108. (4) Confidentiality is the maintenance of privacy of information. The question does not suggest that confidentiality has been breached. The client is likely to demand the other rights and may exercise them in choosing to leave the hospital early. Coordinated Care 109. (4) This nurse manager is demonstrating assertive behavior. Aggressive behavior dominates or embarrasses. Passive behavior is nervous or timid. Passive-aggressive behavior is dominating or manipulative without directness. Coordinated Care 110. (4) Legal protection of confidentiality extends to both written and verbal information identifiable as individual private health information. Coordinated Care 111. (2) A gynecologist is the physician who treats and manages disease of the female reproductive organs. A radiologist evaluates X-rays. A physiatrist is the physician manager of a rehabilitation team. An oncologist treats clients with cancer. Coordinated Care 112. (4) Statistical patterns of health care utilization indicate that Emergency Departments and urgent care centers provide a large portion of health care to those who live in poverty. Coordinated Care 113. (2) Compliance or performance at the minimally acceptable level is not considered quality care. Coordinated Care 114. (3) If a delegator has confidence in his subordinates and feels that a task will be performed correctly, he is more likely to delegate. Reasons that delegators are reluctant to delegate include their own lack of confidence, fear of losing authority or personal satisfaction, and feeling that the task can only be performed correctly if they do it themselves. Coordinated Care 115. (3) The nurse changes the plan to respond to changes in needs. Coordinated Care 116. (4) All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. The body has a physiological response to stress that can decrease the immune response and increase the risk of disease. Health Promotion and Management

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118. (4) All the choices are elements of the ANA Code of Ethics for Nurses. Coordinated Care 119. (2) Incident reports are a tool for determining how future problems can be avoided. Incident reports do not provide liability protection. Incident reports are not meant to be used for disciplining staff. Safety and Infection Control 120. (3) The 72-year-old client scheduled for heart transplant surgery may give informed consent for the surgery. There are no age limitations with the exception of minors. Choices 1, 2, and 4 are incorrect. An individual with advanced Alzheimer’s disease is incompetent to make decisions. Only an emancipated minor may give consent (a 14-year-old child who lives alone, away from family, and is totally independent). Infants are unable to give consent. Coordinated Care 121. (1) Torts are wrongs committed by one person against another person (or against the property of another), which might result in civil trials. A crime is also defined as a wrong against a person or their property but is considered to be against the public as well. Misdemeanors are crimes that are commonly punishable with fines or imprisonment for less than one year, with both or with parole. A felony is a serious crime punishable by imprisonment in a State or Federal penitentiary for more than one year. Coordinated Care 122. (2) The family provides sick care to its members. The other options are incorrect. Prevention and Early Detection of Disease 123. (1) The Health Belief Model describes readiness factors; the perceived feelings of susceptibility and seriousness of the health problem (the threat); and positive motivation to maintain, regain, or attain wellness. Health Promotion and Maintenance 124. (4) Health promotion activities are designed to help clients reduce the risk of illness, maintain maximum function, and promote health habits related to health care. Health Promotion and Maintenance 125. (1) Rehabilitation services should begin when the client enters the health care system. Health Promotion and Maintenance 126. (2) By 12 months of age, the child should have had DtaP and polio. MMR is not administered until a child is 12 months of age. Health Promotion and Maintenance 127. (3) Toddlers are possessive and struggle for independence. The other play activities are too advanced for a 2-year-old child. Health Promotion and Maintenance 128. (1) Vaccines provide active immunity. Passive immunity comes from antibodies produced in another human or host. Transplacental immunity comes from passive immunity transferred from mother to infant. Health Promotion and Maintenance 129. (1) Pneumococcal vaccine should be administered as a supplemental vaccine. Hepatitis A vaccine is for travelers and individuals with chronic liver disease. The Lyme disease vaccine is for people between the ages of 15 and 70 who are at risk for Lyme disease (transmitted by ticks primarily). The typhoid vaccine is for workers in microbiology laboratories who frequently work with Salmonella typhi. Health Promotion and Maintenance 130. (4) These are appropriate measure to promote sleep. Choices 1, 2, and 3 are all stimulation actions that increase arousal and wakefulness. Basic Care and Comfort 131. (3) Preschool-age children require bedtime rituals that should be followed in the hospital if possible. Choice 1 increases a child’s fear. Choices 2 and 4 do not promote sleep. Basic Care and Comfort 132. (1) Circadian rhythm is rhythmic repetition of patterns each 24 hours. The other options are incorrect. Basic Care and Comfort

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117. (2) Assessment is the first step. Assessing what the client eats helps the nurse determine a plan for dietary recommendations based on the ADA and AHA guidelines. Providing the client with a copy of the guidelines is important but is not the first priority. Based on the client’s wish to reduce her chances of heart disease and diabetes, a high-protein diet plan might not be appropriate. Providing information to the client related to risk factors for heart disease and diabetes is important but is not the first step. Health Promotion and Management

Part II: NCLEX-PN Practice Tests

133. (1) Normal saline is 0.9% sodium chloride. This solution has the same osmolarity as blood. Its use does not cause lysis of cells. Choices 2 and 3 are hypotonic solutions that can cause cell lysis. Choice 4 is an anticoagulant. Pharmacological Therapies 134. (3) Many chemotherapeutic drugs are vesicants (highly active corrosive materials that can produce tissue damage even in low concentrations). Administration into a large vein is optimal. Choice 1 is incorrect because CVADs are more expensive than a peripheral IV. Choice 2 is incorrect because dosing depends on the drug. Choice 4 is incorrect because IV chemotherapeutic agents are not routinely administered at home; they are usually given in a hospital or in an outpatient or clinic setting. Pharmacological Therapies 135. (1) Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription. Choice 2 is incorrect because alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression. Choice 3 is incorrect because nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkin’s lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA crosslinkage. Choice 4 is incorrect because alkylating agents are non-cell-cycle-specific agents. Pharmacological Therapies 136. (3) Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect. Choice 1 is incorrect because less drug is available if it is bound to protein. Choice 2 is incorrect because distribution to receptor sites is irrelevant if the drug, which is bound to protein, cannot bind with a receptor site. Choice 4 is incorrect because metabolism is not increased. The liver first has to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again. Pharmacological Therapies 137. (2) A client with an infection needs both antibiotics as soon a possible. However, the pH of ampicillin is 8–10, and the pH of gentamicin is 3–5.5 (making them incompatible when given together). Flushing well between drugs is necessary. Choice 3 is incorrect because the PN determines the correct steps and consults with the pharmacist and the physician as necessary. Choice 4 is incorrect because delaying the second medication by several hours slows the treatment of the client’s infection. Pharmacological Therapies 138. (1) They have a high energy-to-fluid-volume ratio. Fat emulsions are formulated in 10%, 20%, and 30% solutions and supply 1.1, 2, and 3 kilocalories respectively for each milliliter. A milliliter of 5% dextrose only supplies 0.17 kilocalories. Choices 2, 3, and 4 are incorrect because fat emulsions are essentially pH neutral and isotonic. Pharmacological Therapies 139. (2) The nurse should positively reinforce each expression of feelings. Psychosocial Integrity 140. (3) The nurse can raise the client’s self-esteem by communicating confidence the client can participate in actively finding solutions to the problem. The nurse also conveys the client is a worthwhile person by listening and accepting the client’s feelings and praising the client for seeking assistance. Psychosocial Integrity 141. (4) Barriers to reporting elder abuse include victim shame, fear of reprisals, fear of loss of caregiver, and lack of knowledge of agencies that provide services. Many elders fear that reporting abuse results in their placement in long-term care because the current caregiver is the abuser. Choices 1 and 3 are incorrect. Choice 2 might be true but is not the best choice. Psychosocial Integrity 142. (2) Using a direct approach is best when asking about suspected abuse. Clients are reluctant to report abuse because of shame and fear of reprisal. Psychosocial Integrity 143. (4) Highly perfused tissue includes all vital organs: the brain, heart, kidneys, adrenal glands, and liver. Choices 1, 2, and 3 are incorrect because the skin and adipose tissue are poorly perfused, while the skeletal muscle is better perfused. Pharmacological Therapies 144. (4) Small volumes of medication or fluids are delivered and sometimes at slow rates to neonates and pediatric clients. The syringe pump allows precise infusion of small volumes. Choice 1 is incorrect because a syringe pump can be used in almost any setting, but is not generally for adult clients. Choices 2 and 3 are incorrect because large volumes of fluids are not administered with a syringe pump. Pharmacological Therapies

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146. (4) The only skilled service listed is medication instruction. Grocery shopping, house-cleaning services, and transportation services are all examples of unskilled services offered by volunteer and fee-for-service agencies. Coordinated Care 147. (3) The therapeutic index is the ratio between the median lethal dose and median effective dose of a drug. It provides a general indication of the margin of safety of a drug. Choice 1 is incorrect because pharmacokinetics is the process of adsorption, distribution, metabolism, and elimination. Choice 2 is incorrect because narrow therapeutic index drugs require close monitoring since there is often little difference between the desired drug effect and toxicity. Choice 4 is incorrect because narrow therapeutic index drugs have the potential for severe toxic effects with only slight increases in the dose or slight decreases in elimination. Pharmacological Therapies 148. (4) A simple cold without fever does not preclude vaccination. Choices 1 and 2 are incorrect because pregnant women and immunocompromised individuals cannot have the MMR vaccine because the rubella component is a live virus and might cause birth defects and/or disease. Choice 3 is incorrect because the American Academy of Pediatrics states, “Persons who have experienced anaphylactic reactions to topically or systemically administered neomycin should not receive measles vaccine.” Pharmacological Therapies 149. (1) This occurs most often when drug solutions are combined before they are given intravenously but can occur with orally administered drugs as well. Choices 2, 3, and 4 are incorrect because drugs can cause these events after administration and absorption. Pharmacological Therapies 150. (1) Naloxone is an opiate antagonist. It attaches to opiate receptors and blocks or reverses the action of narcotic analgesics. Choice 2 is incorrect because Labetalol is a beta blocker. Choice 3 is incorrect because Neostigmine is an anticholinesterase agent. Choice 4 is incorrect because Thiothixene is an antipsychotic agent. Pharmacological Therapies 151. (2) Tolerance is the capacity to ingest an increasing amount of a substance without effect and the experience of decreased sensitivity to the substance. Tolerance can develop with long-term use of many drugs. Choice 1 is the dose required to produce a defined magnitude of drug effect. Choice 3 binds to a receptor and causes an action. Choice 4 is the maximal response produced by a drug. Pharmacological Therapies 152. (1) The greatest time-savers when planning client care are activities that facilitate focus and completion of priority items. Time-savers include setting goals, establishing priorities, planning tasks, delegating where appropriate, re-assessment, and ongoing evaluation of needs. Coordinated Care 153. (1) Facilitating the development of staff members is an important goal for a supervisor. Micromanagement, intolerance for individual differences in style, and inability to delegate all interfere with team building and overall effectiveness. Coordinated Care 154. (2) Transference phenomena are intensified in relationships with authority, such as physicians and nurses. Common positive transferences include desire for affection and gratification of dependency needs. Common negative transferences include hostility and competitiveness. These transferences must be recognized and resolved before growth and positive change can be undertaken in the working stage. Psychosocial Integrity 155. (3) The client has a right to know the parameters of the nurse-client relationship. If the relationship is to be time limited, the client should be informed of the number of sessions. If it is open-ended, the termination date is not known at the outset, and the client should know that this is an issue that is negotiated at a later date. Coordinated Care 156. (1) Denial (Kübler-Ross’s Stages of Grieving) is the refusal to believe that loss is happening. Psychosocial Integrity 157. (2) Cheyne-Stokes respirations are rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure. This can be a sign of impending death. Psychosocial Integrity 158. (1) The nurse needs to recognize her own beliefs and biases and learn about the client’s cultural beliefs. Psychosocial Integrity

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145. (3) The client’s legally responsible party may make the decision for organ donation if the client is unable to do so. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process regarding whether organ donation is appropriate for a specific donor. Coordinated Care

Part II: NCLEX-PN Practice Tests

159. (2) Special hair, skin, and nail care might be required for African-American clients. Psychosocial Integrity 160. (4) Because Hispanic people represent a large percentage of migrant workers in the United States, many work in agricultural settings and might be exposed to pesticides, putting them at higher risk than the other groups. Safety and Infection Control 161. (4) The most common type of first-degree burn is sunburn, underscoring the need for education regarding the use of sunscreens and avoiding exposure. Safety and Infection Control 162. (4) Inhalation is the most common cause of injury from a house fire. Accident Prevention 163. (1) Testing that identifies clients without a disease is said to be specific, while testing that identifies clients with a disease is said to be sensitive. Safety and Infection Control 164. (2) A false-positive result occurs when a test result is labeled positive in error, when the actual result is negative. Safety and Infection Control 165. (2) The vast majority of deaths resulting from unintentional poisoning occur in toddlers. Safety and Infection Control 166. (3) Genital herpes can be transmitted by oral, genital, and anal sex. The other statements are myths. Safety and Infection Control 167. (4) All of the choices are anti-HIV drugs. Safety and Infection Control 168. (3) Tattooing puts a client at risk for blood-borne hepatitis B or C if strict sterile procedures are not followed. Tuberculosis is an airborne pathogen, while herpes and syphilis are spread directly (such as through sexual contact). Safety and Infection Control 169. (2) The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure. Safety and Infection Control 170. (3) The scenario describes classic impetigo for which the physician is likely to order antibiotic therapy. Chickenpox is highly contagious but presents with a history of high fever followed by a vesicular rash. Safety and Infection Control 171. (3) Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become permanently stained. Clients should be taught about these side effects to avoid unnecessary concern. Safety and Infection Control 172. (1) There is a concern that a segment of the population is not accessing prenatal care, affecting infant and maternal mortality and morbidity. Health Promotion and Maintenance 173. (4) Start a fast weight-loss diet. Health Promotion and Maintenance 174. (1) The posterior fontanel should close by the age of 2 months. Health Promotion and Maintenance 175. (1) Flexed toward the side being examined. Health Promotion and Maintenance 176. (4) Lip quivering is a distracter. Signs of impaired breathing in infants and children include all the other options. Physiological Adaptation 177. (3) It is not enough to simply make sure the client is breathing. The client must be breathing adequately. Physiological Adaptation 178. (1) COPD clients are compensating for low oxygen and high carbon dioxide levels. Hypoxia is the main stimulus to breathe in persons with chronic hypercapnia. Increasing the level of oxygen decreases the stimulus to breathe. Physiological Adaptation 179. (4) A combined low PO2 and lowSaO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. Depending on the degree of the pneumonia, the PO2 and PCO2 might be low because hypoxia stimulates hyperventilation. Physiological Adaptation 180. (2) Fifth’s disease, erythema infectiosum, is uncommon in adults. All the other statements are correct. Safety and Infection Control

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182. (2) Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client’s coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims. Coordinated Care 183. (4) A situational crisis is an unexpected, unplanned event, such as the death of a spouse. Option 1 is a normal maturational crisis; Choices 2 and 3 are not recognized crisis states. Coordinated Care 184. (2) Hyperkalemia occurs in a state of acidosis because potassium moves from injured cells into the bloodstream. Physiological Adaptation 185. (3) Reverse isolation does not affect the risk of hemorrhage. Physiological Adaptation 186. (2) Chemotherapy causes damage to cells, and uric acid is a cell metabolite. Physiological Adaptation 187. (2) Allopurinol is a drug used to treat gout, and it decreases uric acid formation. Prednisone is a corticosteroid used to decrease inflammation. Indomethacin is an analgesic, anti-inflammatory, and antipyretic agent. Hydrochlorothiazide is a thiazide diuretic used to treat hypertension and edema. Physiological Adaptation 188. (3) Stress can alter a person’s relationships with others. Psychosocial Integrity 189. (2) Biofeedback techniques can be used to quiet the mind, release tension, and counteract responses of general adaptation syndrome or stress syndrome. Nurses teaching relaxation techniques should encourage use of these techniques in stressful situations. Psychosocial Integrity 190. (1) Ability to speak is a major way to identify an airway obstruction. Safety and Infection Control 191. (3) Bleeding problems are not characteristic of diabetes. All the other options are appropriate areas of assessment. Safety and Infection Control 192. (3) After the baby delivers, the nurse should clear the mouth and nose of the infant first. Choice 4 is the next step. Choices 1 and 2 might be performed depending on the situation. Safety and Infection Control 193. (4) Policies and procedures, though important, are not in the category of ethical and moral issues. The other options are ethical and moral issues. Safety and Infection Control 194. (2) Attaching a restraint to a movable part of the bed can cause client injury if that part of the bed is moved before releasing restraints. Safety and Infection Control 195. (1) Restraints must be released every 2 hours, and the client must be assessed every 30 minutes while restrained. Safety and Infection Control 196. (4) Use of coping skills and verbalization for anger management are personal strategies, not examples of social support systems. Choices 1, 2, and 3 are all social support systems. Psychosocial Integrity 197. (3) The exploration of life problems of support-team members is not necessary to enhance the support system. Choices 1, 2, and 4 are all enhancements for a support system. Psychosocial Integrity 198. (4) The use of clichés in therapeutic communication is commonly construed by the client as the nurse’s lack of understanding, involvement, and caring, so the client might feel demeaned and discounted. Psychosocial Integrity 199. (2) Questions should be asked in a precise order (specifically, from the most-simple description to the moredifficult disclosure of feelings). When the problems have been described, eliciting the client’s thoughts about the dilemmas provides further assessment data as well as the client’s interpretation of what has happened. Feelings, solutions and articulating intent are more complex processes. Psychosocial Integrity 200. (1) Encouraging the client to identify his own strengths is the most effective strategy. Psychosocial Integrity 201. (2) All clients must be treated with dignity. Rather than a strategy, treating clients with dignity is a basic core value universal to nursing. Psychosocial Integrity

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181. (2) Standard precautions are taken in all situations for all clients and involve all body secretions except sweat and are designed to reduce the rate of transmission of microbes from one host to another or one source (environment such as the client’s bedside table) to another. Safety and Infection Control

Part II: NCLEX-PN Practice Tests

202. (2) Dyskinesia is an impairment of the ability to execute voluntary muscles. Physiological Adaptation 203. (4) It might take several weeks of therapy for the client with Parkinson’s disease to see improvement in symptoms. Choice 1 is also true but is not the best response to the question. Choice 2 might be indicated but is not the best response to the question. Choice 3 is incorrect. Physiological Adaptation 204. (3) A client newly diagnosed with Diabetes Mellitus needs teaching about diet and exercise. Physiological Adaptation 205. (4) Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This hyperpigmentation results from hormonal changes. Health Promotion and Maintenance

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NCLEX-PN Practice Test 2 For each of the following questions, select the choice that best answers the question or completes the statement. 1. Which instruction should be given in a health education class regarding testicular cancer? 1. 2. 3. 4.

All males should perform a testicular exam after the age of 30. Testicular exams should be performed on a daily basis. Reddening or darkening of the scrotum is a normal finding. Testicular exams should be performed after a warm bath or shower.

2. Regardless of their practice area, nurses should be concerned with: 1. 2. 3. 4.

all drug-resistant bacteria. microorganisms that are critical. transmission of microorganisms. overprescription of bacteriostatic drugs.

3. An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client’s care plan? 1.

2. 3. 4.

emotional support to help the family deal with feelings of guilt about the infant’s condition administration of MICRhoGam to the woman within 72 hours of delivery administration of Rh-immune globulin to the newborn within 1 hour of delivery lab analysis of maternal Direct Coombs’ test

4. The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies? 1. 2. 3. 4.

Make a referral for grief counseling. Allow the woman to see her baby initially, and then discourage further visits. Provide opportunities for the woman to express her feelings. Inform the woman she has the right to change her mind about relinquishment.

5. Clients who take iron preparations should be warned of the possible side effects, which might include: 1. 2. 3. 4.

dizziness and orthostatic hypotension. nausea, vomiting, diarrhea or constipation, and stomach cramps. drowsiness, lethargy, and fatigue. neuropathy and tingling in the extremities.

6. What happens if folic acid is given to treat anemia without determining its underlying cause? 1. 2. 3. 4.

Erythropoiesis is inhibited. Excessive levels of folic acid might accumulate, causing toxicity. The symptoms of pernicious anemia might be masked, delaying treatment. Intrinsic factor is destroyed.

7. Which of the following should not be included in the teaching for clients who take oral iron preparations? 1. 2. 3. 4.

Mix the liquid iron preparation with antacids to reduce GI distress. Take the iron with meals if GI distress occurs. Liquid forms should be taken with a straw to avoid discoloration of tooth enamel. Oral forms should be taken with juice, not milk.

8. The test used to differentiate sickle cell trait from sickle cell disease is: 1. 2. 3. 4.

sickle cell preparation. peripheral smear. sickledex. hemoglobin electrophoresis.

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9. While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first? 1. 2. 3. 4.

Ask the parents to allow the infant to lay on her stomach to promote muscle development. Notify the physician because a developmental or neurological evaluation is indicated. Document the findings as normal in the nurse’s notes. Explain to the parents that their child is likely to be mentally retarded.

10. A preschooler has successfully completed the test item “counts 5 blocks” on the Denver II test. This pass is evidence of which of the following developmental concepts? 1. 2. 3. 4.

centration causality nonreversibility conservation

11. Tuberculosis (mycobacterium) usually effects which system? 1. 2. 3. 4.

stomach (GI) heart (cardiac) lungs (respiratory) skin (integumentary)

12. Which of the following statements is true about syphilis? 1. 2. 3. 4.

The cause and mode of transmission is unclear. There is no known cure for the disease. When the primary lesion heals, the disease is cured. Syphilis can be cured with a course of antibiotic therapy.

13. The sexually transmitted disease, sometimes referred to as the silent STD, that is more common than gonorrhea and a leading cause of PID is: 1. 2. 3. 4.

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genital herpes. trichomoniasis. syphilis. chlamydia.

14. Which of the following is true concerning human immunodeficiency virus (HIV)? 1. 2.

3. 4.

HIV infection involves CD4 receptor protein on the surface of helper T-cells. The presence of circulating antibodies that neutralize HIV is evidence that the individual has immunity-HIV. HIV replication occurs extracellularly. DNA replication of HIV is similar to that of other viruses.

15. After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image? 1. 2. 3. 4.

maintaining adequate tissue perfusion demonstrating behaviors that reduce fears restored body integrity remaining free of infection

16. When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification? 1. 2. 3. 4.

grief work facilitation vital signs monitoring medication administration: skin anxiety reduction

17. The nurse should teach a client in the Emergency Department, who has suffered an ankle sprain, to: 1. 2. 3. 4.

use cold applications to the sprain during the first 24–48 hours. expect disability to decrease within the first 24 hours of injury. expect pain to decrease within 3 hours after injury. begin progressive passive and active range of motion exercises immediately.

NCLEX-PN Practice Test 2

18. Jane Love, a 35-year old gravida III para II at 23 weeks gestation, is seen in the Emergency Department with painless, bright red vaginal bleeding. Jane reports that she has been feeling tired and has noticed ankle swelling in the evening. Laboratory tests reveal a hemoglobin level of 11.5 g/dL. After evaluating the situation, the nurse determines that Jane is at risk for placenta previa, based on which of the following data? 1. 2. 3. 4.

anemia edema painless vaginal bleeding fatigue

19. When caring for a client with a possible diagnosis of placenta previa, which of the following admission procedures should the nurse omit? perineal shave enema urine specimen collection blood specimen collection

20. Melissa Smith came to the Emergency Department in the last week before her estimated date of confinement complaining of headaches, blurred vision, and vomiting. Suspecting PIH, the nurse should best respond to Melissa’s complaints with which of the following statements? 1. 2. 3. 4.

“The physician will probably want to admit you for observation.” “The physician will probably order bed rest at home.” “These are really dangerous signs.” “The physician will probably prescribe some medicine for you.”

21. Which physiologic mechanism best describes the function of the sodium-potassium pump? 1. 2. 3. 4.

active transport diffusion filtration osmosis

1. 2. 3. 4.

Ca K Na Cl

23. A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur? 1. 2. 3. 4.

hyperkalemia hypernatremia hypokalemia hypomagnesemia

24. Which statement best describes electrolytes in intracellular and extracellular fluid? 1.

2. 3.

4.

There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid. There is an equal concentration of sodium and potassium in extracellular fluid. There is a greater concentration of potassium in extracellular fluid and sodium in intracellular fluid. There is an equal concentration of sodium and potassium between intracellular and extracellular fluid.

25. Which of the following instructions should a nurse give a client who is about to undergo pelvic ultrasonography? 1. 2. 3. 4.

“Urinate prior to the test.” “Have someone drive you home.” “Do not drink after midnight.” “Drink plenty of water.”

26. Which of the following is not a reason for pelvic ultrasonography? 1. 2. 3. 4.

to measure uterine size to detect multiple pregnancies to measure renal size to detect foreign bodies

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1. 2. 3. 4.

22. Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?

Part II: NCLEX-PN Practice Tests

27. Which of the following allergies might be a contraindication for a client to receive contrast enhancement for intracranial computed tomography? 1. 2. 3. 4.

penicillin iodine erythromycin aspirin

28. Which medication might the physician order if the client expresses discomfort with being in the enclosed space of a CT scanner? 1. 2. 3. 4.

Valium (diazepam) Clozaril (clozapine) Catapress (clonidine) Lasix (furosemide)

29. A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse? 1. 2. 3. 4.

“Because it gives you comfort, you may wear it.” “It is a violation of religious rights to forbid it.” “I am sorry, but it is not safe for you to wear the crucifix during this test.” “You may wear it because it is important to you.”

30. Which of the following statements by a client indicates adequate understanding of preparation for a lipoprotein fractionation test? 1. 2. 3. 4.

“I cannot eat or drink after midnight.” “I cannot eat for 12 hours before the test.” “I need to limit my fluid intake.” “I need to ingest a lipid solution.”

31. Which of the following tests is commonly performed on newborns with jaundice? 1. 2. 3. 4.

blood urea nitrogen magnesium bilirubin prolactin

32. An elevation in which of the following enzymes is indicative of pancreatitis? 1. 2. 3. 4.

33. Which of the following isoenzymes is elevated in a client who has had a myocardial infarction? 1. 2. 3. 4.

CPK-BB CPK-MM CPK-MB CPK-MI

34. Which of the following lab values is elevated first after a client has a myocardial infarction? 1. 2. 3. 4.

LDH troponin CPK SGOT

35. Which is the most common microorganism associated with gastritis? 1. 2. 3. 4.

syphilis cytomegalovirus H. pylori mycobacterium

36. Which of the following procedures describes an opening between the colon and abdominal wall? 1. 2. 3. 4.

ileostomy jejunostomy colostomy cecostomy

37. A client had a colostomy done one day ago. Which of the following is an abnormal finding when assessing the stoma? 1. 2. 3. 4.

mild edema minimal bleeding rose color dark red color

38. A client with jaundice has which skin color? 1. 2. 3. 4.

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alkaline phosphatase acid phosphatase creatine phosphokinase amylase

pale ruddy yellow pink

NCLEX-PN Practice Test 2

39. Which type of hepatitis is transmitted via the fecal-oral route? 1. 2. 3. 4.

A B C D

40. To ensure proper immobilization and increase client comfort when using a rigid splint: 1. 2. 3. 4.

place the client on a stretcher before splinting. place the client on a long spine board before splinting. pad the spaces between the body part and the splint. ensure that the splint conforms to the body curves.

41. The method of splinting is always dictated by:

2. 3. 4.

location of the injury and whether it is open or closed. the severity of the client’s condition and the priority decision. the number of available rescuers and the type of splints. all of the above.

42. Hazards of improper splinting include: 1. 2. 3. 4.

aggravation of a bone or joint injury. reduced distal circulation. delay in transport of a client with a lifethreatening injury. all of the above.

43. In evaluating the lab work of a client in a hepatic coma, which of the following lab tests is most important? 1. 2. 3. 4.

blood urea nitrogen serum calcium serum ammonia serum creatinine

44. A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is: 1. 2. 3. 4.

1. 2. 3. 4.

simplify medication administration. measure accurate input and output. prevent accumulation of fluids and gas. facilitate collection of specimens.

46. A client is having problems with her ankles. To assess her ankles’ ROM, which ROM exercises should the nurse have her perform? 1. 2. 3. 4.

flexion, extension, hyperextension flexion, extension, abduction, adduction external rotation, internal rotation extension, flexion, inversion, eversion

47. Pulling is easier than pushing. So pulling a client rather than pushing him or her has which of the following advantages? 1. 2. 3. 4.

reduces workload decreases opposition from gravity maintains stability prevents muscle strain

48. The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure? 1. 2. 3. 4.

Pull the client toward you, and pivot him on the unaffected limb. Pull the client toward you, and pivot him on the affected limb. Push the client toward the bed, and pivot him on the affected limb. Stand the client on both legs, and push him toward the bed.

49. Pressure ulcers usually occur: 1. 2. 3. 4.

when clients are left in one position in bed for extended periods of time. when clients are underweight. when clients are overweight. only in underweight and overweight clients.

measure intake and output. check albumin level. monitor glucose levels. increase enteral feeding.

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1.

45. A client has a nasogastric (NG) tube in place following abdominal surgery. The purpose of this tube immediately following surgery is to:

Part II: NCLEX-PN Practice Tests

50. Accurate documentation of assessment findings regarding pressure ulcers is very important because: 1. 2. 3. 4.

the law requires the nurse to document lesions. the hospital requires the nurse to document lesions. the physician requires the nurse to document lesions. the nursing assessment of ulcers is a standard of nursing practice.

51. Perineal care to a female client by the nurse can be performed: 1. 2. 3. 4.

without gloves, pouring water from a sterile bottle. without gloves, having the client perform all care. with gloves, washing the perineal area from front to back. with gloves, washing the perineal area from back to front.

52. When a client who is having trouble conceiving says to the nurse, “I have started taking ginseng,” the best response by the nurse is: 1. 2. 3.

4.

“No studies show that ginseng is effective for infertility.” “Some studies show that ginseng enhances in vitro sperm motility.” “Why don’t you try acupuncture instead. Many studies have shown it to be effective for infertility.” “It’s probably not going to hurt you, but it’s also probably not going to help. Let’s look at some other alternatives.”

53. A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8–10 cm. The nurse correctly documents the finding as: 1. 2. 3. 4.

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ferning capacity. lack of ferning. spinnbarkheit. inhospitable.

54. A client with a nasogastric (NG) tube begins vomiting. What action should the nurse take? 1. 2. 3. 4.

Retape the NG tube. Clamp the NG tube. Remove the NG tube. Check the NG tube placement.

55. Which of the following is the most appropriate diet for a client who is unable to swallow? 1. 2. 3. 4.

nothing by mouth nasogastric feedings clear liquids total parenteral nutrition

56. Which of the following is a predisposing factor for cancer of the tongue? 1. 2. 3. 4.

tobacco use obesity sun exposure eating sweets

57. Which of the following statements by a client with gastroesophageal reflux disease (GERD) indicates adequate understanding? 1. 2. 3. 4.

“I should eat right before bedtime.” “I should eat large meals.” “I should sit up after eating.” “I should lie flat after eating.”

58. Which of the following medications might cause upper-gastrointestinal (UGI) bleeding? 1. 2. 3. 4.

Cardizem (diltiazem) Naprosyn (naproxen) Elavil (amitryptiline) Corgard (nadolol)

59. A contraindication for topical corticosteroid use in a client with atopic dermatitis (eczema) is: 1. 2. 3. 4.

parasite infection. viral infection. fungal infection. spirochete infection.

NCLEX-PN Practice Test 2

60. A client’s postoperative pain seems to be getting worse instead of better. When the nurse asks the client, “Why do you think it’s getting worse?” the client replies, “My wife died last month. It’s all I can think about.” The nurse must now consider: 1. 2. 3. 4.

calling the physician for an increased dosage of pain medication. calling the physician for a sedative. referring the client for a psychiatric consult. developing interventions for grief and loss.

61. Client education by the nurse entails: 1.

2. 3.

62. Distraction therapy is: 1. 2. 3. 4.

focusing one’s attention on stimuli other than pain. cognitive reappraisal. the replacement of positive images of pain with other images. the use of medication and meditation.

63. Which of the following foods present a problem for a client diagnosed with Celiac Disease? 1. 2. 3. 4.

butter oats or barley cereal fresh vegetables coffee or tea

64. The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response? 1. 2. 3. 4.

pureed canned squash pureed apples yogurt infant rice cereal

1. 2. 3. 4.

reduced calories and reduced fat caffeine and sodium restrictions decreased protein and increased complex carbohydrates fluid restriction and reduced calories

66. Which of the following NSAIDS is most commonly used for a brief time for acute pain? 1. 2. 3. 4.

Advil Aleve Toradol Bextra

67. A hospital discharge planning nurse is making arrangements for a client who has an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse? 1.

2.

3.

4.

Ask the physician for an extension of hospitalization until the epidural catheter is discontinued to allow for placement at the neighborhood facility. Arrange for immediate in-services for the long-term care facility staff on pain management using epidural catheters. Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital. Encourage the family to hire private duty nurses skilled in epidural catheter pain management to allow the client to be transferred to the neighborhood facility.

68. In managing nausea related to Morphine epidural analgesia, the nurse should administer: 1. 2. 3. 4.

Indocin Codeine Motrin Compazine

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4.

telling the client everything about his disease, what is going to happen in the course of the disease, and the outcome. giving information to the client that is accurate and understandable. telling the client that the pain he experiences might not be real. giving the client medication when pain is experienced.

65. A pregnant client has congenital heart disease. The nurse should expect to see which alterations in this client’s diet during pregnancy?

Part II: NCLEX-PN Practice Tests

69. A client with sickle cell disease is worried about passing the disease on to children. Which of the following statements by the PN is most appropriate for this client? 1. 2. 3. 4.

“You should discuss this with your physician.” “Sickle cell disease is genetically based and might be passed on to children.” “Sickle cell disease is genetically based and is not passed on to children.” “Sickle cell disease is caused by an infection and cannot be passed on to children.”

70. When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize: 1. 2. 3. 4.

when started, therapy must not be interrupted to prevent viral resistance. when started, therapy must not be interrupted to prevent opportunistic infection. therapy should be interrupted for one day each month to prevent toxicity. therapy should be interrupted for one week every three months to prevent toxicity.

71. The best lab test to diagnose disseminated intravascular coagulation (DIC) is: 1. 2. 3. 4.

platelet count. protime (PT). partial thromboplastin time (PTT). D-dimer.

72. In teaching bleeding precautions to a client with leukemia, the PN should include which of the following instructions? 1. 2. 3. 4.

Use a soft toothbrush. Use dental floss daily. Hold pressure on any scrapes for 1–2 minutes. Use a triple-edged razor.

73. Which of the following describes the stages of domestic violence in an intimate relationship? 1. 2. 3. 4.

happiness, crisis, angry outburst, intervention honeymoon period, escalation of stress, outburst, reconciliation acting out and making up peace and calm, angry outburst, peace and calm, denial

74. Which of the following statements is correct regarding rape? 1. 2. 3. 4.

75. An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is: 1. 2. 3. 4.

discussing the repetitive action. insisting the client not perform the repetitive act. informing the client that the act is not necessary. encouraging daily exercise.

76. A man reports his wife is constantly cleaning. The activity has interfered with the family life. Friends have stopped visiting because she makes them uncomfortable. He states he has awakened in the middle of the night and found her cleaning. The nurse should consult with the couple and recommend the husband help with therapy by: 1. 2. 3. 4.

telling his wife to stop cleaning whenever he notices her actions. making a baseline record of the time the wife spends cleaning. decreasing the stimuli in the home. helping his wife with the cleaning.

77. An 8-year-old Asian child is being examined during a school screening. The nurse notices small bruises on the anterior and posterior ribs. The nurse should ask the child: 1. 2. 3. 4.

if the family practices coining. who hit him. if the child has fallen. how long the abuse has been occurring.

78. Incidences of child abuse apperar to be higher in the African-American community and might be explained by: 1. 2. 3. 4.

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Most rapes are reported. Legally, a woman can be raped by her spouse. Prosecution and conviction for rape is easy. The most common location of rape is the victim’s own home.

the increased number of African Americans viewing violence on television. more single-parent households in AfricanAmerican communities. stricter child-rearing practices in AfricanAmerican households. a higher occurrence of rage in African Americans.

NCLEX-PN Practice Test 2

79. When teaching parents how their children learn sex role identification, the nurse should include which of the following statements? 1. 2. 3. 4.

Sex role identification begins in infancy. Sex role identification begins in the preschool years. Sex role identification begins during the school-age years. Sex role identification begins during early adolescence.

80. When working with multicultural populations, the nurse should consider all of the following when planning care for a client with an altered sexuality pattern except: 1.

3.

4.

81. Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population? 1. 2. 3. 4.

single, adult men single mothers with 2 or 3 children runaway adolescents single, adult women

82. Which of the following strategies should the nurse include when planning care for children of migrant workers? 1. 2. 3. 4.

Delay immunization because of acute illness. Provide parents with copies of medical records. Schedule preventive services at acute illness visits. Stress the importance of using one primary care provider.

1. 2. 3. 4.

mental confusion muscular weakness sensory loss emotional liability

84. A Hispanic client brings her father to the clinic because he is becoming more forgetful. He is diagnosed with Alzheimer’s disease. The woman tells the nurse that she wants to try ginkgo biloba for her father, before using prescription medications. Which of the following is an appropriate response by the nurse? 1. 2. 3. 4.

“It is wiser to start a prescription.” “That herb won’t do your father any good.” “You can’t expect an herb to treat Alzheimer’s.” “I will let the physician know of your wishes.”

85. Which of the following statements by an adult child of a client with late-stage Alzheimer’s disease indicates a need for further teaching by the nurse? 1. 2. 3. 4.

“I should provide a regular schedule for toileting.” “I should talk to my father less because he can’t communicate.” “I should give my father oral care after every meal and bedtime.” “I should assist my father with eating and drinking.”

86. An Asian family has an elderly member with latestage Alzheimer’s disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response to the family by the nurse? 1. 2. 3. 4.

“You really need to listen to what the physician says.” “You will get too tired to take care of him at home.” “What can I do to assist you to care for him at home?” “You are too busy to be taking care of an elderly person.”

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2.

some members of the Hispanic and NativeAmerican cultures are very open when discussing sexuality. some cultures view the postpartum period as a state of impurity. some women in the African-American culture view childbearing as a validation of their femaleness. some Native-American women believe monthly menstruation maintains physical well-being and harmony.

83. When assessing a client with amytrophic lateral sclerosis (ALS), the nurse should expect which of the following findings?

Part II: NCLEX-PN Practice Tests

87. Which of the following conditions has a severe complication of respiratory failure? 1. 2. 3. 4.

Bell’s palsy Guillain-Barré syndrome trigeminal neuralgia tetanus

88. Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. When the nurse who was not promoted first read the memo and learned that the other nurse had received the promotion, she left the room in tears. This behavior is an example of: 1. 2. 3. 4.

conversion. regression. introjection. rationalization.

89. The nurse who was not promoted then went to the utility room and slammed several cupboard doors while looking for Kleenex. This behavior exemplifies: 1. 2. 3. 4.

displacement. sublimation. conversion. reaction formation.

90. Which of the following coping mechanisms protects an individual from anxiety? 1. 2. 3. 4.

denial and fantasy rationalization and suppression regression and displacement reaction formation and projection

91. Milieu therapy is best employed to perform which activity? 1. 2. 3. 4.

investigating the client’s view of the world promoting socialization skills focusing on inappropriate behavior providing repetitive ordinary experiences on a daily basis

92. When discussing the patterns of use of alcohol and other drugs, the nurse should include which piece of information? 1. 2. 3.

4.

Lifetime prevalence and intensity of alcohol use is greater in women than men. Hispanics and African Americans have higher levels of alcohol use than Caucasians. Overuse of alcohol and other drugs increases into the mid-20s, then levels off and decreases with age. Heavy use is more common in higher socioeconomic groups because they can afford to buy the drugs.

93. A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that: 1. 2.

3.

4.

multiple drug use is very uncommon. people might use more than one drug to enhance the effect or relieve withdrawal symptoms. alcohol and barbiturates used together are not dangerous because one is a stimulant and the other is a depressant. assessment and intervention are easier with multiple drug use because of the synergistic effect.

94. When the nurse is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client? 1. 2. 3. 4.

corner of the mouth to tragus of the ear corner of the eye to top of the ear tip of the chin to the sternum tip of the nose to the earlobe

95. When suctioning a client, what is the usual amount of time the nurse should spend for each suction pass? 1. 2. 3. 4.

2 seconds 10 seconds 20 seconds 30 seconds

96. When a client has a chest drainage system in place, where should the system be placed? 1. 2. 3. 4.

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above the client’s head at the client’s shoulders at the level of the chest below the level of the chest

NCLEX-PN Practice Test 2

97. A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do? 1. 2. 3. 4.

Notify the physician. Clamp the chest tube. Replace the system. Document the finding.

101. An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should: 1.

2. 98. A visitor accidentally knocks over a plastic pleural drainage system connected to a client, and it cracks. What should the nurse do first? 1. 2. 3. 4.

Observe the client’s response. Notify the physician. Change the drainage system. Observe for leaks.

1. 2. 3. 4.

the pathophysiology and acting out behaviors of schizophrenia. support groups that can help the parents release their feelings of frustration. the prolonged recovery time and depressive effects of medicines to prevent relapse. motivational techniques that are effective in clients with schizophrenia.

100. A nurse is teaching a group of clients with a diagnosis of Schizophrenia who are nearing discharge from a residential care facility. An essential topic to include is: 1. 2. 3. 4.

pathophysiology of the disease and expected symptoms. how to recognize and manage symptoms of relapse. the need to take extra medication when feeling stressed. the importance of contact with follow-up care daily.

4.

102. A client goes to the mental health center for difficulty concentrating, insomnia, and nightmares. The client reports being raped as a child. The nurse should assess the client for further signs of: 1. 2. 3. 4.

general anxiety disorder. schizophrenia. post-traumatic stress disorder. bipolar disorder.

103. The advanced directive in a client’s chart is dated August 12, 1998.The client’s daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care direction(s). The nurse is supposed to: 1. 2. 3. 4.

follow the 1998 version because it’s part of the legal chart. follow the 1998 version because the physician’s code order is based on it. follow the 2003 version, place it in the chart, and communicate the update appropriately. follow neither until clarified by the unit manager.

104. The nurse acts as an advocate for the nursing profession by performing all of the following activities except: 1. 2. 3. 4.

encouraging political involvement by nurses with their legislators. acting as a first-aid provider for a children’s athletic team. precepting newly licensed nurses in the work situation. encouraging as many persons to become nurses as possible.

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99. A client with a diagnosis of Schizophrenia has been released from an acute care setting. The client had a prolonged recovery from relapse. One of the parents says to the discharge nurse, “I do not understand what is going on. The hospital said she was better, but all she does is sit around all day and smoke. We cannot get her to go to the vocational training you arranged.” The nurse recognizes that more teaching is needed about:

3.

inform the client that because she is underage, she is at fault for attending a party where alcohol was served. ask the client if anyone witnessed the event because the client was intoxicated and might not remember correctly. inform the client that it was not her fault, and support the client through the physical examination. question whether the woman had consensual sex and now just feels guilty.

Part II: NCLEX-PN Practice Tests

105. The physician’s role in case management includes all of the following except: 1. 2. 3. 4.

participating in interdisciplinary planning for clients. serving as the expert for resource utilization. consulting with the case management team to facilitate timely orders as needed. contributing to the documentation of a client’s needs for services.

106. The nurse and a colleague are on the elevator after their shift, and they hear a group of health caregivers discussing a recent client scenario. Which client right might be breached? 1. 2. 3. 4.

right to refuse treatment right to continuity of care right to confidentiality right to reasonable responses to requests

107. The power a nurse exerts when he or she works to accomplish goals and effect change in an agency or in policy is considered what type of power? 1. 2. 3. 4.

political personal positional professional

108. While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. The nurse should: 1.

2.

3.

4.

make the charge nurse on the unit aware of the situation so that he or she can take the necessary steps to maintain the confidentiality of the information being reported. disregard the information because it changes quickly on the acute care unit and is outdated within 2–3 hours anyway. return to his or her own unit and not disclose that confidential information has been overheard. ignore the situation.

109. In the process of an annual physical exam, a client is diagnosed with Benign Prostatic Hypertrophy (BPH). This client is likely to have a consult with which type of physician? 1. 2. 3. 4.

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gynecologist physiatrist urologist proctologist

110. A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except: 1. 2. 3. 4.

the client has been admitted to the hospital three times in the last 2 months. the client has a Foley catheter. the client’s family is available to care for him 24 hours a day. the client is ordered to continue IV antibiotics 5 days post discharge.

111. As a type of quality indicator, an example of a structure standard is: 1. 2. 3. 4.

a written philosophy. a procedure for a straight catheterization. a protocol for treatment of a client with chest pain. the diagnostic work-up for a client with abdominal pain.

112. All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except: 1. 2. 3. 4.

monitoring intravenous infusion. assisting a client to the bathroom. offering fluid intake every 1–2 hours. monitoring/recording the amount of fluid taken.

113. The nurse uses prioritization to determine all the following except: 1. 2. 3. 4.

time allotment for certain tasks. appropriate interventions. treatment procedures. the need for client education.

114. A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent? 1. 2. 3. 4.

primary secondary tertiary health promotion

NCLEX-PN Practice Test 2

115. A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm and the color is pink. What action should the nurse perform next to prevent ischemia? 1. 2.

3. 4.

Notify the physician immediately. Obtain a Doppler device to check for pulses, and notify the physician if they are still absent. Wait 30 minutes and recheck the pulses. Document the finding.

116. The ethical principle of keeping professional promises or obligations is: veracity. autonomy. fidelity. beneficence.

1. 2. 3. 4.

121. Kleinman’s Explanatory Model of Health and Illness is significant because: 1. 2. 3. 4.

117. A risk management program within a hospital is responsible for all of the following except: 1. 2. 3. 4.

identifying risks. controlling financial loss due to malpractice claims. making sure that staff follow their job descriptions. analyzing risks and trends to guide further interventions or programs.

118. Which of the following factors can impact an individual’s ability to give informed consent? 1. 2. 3. 4.

IQ educational level pain medications financial status

119. There are many types of torts that can be committed against clients. They include all of the following except: 1. 2. 3. 4.

assault. battery. negligence. felony.

structure of the health care system and family structure psychological factors for men and women seeking health care conditions being labeled disabilities and seen as too time consuming health care organizations (HMOs) and disconnected families

it explains what kind of health beliefs a family is likely to have. it brings out the importance of culture in forming health explanations. it discusses the important role that popular and folk domains of influence have. it has an educational base to the structure.

122. An example of an extended care facility is a: 1. 2. 3. 4.

home health agency. suicide prevention center. state-owned psychiatric hospital. nursing facility.

123. A client and his family facing the end stage of a terminal illness might be best served by: 1. 2. 3. 4.

a rehabilitation center. an extended care facility. Hospice. a crisis intervention center.

124. During a routine health screening, the nurse should talk to the parents of a 1-year-old child about which of the following? 1. 2. 3. 4.

the potential hazards of accidents appropriate nutrition now that the child has been weaned from breast-feeding toilet training how to purchase appropriate shoes now that the child is walking

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1. 2. 3. 4.

120. American families are having difficulty adequately performing their vital health care function. What are the basic reasons for this difficulty?

Part II: NCLEX-PN Practice Tests

125. The school nurse is conducting health screenings on schoolchildren. During the screening, she identifies a child with the behavioral characteristics of attention deficit disorder. Which of the following behaviors is consistent with this disorder? 1. 2. 3. 4.

slow speech development overreaction to stimuli from the surroundings inability to carry on a conversation concrete thinking

126. Who should receive the hepatitis A vaccine? 1. 2. 3. 4.

children who are 18 months of age infants, who should receive the vaccination at birth people who travel to other countries individuals who might come into contact with blood

127. Which of the following vaccines are not part of the regular schedule of immunizations for children? 1. 2. 3. 4.

DTaP MMR Hib hepatitis A

128. The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep? 1. 2. 3. 4.

serotonin cortisone alcohol narcotics

129. A hospitalized adult client who routinely works from midnight until 8 a.m. has a temperature of 99.1° F at 4 a.m. The nurse determines that this is most likely due to: 1. 2. 3. 4.

delta sleep slow brain waves pneumonia circadian rhythm

130. Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her? 1. 2. 3. 4.

131. A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching? 1. 2. 3. 4.

packed red blood cells platelets plasma granulocytes

132. A client’s central venous access device (CVAD) becomes infected. Why might the physician order antibiotics to be given through the line rather than through a peripheral IV line? 1. 2. 3. 4.

to prevent infiltration of the peripheral line to reduce the pain and discomfort associated with antibiotic administration in a small vein to lessen the chance of an allergic reaction to the antibiotic to attempt to eliminate microorganisms in the catheter and prevent having to remove it

133. Hormonal agents are used to treat some cancers. An example is: 1. 2. 3. 4.

thyroxine to treat thyroid cancer. ACTH to treat adrenal carcinoma. estrogen antagonists to treat breast cancer. glucagon to treat pancreatic carcinoma.

134. Some drugs are excreted into bile and delivered to the intestines. Prior to elimination from the body, the drug might be absorbed. This process is known as: 1. 2. 3. 4.

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Sleep Pattern Disturbances (related to arthritis) Fatigue (related to leg pain) Knowledge Deficit (regarding sleep hygiene measures) Sleep Pattern Disturbances (related to chronic leg pain)

hepatic clearance. total clearance. enterohepatic cycling. first-pass effect.

NCLEX-PN Practice Test 2

135. The intravenous route is potentially the most dangerous route of drug administration because: 1. 2. 3. 4.

the IV might infiltrate. it is expensive and nursing intensive. rapid administration of a drug can lead to toxicity. the client always has more side effects.

140. When questioning an elder about suspected abuse, the nurse should keep the questions: 1. 2. 3. 4.

nonjudgmental. probing. confrontational. indirect.

141. The primary organ for drug elimination is the: 136. A complication of total parenteral nutrition (TPN) is the development of cholestasis. What is this condition? 1. 2. 3. 4.

an inflammatory process of the extrahepatic bile ducts an arrest of the normal flow of bile an inflammation of the gallbladder the formation of gallstones

1. 2. 3. 4.

viewing crisis intervention as the first step in solving bigger problems wanting to help clients solve all problems identified taking an active role in guiding the process feeling that work requires identification with all of a client’s problems

138. The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment? 1. 2. 3. 4.

Provide a liaison to meet housing needs. Attentively listen when clients describe their feelings. Offer nurturing support for clients who are confused by the events. Provide structure for clients exhibiting moderate to severe anxiety.

139. The nurse suspects an elderly client has been the victim of abuse. The client denies abuse and declines assistance. The nurse’s next action should be to: 1. 2. 3. 4.

do nothing; the client has the right to refuse treatment. report the incident to the police. arrange an appointment with the client’s next of kin. educate the client about available services.

skin. lung(s). kidney(s). liver.

142. A 50 milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at: 1. 2. 3. 4.

100 ml per hour for one hour. 60 ml per hour for one-half hour. 120 ml per hour for one hour. 50 ml per hour for one hour.

143. Carrying a donor card for organ donation means that: 1. 2.

3. 4.

medical care is altered in the event of serious injuries to get organs for donation. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation. a client is allowed to revoke his decision for organ donation at any time. a client is considered an organ donor for only one organ or tissue.

144. Referral for client education in the community can be accomplished through all of the following except: 1. 2. 3. 4.

community agencies such as the American Heart Association. parish nurses. home health care agencies. unlicensed massage therapists.

145. The tendency of a drug to combine with its receptor is called: 1. 2. 3. 4.

potency. efficacy. kinetics. affinity.

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137. Which of the following attitudes is essential in a nurse who assists clients during crises?

1. 2. 3. 4.

Part II: NCLEX-PN Practice Tests

146. Levothyroxine (Synthroid) is the drug of choice for thyroid replacement therapy in clients with hypothyroidism because: 1. 2. 3. 4.

it is chemically stable, nonallergenic, and can be administered orally once a day. it is available in a single 25mg tablet, which makes dosing simple. it is not a prodrug. it has a short half-life.

147. When medications have an additive, synergistic, or antagonistic effect on a tissue, a ________ reaction has occurred. 1. 2. 3. 4.

pharmaceutical pharmacodynamic pharmacokinetic drug incompatibility

148. Local anesthetics block the conduction of pain impulses to the spinal cord. Their duration of action: 1. 2. 3. 4.

is always longer than general anesthesia. is determined by the rate of diffusion and absorption at the site of administration. is usually short (10 minutes). varies, depending on the client’s weight.

149. Which of the following clients should refrain from therapy with the thiazide diuretic hydrochlorothiazide (HCTZ)? 1. 2. 3. 4.

a client with renal impairment a client with hypertension a client with diabetes mellitus, type II a client with renal calculi (kidney stones)

150. Delegation of tasks to appropriate personnel allows the nurse to: 1. 2. 3. 4.

take a break. keep other members of the team productive. maintain tight control of all aspects of the workflow. realize the importance of her role by making all decisions.

151. Activities of effective supervisors can be taskrelated or people-related activities. An example of a task-related supervisory activity is: 1. 2. 3. 4.

152. What is the reason for a contract between nurse and client? 1. 2. 3. 4.

Contracts state the roles the participants take. Contracts are indicative of the feeling tone established between participants. Contracts are binding and prevent either party from ending the relationship prematurely. Contracts spell out the participation and responsibilities of both parties.

153. The nurse can best communicate to a client that he or she has been listening by: 1. 2. 3. 4.

restating the main feeling or thought the client has expressed. making a judgment about the client’s problem. offering a leading question such as, “And then what happened?” saying, “I understand what you’re saying.”

154. In the United States, several definitions of death are currently being used. The definition that uses apnea testing and pupillary responses to light is termed: 1. 2. 3. 4.

whole brain death. heart-lung death. circulatory death. higher brain death.

155. The nurse is caring for a dying client who has persistently requested that the nurse “help her to die and be in peace.” According to the Code of Ethics for Nurses, the nurse should: 1. 2. 3. 4.

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coaching. evaluating. delegating. facilitating.

Ask the client whether she has signed the advance directives document. Tell the client that he or she will ask another nurse to care for her. Instruct the client that only a physician can legally assist a suicide. Try to make the client as comfortable as possible, but refuse to assist in death.

NCLEX-PN Practice Test 2

156. When caring for a Native-American family, the nurse needs to consider which of the following? 1. 2. 3. 4.

The family consists solely of the parents and children. Native Americans tend to be future oriented. Some Native Americans use herbs and psychologic treatment of illnesses. Health care is usually prescribed by a medicine man (shaman).

157. The three universal spiritual needs include all of the following except: 1. 2. 3. 4.

meaning and purpose. love and relatedness. forgiveness. God’s permission.

1. 2. 3. 4.

orthopedic eye insect sting or snakebite gynecological trauma

159. A client has sustained a hyphema. What intervention should the nurse take? 1. 2. 3. 4.

Have the client wear ear protectors in the future. Keep the client at bed rest, typically with the head of the bed propped up. Apply atropine eye drops. Apply an ice pack to the site of injury.

160. The nurse’s first action upon discovery of an electrical fire should be which of the following? 1. 2. 3. 4.

Disconnect the electrical power if it can be performed safely. Smother the source with an object such as a blanket. Saturate the source with water or other readily available liquid. Activate the fire alarm immediately.

1.

2.

3.

4.

testing that is performed by volunteers at a local department store and is open to the public at a professional health fair activity available for selected persons who have been screened as being at risk mass-marketing vouchers for free fingersticks at a local drug store, where the pharmacist makes recommendations on the findings testing that is performed by a nurse professional, who immediately provides education regarding the findings

162. Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of: 1. 2. 3. 4.

primary prevention. secondary prevention. tertiary prevention. disability prevention.

163. The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first? 1. 2. 3. 4.

performing a physical assessment prior to administration obtaining the most recent lab values regarding renal function reviewing peaks and troughs for the past few days ensuring the client is not allergic to the medication

164. The orientation nurse educator reviewing the biohazard legend with a class of new employees states that the emblem is affixed to containers whenever: 1. 2. 3. 4.

there is presence of blood and body fluids. there is the need for droplet precaution. there is contact isolation. there is the potential for airborne transmission.

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158. Acute hyphema is associated with what type of injury?

161. A community health nurse is asked to organize a health promotion project that plans to provide glucose screening. This activity is most beneficial within what realm?

Part II: NCLEX-PN Practice Tests

165. The emergency triage nurse should perform which action upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting? 1. 2. 3. 4.

Place the client in the waiting room until an available cubicle is open. Seclude the client from other clients and visitors. Perform no intervention because it might not be necessary until tests confirm a disease. Don gown, gloves, and mask immediately.

166. Which of the following clients require airborne precautions? 1. 2. 3. 4.

a client with fever, chills, vomiting, and diarrhea a client suspected of varicella (chickenpox) a client with abdominal pain and purpura a client diagnosed with AIDS

167. A stool culture reveals Shigella. What corollary should the nurse recognize regarding this bacterial infection? 1. 2. 3. 4.

People who have been in contact with the client need to be tested. Shigella is an airborne infection. Shigella is a bacteria sometimes found in stagnant water. The nurse should wear a one-way breathing apparatus when giving client care.

168. A client asks the nurse what risk factors increase the changes of getting skin cancer. The risk factors include all except: 1. 2. 3. 4.

light or fair complexion. exposure to sun for great periods of time. certain diet and foods. history of bad sunburns.

169. To improve overall health, the nurse should place highest priority on assisting a client to make lifestyle changes for which of the following habits? 1. 2. 3. 4.

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drinking a six-pack of beer each day eating an occasional chocolate bar exercising twice a week using relaxation exercises to deal with stress

170. The gag reflex test assesses which cranial nerves? 1. 2. 3. 4.

IX and X V and VII IX and XII V and X

171. How many temporary teeth should the nurse expect to find in a 5-year-old client’s mouth? 1. 2. 3. 4.

up to 10 up to 15 up to 20 up to 32

172. When assessing a client with early impairment of oxygen perfusion, such as pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms? 1. 2. 3. 4.

warm, dry skin bradychardia tachycardia eupnea

173. One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect: 1. 2. 3. 4.

cor pulmonale. atelectasis. pulmonary embolus. cardiac tamponade.

174. Which of the following needs immediate medical attention and emergency intervention? The client who: 1. 2. 3. 4.

complains of sharp pain upon taking a deep breath and excessive coughing. exhibits yellow, productive sputum, lowgrade fever, and crackles. has a shift of the trachea to the left, with no breath sounds on the right. has asthma and complains of an inability to catch her breath after exercise.

175. Which of the following symptoms is most characteristic of a client with cancer of the lungs? 1. 2. 3. 4.

exertional dyspnea persistent changing cough air hunger; dyspnea cough with night sweats

NCLEX-PN Practice Test 2

176. A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information. The nurse knows that another name for the disorder is: 1. 2. 3. 4.

Kawasaki disease. rheumatic disease. lupus erythematosus. fifth disease.

177. The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase. Which type is it? 1. 2. 3. 4.

hepatitis A hepatitis B hepatitis C hepatitis D

1. 2. 3. 4.

puberty, pregnancy, and menopause. death of a spouse, menopause, and childbirth. rape, divorce, and menarche. dating, engagement, and separation.

179. A female having her first child is experiencing which type of crisis event? 1. 2. 3. 4.

situational maturational adventitious reactive

180. Nursing care for a client undergoing chemotherapy includes assessment for signs of bone marrow depression. Which finding accounts for some of the symptoms related to bone marrow depression? 1. 2. 3. 4.

erythrocytosis leukocytosis polycythemia thrombocytopenia

1. 2. 3. 4.

Administer O2. Turn the client on her left side. Notify the physician. No action is necessary.

182. A serious complication of a total hip replacement is displacement of the prosthesis. What is the primary sign of displacement? 1. 2. 3. 4.

pain on movement and weight bearing hemorrhage affected leg appearing 1–2 inches longer edema in the area of the incision

183. Paula is a 32-year-old woman seeking evaluation and treatment of major depressive symptoms. A major nursing priority during the assessment process includes which of the following? 1. 2. 3. 4.

meaning of current stressors possibility of self-harm motivation to participate in treatment presence of alcohol or other drug use

184. A client is assessed by the nurse as experiencing a crisis. The nurse plans to: 1. 2. 3. 4.

allow the client to work through independent problem-solving. complete an in-depth evaluation of stressors and responses to the situation. focus on immediate stress reduction. recommend ongoing therapy.

185. A client is having psychological counseling for problems communicating with his mother. Which model of stress is the most useful in reference to this stressor? 1. 2. 3. 4.

Adaptation Model Stimulus-Based Model Transaction-Based Model Selye’s Model of Stress

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178. The three major sequential maturational crises for females include:

181. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?

Part II: NCLEX-PN Practice Tests

186. During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis? 1. 2. 3. 4.

brain bone liver mediastinum

187. In a disaster, triage situation, the nurse should be least concerned with which of the following regarding a client in crisis? 1. 2. 3. 4.

ability to breathe pallor or cyanosis of the skin number of accompanying family members motor function

188. All of the following clients are in need of an emergency assessment except: 1. 2. 3. 4.

a bleeding client who has an injury from falling debris. an unresponsive client. a client with an old injury. a pregnant woman with imminent delivery.

189. All of the following are causes of vaginal bleeding in late pregnancy except: 1. 2. 3. 4.

placenta previa. eclampsia. abruptio placentae. uterine rupture.

190. Padding on a restraint helps: 1.

2. 3. 4.

with pressure distribution so that bony prominences do not receive pressure when a client pulls against the restraints. the client feel more secure. to keep infection and wounds down. to keep restraints in place.

192. Which of the following statements describes the purpose of client restraint? 1. 2.

3.

4.

193. Support systems during the grieving process include all of the following except: 1. 2. 3. 4.

1. 2. 3. 4.

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confuses both groups more helps with coping and stress levels encourages cooperation with the client and family puts the responsibility on the client and family, not the nurse

a despondent friend. a nurse. a social worker. a family member.

194. Mrs. Owens is the 81-year-old mother of Jonathan, who is 54 years old. Jonathan has had schizophrenia since he was 16 years old. Which of Mrs. Owens’s concerns is likely to predominate? 1. 2. 3. 4.

“Will my retirement funds outlast me?” “Who will handle my funeral arrangements?” “What will become of Jonathan when I am gone?” “How can I get Jonathan’s physician to talk to me?”

195. A client tells the nurse that his wife’s nagging really gets on his nerves. He asks the nurse to talk with her about her nagging during their family session tomorrow afternoon. Which of the following responses is the most therapeutic for the client? 1. 2.

191. What does client and family communication and education concerning restraints do?

Restraints are a nursing measure used to maintain client control. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger. Restraints are a therapeutic measure designed to positively reinforce client behavior. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

3. 4.

“Tell me more specifically about her complaints.” “Can you think why she might nag you so much?” “I’ll help you think about how to bring this up yourself tomorrow afternoon.” “Why do you want me to initiate this in tomorrow’s session rather than you?”

NCLEX-PN Practice Test 2

196. During the work phase of the nurse-client relationship, the client says to her primary nurse, “You think that I could walk if I wanted to, don’t you?” What is the best response by the nurse? 1. 2. 3. 4.

“Yes, if you really wanted to, you could.” “Tell me why you’re concerned about what I think.” “Do you think you could walk if you wanted to?” “I think you’re unable to walk now, whatever the cause.”

197. A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic selfexpectations) is when the client can: report a positive self-concept. identify negative thoughts. recognize positive thoughts. give one positive cue with each negative cue.

198. A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is: 1. 2. 3. 4.

Actual Chronic Low Self-Esteem (related to obesity). Potential Chronic Low Self-Esteem (related to obesity). Actual Situational Low Self-Esteem (related to fear of weight regain and pregnancy). Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).

199. The nurse should utilize data about which of the following to provide information about the nutritional status of a client being evaluated for malnutrition? 1. 2. 3. 4.

triceps skinfold measurement fasting blood glucose level hemoglobin A1c level serum lipid profile results

1. 2. 3. 4.

It increases food intake in clients, thereby promoting obesity. It assists in the regulation of steroids. It increases the total fat mass of people who are obese. It might decrease the total fat mass in the bodies of people who are obese.

201. What are the implications for a client with renal insufficiency who wants to start a low-carbohydrate (CHO) diet? 1. 2. 3.

4.

As long as the client eats a minimum of 30g of CHO/day, there should be no problem. The client’s clinical condition is a contraindication to starting a low CHO diet. Calcium supplements should be utilized to prevent the development of osteoporosis while on a low CHO diet. As long as the client eats foods that are high biologic protein sources, a low CHO diet can be followed.

202. Herbal therapy has several indications for use. Primarily, herbal therapy is: 1. 2. 3. 4.

used to treat many common complaints and diseases. used to promote certain types of low-carb diets. used as an adjunct to medications. used to create a diet without salt and carbohydrates.

203. The chemotherapeutic agent 5-fluorourcacil (5-FU) is ordered for a client as an adjunct measure to surgery. Which statement about chemotherapy is true? 1. 2. 3. 4.

It is a local treatment affecting only tumor cells. It is a systemic treatment affecting both tumor and normal cells. It has not yet been proved an effective treatment for cancer. It is often the drug of choice because it causes few, if any, side effects.

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1. 2. 3. 4.

200. The nurse should make which of the following responses when questioned by a client about the role of leptin in the body?

Part II: NCLEX-PN Practice Tests

204. When teaching a woman about possible side effects of hormone replacement therapy, the nurse should include information about all of the following except: 1. 2. 3. 4.

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hypoglycemia in diabetic women. the possible return of monthly menses when taking combination hormones. increased risk of gallbladder disease. increased risk of breast, cervical, and ovarian cancer with long-term use.

205. After 12 months of cessation of menses, which of the following assessment findings in a client who is taking hormone replacement therapy should the nurse report to the physician immediately? 1. 2. 3. 4.

breast tenderness weight gain fluid retention uterine bleeding

NCLEX-PN Practice Test 2

Answers and Explanations for Practice Test 2 For your reference, the appropriate review chapter is listed at the end of each answer explanation below. 1. (4) Testicular exams should be performed after a warm shower or bath to relax the scrotum. Testicular exams should be performed on a monthly basis by all men beginning at about age 15. Reddening or darkening of the scrotum is not normal finding and should be reported to a physician. Physiological Adaptation 2. (3) All nurses should be concerned with preventing the transmission of microorganisms to themselves as well as to others. One way to accomplish this goal is by asepsis. Nursing practice focuses on providing a safe and therapeutic environment to protect clients, family members, and health care providers from acquiring infections. Safety and Infection Control 3. (1) If a woman is sensitized to the Rh factor, it poses a threat to any Rh-positive fetus she delivers. The nurse needs to provide emotional support to help the family deal with the infant’s condition, which might involve a host of conditions that could lead to death or marked neurological damage. RhoGam is never given to a woman already sensitized. If not previously sensitized, MICRhoGam (a smaller dose of Rh immune globulin) is given after an abortion or ectopic pregnancy to prevent sensitization. If not sensitized, RhoGam is given to the woman within 72 hours of delivery. Rh-immune globulin is never given to the newborn. To determine if sensitization has occurred, an Indirect Coombs’ is drawn on the mother to measure the number of Rh-positive antibodies. Health Promotion and Maintenance

5. (2) Oral iron preparations are often used to treat clients who have iron deficiency anemia to regain a positive iron balance. These preparations need to be supplemented with adequate dietary intake of iron. It can take 2–3 weeks to see improvement and up to 6–10 months to return to a stable iron level after a deficiency exists. The most common adverse effects associated with oral iron intake are related to direct GI upset, anorexia, nausea, vomiting, diarrhea, dark stools, and constipation. Nursing comfort measures include taking the preparations with meals, teaching about black stools, encouragement, and proper nutrition. Physiological Adaptation 6. (3) Folic acid should not be used if pernicious anemia is suspected because it does not protect the client from CNS changes common to this type of anemia. Folic acid is usually given with Vitamin B12. Both are part of the Vitamin B complex and are essential for cell growth and division. Folic acid is sometimes used as a rescue drug for cells exposed to some toxic chemotherapeutic agents. The nature of the anemia must be confirmed to ensure that the proper drug regimen is being used. Physiological Adaptation 7. (1) Iron should not be mixed with antacids. Physiological Adaptation 8. (4) Hemoglobin electrophoresis is used to differentiate between sickle cell trait and sickle cell disease. Physiological Adaptation 9. (2) Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation. Laying the infant on her stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. These findings are not normal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurologic and other metabolic disorders. Some of those disorders might have mental retardation as a component. However, this child needs to have the referral to determine the cause of the head lag first. Health Promotion and Maintenance

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4. (3) Most women who relinquish their infants at birth have come to that decision with a great deal of love and pain. They have made plans in advance. The nurse needs to first provide them with opportunities to express their feelings that might include grief, loneliness, and guilt. A referral for grief counseling might be appropriate if no other support system exists or the mother indicates that she wants assistance working through her grief. If the nurse assesses that the grief process is abnormal, a referral is also appropriate. The mother has probably already made a decision about whether or not she wants to see her baby. The nurse should ask her and make arrangements for that to happen if the mother requests it. Seeing the baby might aid in the grief process. Until relinquishment occurs, this is the mother’s baby and she should be allowed to see it as often as she wants. The mother does have the right to change her mind until final legal arrangements are made. But suggesting this option might lead her to think that the nurse believes she shouldn’t relinquish her baby. Health Promotion and Maintenance

Part II: NCLEX-PN Practice Tests

10. (4) The ability to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn’t change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Nonreversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes. Health Promotion and Maintenance 11. (3) Mycobacterium tuberculosis is an aerobic bacillus that requires a great deal of oxygen to grow and flourish. It needs highly oxygenated body sites, such as lungs, growing ends of bones, and the brain. The bacillus is airborne. Physiological Adaptation 12. (4) Syphilis is an acute and chronic treponemal disease characterized clinically by a primary lesion, a secondary eruption involving skin and mucous membranes, long periods of latency, and late lesions of skin, bone viscera, the CNS, and the cardiovascular system. The primary lesion (chancre) appears about three weeks after exposure as an indurated, painless ulcer with serous exudate at the site of initial invasion. Invasion of the bloodstream precedes development of the initial lesion, and a firm, nonfluctuant, painless lymph node (bubo) commonly follows. Infection might occur without a clinically evident chancre; that is, it might be in the rectum or on the cervix. After four–six weeks, even without specific treatment, the chancre begins to involute, and, in approximately one-third of untreated cases, a generalized secondary eruption appears, often accompanied by mild constitutional symptoms. This symmetrical maculopapular rash involving the palms and soles, with associated lymphadenopathy is classic. Secondary manifestations resolve spontaneously within weeks to 12 months. Again, about one-third of untreated cases of secondary syphilis become clinically latent for weeks to years. In the early years of latency, infectious lesions of the skin and mucous membranes might recur. Specific treatment includes long-acting penicillin G (benzathine penicillin), 2.4 million units given in a single IM dose on the day that primary, secondary or early latent syphilis is diagnosed. This ensures effective therapy, even if the client fails to return. Serologic testing is important to ensure adequate therapy. Tests are repeated three and six months after treatment and later as needed. In HIV-infected clients, testing should be repeated one, two, and three months after treatment, and at three-month intervals thereafter. Any fourfold titer rise indicates the need for retreatment. Physiological Adaptation 13. (4) Chlamydia is a sexually transmitted genital infection and is manifested in males primarily as urethritis and in females as mucopurulent cervicitis. Clinical manifestations of urethritis are often difficult to distinguish from gonorrhea and include mucopurulent discharges of scant or moderate quantity, urethral itching, and burning on urination. Possible complications or sequelae of male urethral infections include epididymitis, infertility, and Reiter syndrome. In homosexual men, receptive anorectal intercourse might result in chlamydial proctitis. In women, the clinical manifestations might be similar to those of gonorrhea and frequently present as a mucopurulent endocervical discharge, with edema, erythema, and easily induced endocervical bleeding caused by inflammation of the endocervical columnar epithelium. However, up to 70% of sexually active women with chlamydial infections are asymptomatic. Complications and sequelae include salpingitis with subsequent risk of infertility, ectopic pregnancy, or chronic pelvic pain. Asymptomatic chronic infections of the endometrium and fallopian tubes might lead to the same outcome. Physiological Adaptation 14. (1) The virus makes a DNA copy of its own RNA using the reverse transcriptase enzyme, and the DNA copy is inserted into the genetic material of the infected cell. Physiological Adaptation 15. (3) A sense of restored body integrity is an expected outcome for interventions related to disturbed body image. Adequate tissue perfusion is an outcome for risk of injury and risk of infection, not disturbed body image. Demonstrating behaviors that might reduce fears is an outcome for anxiety. Remaining free of infection is an outcome for risk of infection. Health Promotion and Maintenance 16. (1) Grief work facilitation is a nursing intervention classification for disturbed body image in burn clients. The expected outcome is grief resolution. Vital signs monitoring is a nursing intervention classification for deficient fluid volume in clients with major burns. Medication administration: skin is a nursing intervention classification for impaired skin integrity for clients with major burns. Anxiety reduction is a nursing intervention classification for anxiety experienced by clients with major burns. Health Promotion and Maintenance

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17. (1) Cold applications are believed to produce vasoconstriction and reduce development of edema. Disability and pain are anticipated to increase during the first 2–3 hours after injury. Progressive passive and active exercises may begin in 2–5 days, according to the physician’s recommendation. A sprain is a traumatic injury to the tendons, muscles, or ligaments around a joint, characterized by pain, swelling, and discoloration of the skin over the joint. The duration and severity of the symptoms vary with the extent of damage to the supporting tissues. Treatment requires support, rest, and alternating cold and heat. X-ray pictures are often indicated to be certain that no fracture has occurred. Physiological Adaptation 18. (3) Placenta previa is a disorder where the placenta implants in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. The bleeding results from tearing of the placental villi from the uterine wall as the lower uterine segment contracts and dilates. It can be slight or profuse and can include bright red, painless bleeding. The abdomen might be soft, nontender, and relax between contractions. Physiological Adaptation 19. (2) An enema could dislodge the placenta and increase bleeding. Physiological Adaptation 20. (2) Pregnancy-induced hypertension (PIH) is a hypertensive disorder of pregnancy, developing after 20 weeks gestation. It is characterized by edema, hypertension, and proteinuria (preclampsia and eclampsia). The cause is unknown. The client with advanced PIH needs rest, and home is the best place to get it. Hospitalization is not necessary in this situation. Medication is not indicated. Physiological Adaptation

22. (2) Normal serum potassium level ranges between 3.5 and 5.5 mEq/L. The levels in choices 1, 3, and 4 are within normal ranges. Physiological Adaptation 23. (3) Diuretics such as furosemide might deplete serum potassium. Additionally, the action of digitalis might be potentiated by hypokalemia. These drugs are not associated with hyperkalemia. Diuretic therapy could cause hyponatremia, not hypernatremia. Choice 4 is generally associated with poor nutrition, alcoholism, and excessive GI or renal losses. Physiological Adaptation 24. (1) There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid. Physiological Adaptation 25. (4) A full bladder is required to serve as a landmark to define pelvic organs. No sedation is given, so the client may drive herself home after the test. Reduction of Risk Potential 26. (3) The remainder of the responses are indications for pelvic ultrasonography. Reduction of Risk Potential 27. (2) Iodine allergy might be a contraindication for contrast media, not the other allergies. Reduction of Risk Potential 28. (1) Valium is a sedative that might be given prior to receiving a CT scan. The other medications are not sedatives. Reduction of Risk Potential 29. (3) No metal objects may be worn while receiving magnetic resonance imaging, due to safety risks involved with the strong magnet. Other options for spiritual support should be explored with the client. Reduction of Risk Potential 30. (2) For lipid fractionation, the client cannot eat for 12 hours prior to the test, but he or she can drink an unrestricted amount of water. No lipid solution is given. Thus, the other choices are incorrect. Reduction of Risk Potential 31. (3) A high bilirubin level is found with hepatic immaturity in newborns, from which jaundice results. The other choices are not. Reduction of Risk Potential 32. (4) Amylase is elevated in conditions of pancreatic inflammation, such as pancreatitis. The other enzymes are associated with other types of tissue damage. Reduction of Risk Potential 33. (3) CPK-MB is elevated in clients who have had a myocardial infarction. CPK-BB is elevated in clients who have brain damage, and CPK-MM is elevated in clients who have skeletal muscle damage. CPK-MI does not exist. Reduction of Risk Potential

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21. (1) Active transport is a process requiring energy to transport ions against a concentration gradient, as is needed in the sodium-potassium pump. Choices 2, 3, and 4 are other regulatory mechanisms involved in fluid and electrolyte balance. Physiological Adaptation

Part II: NCLEX-PN Practice Tests

34. (2) The troponin level is the first to rise in a client who has had a myocardial infarction, followed by CPK, SGOT, and LDH. Reduction of Risk Potential 35. (3) H. pylori is the most common microorganism associated with gastritis. The other microorganisms listed might be associated with gastritis but to a lesser degree. Physiological Adaptation 36. (3) A colostomy is an opening between the colon and abdominal wall. The remaining terms describe other types of ostomies. Physiological Adaptation 37. (4) A dark red color is an abnormal finding when assessing the stoma. It indicates inadequate blood supply. The other findings are normal one day postoperatively. Physiological Adaptation 38. (3) Jaundice turns the skin yellow. The other skin colors are not symptoms of jaundice. Physiological Adaptation 39. (1) Type A hepatitis is transmitted via the fecal-oral route. The remaining types have other modes of transmission. Physiological Adaptation 40. (3) To ensure proper immobilization and increase client comfort when using a rigid splint, pad the spaces between the body part and the splint. Basic Care and Comfort 41. (2) The method of splinting is always dictated by the severity of the client’s condition and the priority decision. Basic Care and Comfort 42. (4) Hazards of improper splinting include aggravation of a bone or joint injury, reduced distal circulation, and delay in transport of a client with a life-threatening injury. Basic Care and Comfort 43. (3) When a client is in a hepatic coma, he is in live liver failure. The liver can no longer metabolize amino acids completely, thus ammonia levels increase causing brain-tissue irritation. Basic Care and Comfort 44. (1) It is important to measure intake (I) and output (O), which should be approximately equal. Enteral feedings are hyperosmotic agents pulling fluid from cells into the vascular bed. Water given before feeding presents a hyperosmotic diuresis. I and O measures assess fluid balance. Basic Care and Comfort 45. (3) Immediately postop abdominal surgery, the NG tube keeps the stomach decompressed to prevent surgical-site disruption and fluid loss through vomiting. Basic Care and Comfort 46. (4) Moving a joint through the full range of motion identifies limitation of movement. Basic Care and Comfort 47. (1) Pulling an object works with gravitational force not opposing it, lowering risk of muscle strain. Basic Care and Comfort 48. (1) Pulling the client toward the nurse lowers the workload force. Pivoting on the unaffected limb offers strength to support the affected limb while pivoting to the bed. Basic Care and Comfort 49. (1) Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer. Basic Care and Comfort 50. (4) Documentation of assessments by the nurse promotes continuity of care and helps prevent further progression of the ulcer. Basic Care and Comfort 51. (3) Gloves should always be worn, and the perineal area should be washed with a washcloth from front to back. This method prevents E. coli and other bacteria from being swept into the urethra. The procedure should be performed and explained in a private area with all equipment gathered first. Basic Care and Comfort 52. (2) Some studies have shown that ginseng and astragalus have enhanced in vitro sperm motility. Ginseng has long been used in traditional Chinese medicine to enhance male fertility. So, Choice 2 is correct and directly addresses the client’s comments. Many times couples struggling with infertility turn to alternative therapies in desperation. They can be very expensive, and some are harmful. Ginseng should not interfere with any of the traditional fertility treatments and might help the couple feel empowered that they are also doing something on their own. Choice 1 is not true. Choice 3 introduces another alternative therapy. It is true that acupuncture is a traditional Chinese medical therapy and has been shown in several clinical studies to be effective in treating infertility in both women and men. The best response by the nurse should address the therapy the client states

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she is using. Choice 4 dismisses the client’s attempts to work through her issues and contribute to the solution. One concern is always that more traditional therapies might be ignored, and time might be lost to alternative therapies. But this response causes the client to perceive the nurse as unsupportive and inhibits further discussion and disclosure. Health Promotion and Maintenance 53. (3) Spinnbarkheit is the correct terminology to identify the cervical mucus described. This type of mucus occurs at ovulation and its assessment is used to help couples determine the time they are most likely to conceive. Ferning capacity or crystallization also increases as ovulation approaches. The only way that ferning can be identified is to place the cervical mucus on a microscope slide, let it air dry, and then examine it for a fern-type appearance. Lack of ferning cannot be determined without microscopic examination. Inhospitable cervical mucus refers to mazelike patterns of mucoid strands in cervical mucus that prohibit sperm motility. Other characteristics that make the mucus inhospitable relate to hormone levels, infection, and so on. These conditions cannot be determined by the description supplied in the question. Health Promotion and Maintenance 54. (4) For the client with an NG tube who begins vomiting, the nurse should check the tube placement because it might be displaced, thereby leading to vomiting. The other responses are not appropriate. Reduction of Risk Potential 55. (2) Nasogastric feedings are most appropriate for a client who is unable to swallow. Nothing by mouth leads to nutritional deficiencies. The client might aspirate a clear liquid diet. TPN is not necessary as long as the gut is still functioning. Reduction of Risk Potential

57. (3) The client with GERD needs to sit up after eating or have the head of the bed elevated to avoid reflux. Thus, choices 1 and 4 are incorrect. Choice 2 is incorrect because the client needs to eat small, frequent meals. Reduction of Risk Potential 58. (2) Naprosyn might cause upper-gastrointestinal (UGI) bleeding. Reduction of Risk Potential 59. (2) Topical agents produce a localized, rather than systemic, effect. When treating atopic dermatitis with a steroidal preparation, the site is vulnerable to invasion by organisms. Viruses, such as herpes simplex or varicella zoster, present a risk of disseminated infection. Educate the client using topical corticosteroids to avoid crowds or people known to have infections and to report even minor signs of an infection. Topical corticosteroid use results in little danger of concurrent infection with the agents in choices 1, 3, and 4. Pharmacological Therapies 60. (4) The client’s pain is affective as well as sensory. Grieving his wife’s death is a normal response that does not necessarily require psychiatric consult. Choices 1 and 2 address the sensory, not the affective component of his pain. Basic Care and Comfort 61. (2) Client education entails giving the client accurate and understandable information. Basic Care and Comfort 62. (1) The focus of distraction therapy is on positive stimuli rather than negative input. Basic Care and Comfort 63. (2) Celiac disease, or celiac sprue, is a malabsorption disorder affecting the small intestine in which there is a problem with the ingestion of gluten, a protein normally found in grain products such as wheat, rye, oats, or barley. The other choices reflect substances that do not contain gluten and should not pose problems for a client with this disorder. Basic Care and Comfort 64. (4) Single-grain infant cereals are recommended first because they are easily digestible and have added iron content. Choice 3 is incorrect because yogurt is a milk product and introduction should be delayed until the child is 12 months of age because of the risk of milk allergy. Choices 1 and 2 are incorrect because fruits and vegetables are usually given following the introduction of cereals. Basic Care and Comfort 65. (2) Caffeine might increase heart rate that is already stressed due to pregnancy. Sodium can cause fluid retention. Both might need to be restricted. The other choices are incorrect because calories, fat, and protein are not usually decreased due to the risk of nutrient deficiencies. Basic Care and Comfort 66. (3) Toradol is an NSAID found to be very effective for brief periods of time for acute pain. It can be given IM, IV, or PO. Basic Care and Comfort

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56. (1) Tobacco use is a predisposing factor for cancer of the tongue; the other choices are not. Reduction of Risk Potential

Part II: NCLEX-PN Practice Tests

67. (3) Safety demands that a client be transferred to a facility that can deliver care equal to the hospital. Basic Care and Comfort 68. (4) Compazine is the drug that should be administered. Basic Care and Comfort 69. (2) A client with sickle cell disease passes on the least sickle cell trait and possibly sickle cell disease, depending on the sickle status of the other parent. Choice 1 is not helpful to the client. Choices 3 and 4 are not true. Physiological Adaptation 70. (1) HIV mutates very rapidly, and any interruption of therapy can allow viral resistance to emerge—even taking a dose late. Choice 2 is incorrect because, when the virus is kept in check with anti-retrovirals, the client’s own immune system is able to keep opportunistic infections at bay. Choices 3 and 4 are incorrect because therapy should not be interrupted for any reason. If the client develops toxicity, another anti-retroviral drug might be prescribed. Physiological Adaptation 71. (4) In DIC, many small clots form throughout the body and are immediately broken down. D-dimer measures a specific fibrin split (or degradation) product and is the most specific test for DIC. Choice 1 is incorrect because platelets are consumed in DIC, but this is not specific. Choices 3 and 4 are both elevated (because clotting factors have been used up) but, again, are not specific. Physiological Adaptation 72. (1) A soft toothbrush is less likely to cause the gums to bleed than a stiff one. So many white cells are produced in clients with leukemias that other cell types (like platelets) are crowded out, putting the client at risk for bleeding. Choice 2 is incorrect because dental floss is contraindicated; it can make the gums bleed. Choice 3 is incorrect because when clotting is impaired, pressure should be held for 5–10 minutes or longer, until the bleeding stops. Choice 4 is incorrect because an electric razor should be used to prevent small cuts. Physiological Adaptation 73. (2) A pattern of behavior known as the cycle of abuse has been described in the literature. It involves a honeymoon stage, followed by a buildup of stress, an angry outburst that might involve beating, reconciliation, and another honeymoon phase. Clients who do not receive help are at increased risk of harm, which might include homicide. Psychosocial Integrity 74. (2) The definition of rape is sexual intercourse against someone’s will. It is a degrading, brutal crime of violence and can occur between any two persons regardless of their marital status. Psychosocial Integrity 75. (4) Obsessive-Compulsive Disorder is an anxiety disorder. Exercise releases emotional energy, limits time for the maladaptive behavior, and directs the client’s attention outward. Initially, nurses should not interfere with performance of the repetitive act, try reasoning the client out of the behavior, or ridicule the behavior. Psychosocial Integrity 76. (3) His wife is exhibiting obsessive-compulsive behavior. Because this is an anxiety disorder, it is desirable to maintain an environment that is calm and as stress free as possible. Attempting to stop or focusing on the behavior can increase the wife’s anxiety and therefore the repetitive behavior. Psychosocial Integrity 77. (1) The nurse must be aware of cultural practices that resemble child abuse. These practices include coining, cupping, and fallen fontanella. Coining and cupping are thought to draw infections from the body. Coining involves rubbing a heated coin on the chest and torso and might cause bruising. Cupping uses heated glasses that can produce erythematous and ecchymotic rounded lesions or linear streaks on the body from the suction. Fallen fontanella involves turning a child upside down to correct a depressed fontanelle; it can cause vomiting, diarrhea, and dehydration in infants. Retinal hemorrhages can also occur, and sometimes Shaken-Baby Syndrome is erroneously diagnosed. Psychosocial Integrity 78. (2) Child abuse is higher in households with lower socioeconomic status and single parents. The increased incidence might be due to increased stress and fewer support systems. Psychosocial Integrity 79. (1) Sex role identification begins during infancy. Infants can identify body parts by the end of the first year. Preschoolers frequently engage in masturbation and sex play with peers. School-age children continue to gain awareness of their sexual identity. During this time they might continue to masturbate and engage in sex play. They might add behaviors such as hugging and kissing members of the opposite sex. Adolescent sex role identification is largely influenced by sexual maturation and trying out or assuming a sex role. Health Promotion and Maintenance

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80. (1) Many cultures (including the Hispanic and Native-American cultures) are sometimes hesitant to discuss sexuality. Some Navajos, Hispanics, and Orthodox Jews view the postpartum period as a state of impurity and might seclude women as long as they are bleeding. The seclusion is usually ended with a ritual bath. Many white teenage girls approve of the prevention of pregnancy, and many African-American teenage girls value pregnancy. Many Native-American women believe in the importance of monthly menstruation to maintain physical wellbeing and harmony. Health Promotion and Maintenance 81. (2) Single mothers with two or three children are the fastest-growing segment of the homeless population. The majority of the children are under the age of five, and the total number of children who are homeless account for more than one-third of the homeless population in the United States. In the past, single adults were the largest group in the homeless population, with more men than women being homeless. Runaway adolescents account for another group of homeless children. Many are victims of abuse or long-term family or school problems. Health Promotion and Maintenance 82. (2) Migrant workers should be provided with the medical records and immunization records for their children, including growth charts. The parents should also be encouraged to take those records with them to every health care visit, including Emergency Department visits. It is important to provide immunizations even when the child is there for an acute illness because preventive care is often not obtained. Preventive services should also be provided, not scheduled, when a child presents for an acute illness. Using a single primary care provider is not an option for most migrant families. The nurse should ask the parents about where they are going next and give them the name, address, and phone numbers of providers there. Health Promotion and Maintenance

84. (4) The culturally sensitive response is to notify the physician of the family member’s wishes and to determine whether it is feasible. Ginkgo biloba has been shown to be of some benefit in treating dementia. The other statements are not culturally sensitive. Reduction of Risk Potential 85. (2) Even though an Alzheimer’s client might not be able to talk or communicate his needs, the family should still communicate through talking and touching. The other statements are correct and indicate adequate understanding. Reduction of Risk Potential 86. (3) This is the only culturally sensitive statement. Many Asian cultures have a high respect for elders, and members of these cultures might not consider placement in a long-term care facility. This is because they feel it is more respectful for them to care for the family member at home. The nurse might be able to assist the family by determining what community resources are available to assist them. Reduction of Risk Potential 87. (2) Guillain-Barré syndrome has a severe complication of respiratory failure. The remaining choices are peripheral nerve conditions, like Guillain-Barré. However, they do not lead to such a severe complication. Reduction of Risk Potential 88. (2) Crying is a regressive behavior. The ego returned to an earlier, comforting, and less-mature way of behaving in the face of disappointment. Conversion involves the transformation of anxiety into a physical symptom. Introjection involves intense unconscious identification with another person. Rationalization involves the unconscious process of developing acceptable explanations to justify unacceptable ideas, actions, or feelings. Psychosocial Integrity 89. (1) Displacement unconsciously transfers emotions associated with a person, object, or situation to another lessthreatening person, object, or situation. The nurse slammed doors instead of striking the promoted nurse or the administrator who made the promotion decision. Sublimation is the unconscious process of substituting constructive activity for unacceptable impulses. This choice cannot be considered correct because the slamming of the cupboard doors cannot be considered a constructive activity. Conversion involves unconsciously transforming anxiety into a physical symptom. Reaction formation keeps unacceptable feelings or behaviors out of awareness by using the opposite feeling or behavior. Psychosocial Integrity 90. (1) Denial, rationalization, regression, and fantasy are coping mechanisms that protect persons from anxiety. Psychosocial Integrity

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83. (2) Clients with ALS have progressive muscular weakness and wasting. However, the mind remains clear and sharp, and there is no sensory loss. There might be periods of grieving, but usually not emotional liability. Reduction of Risk Potential

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91. (4) Milieu therapy provides repetitive ordinary experiences on a daily basis, controls the environment by minimizing change as much as possible, and decreases disruptive behavior by keeping tasks simple. Psychosocial Integrity 92. (3) Recent research reveals that 83% of all persons in the United States, age 12 or older, report using alcohol sometime in their lives. Use of alcohol and illicit drugs appears to increase into the mid-20s, and then levels off and decreases with age. Both lifetime prevalence and intensity of alcohol use are greater in males. Caucasians report higher levels of alcohol use than African Americans or Hispanics. Those with more education are more likely to use alcohol, but heavy use is more common among the less educated and the unemployed. Psychosocial Integrity 93. (2) Simultaneous or sequential use of more than one substance is very common. Multiple drug use can enhance, lessen, or change the nature of the intoxication, or relive withdrawal symptoms. Heroin users often also use alcohol, marijuana, or benzodiazepines. Multiple drug use is especially dangerous if synergistic drugs are combined. Multiple drug use complicates assessment and intervention because the client might be demonstrating the effects or withdrawal from several drugs. Psychosocial Integrity 94. (4) A nasopharyngeal airway is measured from the tip of the nose to the earlobe. Reduction of Risk Potential 95. (2) Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not enough time to remove secretions. The remaining choices are too long and could lead to hypoxia and tissue trauma. Reduction of Risk Potential 96. (4) A chest drainage system should be placed below the level of the client’s chest so that the drainage flows out of the chest into the system. The remaining choices are too high and do not allow fluid to drain out of the chest. Reduction of Risk Potential 97. (4) Gentle bubbling is a normal finding for the client who has a pleural drainage system to suction, so it simply needs to be documented. If the bubbling becomes vigorous, it could indicate a leak, which the nurse needs to investigate. The remaining choices are not necessary. Reduction of Risk Potential 98. (3) If a crack is seen in a pleural drainage system, it should be changed immediately. The remaining choices can be performed later. Reduction of Risk Potential 99. (3) The nurse conducting discharge teaching must stress the lengthy recuperation process with emphasis on the sedative qualities of the medication used to prevent relapse. Support groups are useful for caregivers. The emphasis during recuperation is on maintaining nutrition and hygiene. Psychosocial Integrity 100. (2) Clients are usually aware of the symptoms that indicate relapse is occurring. The client needs to know how to find a safe environment and to seek help. The first two stages of relapse are more difficult to recognize because they do not present symptoms that indicate psychosis. Initially, the client feels anxious and overwhelmed, and might become withdrawn. This is the crucial period to intervene. The client needs to go to a safe environment with someone who is trusted, avoid negative people, and decrease stimuli and stress. Psychosocial Integrity 101. (3) Acquaintance rape remains a controversial topic because of lack of agreement on the definition of consent. Most acquaintance rapes take place in either the victim’s or the assailant’s home or apartment. Most victims of acquaintance rape inform someone close to them, but less than 30% report the incidence to the authorities. Survivors of acquaintance rape report similar levels of depression, anxiety, complications in subsequent relationships, and difficulty attaining prerape levels of sexual satisfaction to what survivors of stranger rape report. Coping is more difficult for victims of acquaintance rape if others fail to recognize that the emotional impact is just as serious. Psychosocial Integrity 102. (3) Childhood sexual abuse is associated with adult-onset depression and with an increased risk for lifetime and current post-traumatic stress disorder (PTSD). About one-third of all victims of sexual abuse meet the diagnostic criteria for PTSD. A person with PTSD has three main types of symptoms: (1) Re-experiencing the traumatic event with flashbacks, nightmares, and exaggerated reactions to triggers that remind the person of the event. (2) Emotional numbing is evidenced by avoidance of activities, places, thoughts, feelings, or conversations related to the trauma; feelings of detachment from others; and restricted or blunted emotions. (3) Increased activity is seen in bursts of anger, difficulty sleeping, hypervigilence, difficulty concentrating, and an exaggerated startle response. Other problems associated with PTSD are panic attacks, suicidal thoughts and feelings, substance abuse, eating disorders, feelings of alienation and isolation, and feelings of mistrust and betrayal. Psychosocial Integrity

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103. (3) The document dated 2003 supersedes the previous version and should be used as a basis for care direction. Choices 1 and 2 are incorrect because the 1998 version is now outdated. Choice 4 is incorrect because the nurse can be held negligent for not responding to the 2003 document as directed. Coordinated Care 104. (4) The nurse acts as an advocate for the nursing profession by encouraging appropriate persons to become nurses, by being a positive role model and mentor, and by communicating the needs of nurses in the most professional manner possible, to those making the laws. Coordinated Care 105. (2) The physician is an integral part of the case-management process in terms of assisting with defining the client’s needs and the time frames for movement through the health care system; however, the physician is the expert for medical diagnosis and treatment rather than resource utilization. Coordinated Care 106. (3) The right to confidentiality of client information might be breached when client care situations are discussed in public areas or without regard to maintaining the information as private and confidential. The other rights listed have not been breached in this instance. Coordinated Care 107. (1) Political power results from one’s ability to work within systems, agencies, or through policy to affect change. Personal power is based on one’s charisma and self-confidence and is often found in informal leadership situations. Positional power is based on designated authority in a legitimized position within which the power is exercised. Professional power is based on one’s professional skills and abilities resulting from one’s recognized expertise in an area of practice. Coordinated Care

109. (3) A urologist is the physician who specializes in urinary tract and prostatic disease. A gynecologist specializes in disease of the female reproductive tract. A physiatrist specializes in rehabilitation care. A proctologist specializes in lower colonic digestive diseases. Coordinated Care 110. (3) Family availability to provide care and assistance is not an indicator for skilled home care. In fact, the nurse might see some opportunity for family education in meeting the client’s needs so that less community support is needed. This needs to be negotiated with the family. Frequent hospital readmissions imply that the client has not been able to manage either due to condition instability or lack of care needs being met. This is a red flag for home care services to be able to meet those needs and appropriately monitor the client. A Foley catheter is an indication for home health care due to infection potential and care requirements. IV antibiotics involve home care due to maintaining line patency and assessment of the site. Coordinated Care 111. (1) Structure standards define all the conditions needed to operate, direct, and control a system. They do not address client care but rather describe structure with regard to purpose, such as philosophy, objectives, goals, hours of operation, and management responsibility. Coordinated Care 112. (1) Monitoring an intravenous infusion must be performed by an RN or LPN. Assisting during activity, offering fluids and recording intake are in the job scope of the nursing assistant. Coordinated Care 113. (3) Treatment procedures are standards of care as defined by the facility or nursing unit. If a treatment is indicated, the nurse is obligated to follow the established procedure to be compliant with practice standards. Established priorities contribute to the determination of time management, appropriate interventions, and the need for client education as a potential intervention. Coordinated Care 114. (1) Primary prevention involves activities that are utilized to promote wellness or prevent illness or injury. There are many dangers in the home for small children. Providing education regarding the need for safety measures to prevent injury in the home is considered primary prevention. Secondary prevention involves early detection of a disease or illness and quick intervention to aid the client in maintenance of the disease or injury. Tertiary prevention involves the reduction of a disability and the promotion of the highest level of functioning for a client in relation to his or her disease or injury. Health promotion is any activity that increases a client’s health and wellness. Health Promotion and Maintenance

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108. (1) To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation so that the information can be communicated in an appropriate way in privacy. Coordinated Care

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115. (2) The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial can be difficult to assess and might need to be verified with a Doppler. Because the client just had a surgery in which a complication is arterial insufficiency, the client must be monitored carefully. If the pulses are not found, the nurse should recognize that this is an emergent situation, and the physician must be notified immediately. If the nurse waits 30 minutes before determining if the pulses can be felt, this could compromise the viability of the client’s foot due to ischemia. Documenting the findings is important but must be performed after the nurse locates the dorsalis pedis and posterior tibial pulses or any necessary interventions are made. Health Promotion and Maintenance 116. (3) The ethical principle of veracity is truth-telling. Autonomy is client self-determination (that is, clients making their own decisions). Beneficence is the principle of doing good, which is a foundation of nursing care. Coordinated Care 117. (3) Risk management is an organizationwide program to identify risks and control incidents and legal liability. It does not have any direct supervisory or management responsibility for staff. Safety and Infection Control 118. (3) Pain medications might alter alertness, thought processes, and reactions. It is recommended that a client be approached for consent at least 4 hours after the last dose of pain medicine to allow minimal impact. Choices 1, 2, and 4 are incorrect. IQ and educational levels might have a bearing on how information is presented through the discussion process, but they do not have a bearing on informed-consent decision-making. Coordinated Care 119. (4) Felonies are serious crimes punishable by time in prison. Types of torts are assault, battery, and negligence in addition to slander, invasion of privacy, false imprisonment, and fraud. Coordinated Care 120. (1) Scholars suggest that the reasons families are having difficulty providing health care for their members lies with both the structure of the health care system and the family structure. Major factors explaining differences in utilization patterns of medical services include the lack of health care insurance coverage, lack of services for special populations (that is, teenage males), perception by families of the health care system and the health care provider, and lack of partnership between health care providers and families in mutually addressing health care issues. Health Promotion and Maintenance 121. (3) The anthropologist Kleinman makes a distinction between disease and illness. Disease is the health care professionals’ biomedical understanding of the health problem, while illness is the client’s personal and unique understanding and definition of what is happening to him. The theorist states that cultural factors determine the importance of the various domains of influence. Health Promotion and Maintenance 122. (4) When an elderly client has been hospitalized for an illness, under Medicare he or she can be transferred to a nursing facility. Health Promotion and Maintenance 123. (3) Hospice has the belief that more humanized alternative care for dying clients is needed than is being provided in hospitals, which focus mostly on medical cures. No matter where the care is delivered, Hospice provides a specialized interdisciplinary team of health care professionals who work together to manage client care. Health Promotion and Maintenance 124. (1) Accidents are the primary source of injury in children and can be life threatening. Appropriate nutrition should have been discussed during the weaning process and while the purchase of appropriate shoes is important, it is not life threatening. One year of age is too early to discuss toilet training. Health Promotion and Maintenance 125. (2) Children with attention deficit disorder are easily distracted but are able to carry on a conversation. Concrete thinking is more indicative of age, and slow speech development has more to do with other learning disabilities. Health Promotion and Maintenance 126. (3) Hepatitis A is for individuals who travel or persons with chronic liver disease. Infants receive the hepatitis B vaccine at birth. DTaP is administered at 18 months of age. Individuals who come into contact with blood should be immunized against hepatitis B. Health Promotion and Maintenance 127. (4) Hepatitis A is not part of the regular immunization schedule for children. DTaP, MMR, and Hib are all regularly scheduled vaccines for children. Health Promotion and Maintenance 128. (1) Serotonin is a substance that is in the body and promotes sleep. Serotonin might play a role in synthesis of a hypnogenic factor that directly causes sleep. Drugs and alcohol can disrupt REM sleep, although they might accelerate the onset of sleep. Basic Care and Comfort

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129. (4) Biological rhythms that follow a cycle lasting about 24 hours are termed circadian rhythm. The sleep-wake cycle is closely linked with cardiac rhythms, such as body temperature. While a person sleeps, core body temperature drops, often reaching the 24-hour low at 4 a.m. When the sleep period shifts, temperature fluctuations also shift to match the new sleep patterns. Basic Care and Comfort 130. (4) The client’s sleep pattern is directly disturbed by the chronic leg pain, which is secondary to the arthritis. This nursing diagnosis is the appropriate one to directly deal with comfort measures and the like. Basic Care and Comfort 131. (1) Packed red blood cells contain antigens and antibodies that must be matched between donor and recipient. Choices 2, 3, and 4 do not contain red cells; thus, they require no cross-matching. Pharmacological Therapies 132. (4) Microorganisms that infect CVADs are often coagulase-negative staphylococci, which can be eliminated by antibiotic administration through the catheter. If unsuccessful in eliminating the microorganism, the CVAD must be removed. CVAD use lessens the need for peripheral IV lines and thus the risk of infiltration. In this case, however, the antibiotics are given to eradicate microorganisms from the CVAD. CVAD use has the effect described in Choice 2, but in this case, the antibiotics are given through the CVAD to eliminate the infective agent. The route does not prevent an allergic reaction. Pharmacological Therapies

134. (3) Drugs and drug metabolites with molecular weights higher than 300 can be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their half-life and duration of action in the body. Choice 1 is the amount of drug eliminated by the liver. Choice 2 is the sum of all types of clearance including renal, hepatic, and respiratory. Choice 4 is the amount of drug absorbed from the GI tract, then metabolized by the liver (reducing the amount of drug that makes it into circulation). Pharmacological Therapies 135. (3) The bioavailability of the injected medication is 100% and might lead to toxicity. An IV infiltration can cause serious problems with tissue necrosis, but this is not life threatening. Expensive and time consuming do not equate with dangerous. Choice 4 is not always true. Pharmacological Therapies 136. (2) Cholestasis due to TPN administration is an intrahepatic process that interrupts the normal flow of bile. Extrahepatic bile duct inflammation is cholangitis. Inflammation of the gallbladder is cholecystitis. Gallstones are formed by bile components. Pharmacological Therapies 137. (1) Viewing crisis intervention as the first step in solving bigger problems is essential in a nurse who assists clients during crises. Assessment of the present problem should be viewed as necessary. Time and limitations of crisis work need to be remembered. Complete diagnostic assessment is unnecessary, and unrelated material should not be explored. Referrals might be necessary for other identified problems. Psychosocial Integrity 138. (1) After physical needs of housing, clothing and food are met, the nurse should focus on assisting clients to manage the psychological effects of loss. Psychosocial Integrity 139. (4) Although clients do have the right to refuse treatment, the nurse should remain nonjudgmental and inform the client of available services. Frequently elders are not aware of existing programs. Psychosocial Integrity 140. (1) Questions about suspected should be direct and nonconfrontational. Indirect questions encourage denial. Psychosocial Integrity 141. (3) Most drugs are excreted in the urine, either as the parent compound or as drug metabolites. Relatively few drugs are excreted in sweat. Some volatile gases are excreted with expiration. The liver primarily metabolizes drugs. Some of them are excreted in bile, especially those with a molecular weight above 300. Pharmacological Therapies

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133. (3) Estrogen antagonists are used to treat estrogen hormone-dependent cancer, such as breast carcinoma. A wellknown estrogen antagonist used in breast cancer therapy is Tamoxifen (Nolvadex). This drug, in combination with surgery and other chemotherapeutic drugs, reduces breast cancer recurrence by 30%. Estrogen antagonists can also be administered to prevent breast cancer in women who have a strong family history of the disease. Thyroxine is a natural thyroid hormone. It does not treat thyroid cancer. ACTH is an anterior pituitary hormone that stimulates the adrenal glands to release glucocorticoids; it does not treat adrenal cancer. Glucagon is a pancreatic alpha cell hormone that stimulates glycogenolysis and gluconeogenesis; it does not treat pancreatic cancer. Pharmacological Therapies

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142. (1) One hundred ml in one hour equals 50 ml in 30 minutes, which is what the physician prescribed. Choice 2 is 10 ml more than the physician prescribed for 30 minutes. Choice 3 is the same as Choice 2; it is 10 ml more than the physician prescribed for 30 minutes. Choice 4 only provides 25 ml over 30 minutes, or half the volume prescribed. Pharmacological Therapies 143. (3) Revocation of the decision for organ donation may occur at any time, by either the client or his responsible party. When organ donation is considered, as many organs as the donor wished to donate are considered and accepted for donation if found appropriate. Medical care for an individual during immediate care and/or resuscitation is not altered to declare a client dead and ready for organ donation. Coordinated Care 144. (4) Client education should be completed by an individual or individuals with acknowledged expertise in the subject area and credentials to support activity within the health care community. Coordinated Care 145. (4) Affinity is a close relationship, mutual attraction, or similarity. The tendency of a drug to combine with its receptor is called affinity. Affinity is a measure of the strength of the drug-receptor bonding. Choices 1 and 2 describe the capability of a drug to produce the desired effect. Choice 3 is the branch of science that deals with the effects of forces on the motions of material bodies or with changes in a physical or chemical system. Pharmacological Therapies 146. (1) Levothyroxine is safe and effective with virtually no side effects when dosed properly. A single, daily dose is possible because of the long half-life (7 days). Levothyroxine tablets are available in a wide range of concentrations to meet individual client requirements. Levothyroxine (T4) is a prodrug of T3. Pharmacological Therapies 147. (2) Pharmacodynamics pertain to the effect of a drug on receptors. Pharmaceutical reactions are chemical reactions between drugs prior to administration or absorption. Pharmacokinetic reactions refer to the body’s effect on the drug. Drug incompatibilities are another term for pharmaceutical reactions. Pharmacological Therapies 148. (2) Diffusion and absorption depend on the chemical properties of the anesthetic and other factors such as local pH and blood flow. Duration might or might not be longer than general anesthesia. Duration can be short if the type of local anesthetic is a short-acting agent. Client weight is not a factor. Pharmacological Therapies 149. (3) The thiazide class of diuretics cause metabolic abnormalities such as elevated blood glucose levels. This elevation is caused in part by diuretic-induced potassium deficiency. Hypokalemia reduces the secretion of insulin by pancreatic beta cells, thereby increasing plasma glucose levels. Thiazides have been used for many years in clients with the conditions described in choices 1 and 2. Thiazides decrease calcium excretion, thus decreasing the likelihood of renal calculi. Pharmacological Therapies 150. (2) Maintaining the productivity of all team members by delegating tasks appropriate to the job descriptions of the personnel increases work effectiveness and efficiency. Coordinated Care 151. (3) Delegating is the act (or task) of assigning work to those that are capable and competent to do the work. Coaching, evaluating, and facilitating are supervisory activities that are people related. Coordinated Care 152. (4) A contract emphasizes that the nurse works with the client, rather than doing something for the client. Working with suggests that each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, nor is premature termination expressly forbidden. Psychosocial Integrity 153. (1) Restating allows the client to validate the nurse’s understanding of what has been communicated. It’s an active listening technique. Regarding Choice 2, judgments should be suspended in a nurse-client relationship. Choice 3 is incorrect because leading questions ask for more information rather than showing understanding. Choice 4 communicates understanding, but the client has no way of measuring the understanding. Psychosocial Integrity 154. (1) Most protocols require two separate clinical examinations, including induction of painful stimuli, pupillary responses to light, oculovestibular testing, and apnea testing. Choices 2 and 4 have no specific test required. Choice 3 is not a current definition of death in the United States. Psychosocial Integrity 155. (4) Try to make the client as comfortable as possible but refuse to assist in death. One of the competencies necessary for nurses to have in giving high quality care to clients/families during the end of life care is: apply legal and ethical principles in the analysis of complex issues and end-of-life care, recognizing the influence of personal values, profession codes, and client preferences. Psychosocial Integrity

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156. (3) Symbols of health or traditions might include certain ritualistic items that are used to maintain, protect, or restore physical, mental, or spiritual health. Psychosocial Integrity 157. (4) Religious teachings help to present a meaningful philosophy and system of practices within a system of social controls having specific values, norms, and ethics. God is the center of many religions (major), but not all. Psychosocial Integrity 158. (2) An acute hyphema occurs as a result of a blunt injury to the eye and is manifested by a half-moon appearance or a horizontal line across the globe when the client is upright (due to blood collected in the anterior chamber). Safety and Infection Control 159. (2) Initial care of the client involves preventing further damage and rebleeding. Clients are kept at bed rest if possible, usually with the head of the bed raised. TV watching is permitted but not reading. The use of atropine, ice, and eye shields are controversial, and a nurse should not administer a pharmacologic agent or thermal therapy without a physician’s order. Safety and Infection Control 160. (1) If it is safe to do so, the nurse should disconnect electrical devices from the power source. Smothering with a blanket is not indicated in an electrical fire and might serve to fuel the fire, just as water or other liquids might incite an explosion or flames. The fire alarm should be activated promptly, and this should be the next action after disconnecting the electrically powered equipment. Safety and Infection Control

162. (2) The three levels of prevention address disease and disability across all phases, from absence of disease and at risk for disease, to preventing further impairment. Hearing impairment associated with prematurity cannot be prevented by screening, but identifying the infants with hearing loss might prevent sequelae and further impairment by allowing early intervention. Safety and Infection Control 163. (4) Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time. Safety and Infection Control 164. (1) When body substances are handled, the potential for transmission is increased; therefore, federal regulations require warning labels to communicate with other employees and/or waste collectors. The biohazard alert is a three-ring symbol overlaying a central concentric ring. Blood, drainage from wounds, feces, and urine are all body fluids that can transfer infection and disease to others. Safety and Infection Control 165. (2) The client is describing signs and symptoms of tuberculosis. The client is potentially infectious to others and should be secluded. A respirator mask should be worn by caregivers, but it is not necessary for the nurse to don a gown and gloves. If the client is moved to other areas such as radiology, a mask should be worn by the client and a respirator mask should be worn by those working in close contact with the client. Safety and Infection Control 166. (2) Chickenpox (varicella) is an acute, infectious, airborne illness that requires others in direct contact to wear a respirator mask. Safety and Infection Control 167. (3) Shigella is a bacteria sometimes found in stagnant water. Transmission of Shigella is typically oral-fecal, so good hand washing and the use of gloves are the best means of prevention when caring for a client with Shigella. The bacteria can be found in food and water contaminated by fecal material. Incidences of Shigella are reportable in many states. Safety and Infection Control 168. (3) Conditions that increase risks for skin cancer are: light or fair complexion, history of having bad sunburns or scars from previous burns, personal or family history of skin cancer, frequently working or playing outdoors with exposure to the sun, exposure to X-rays or radiation, exposure to certain chemicals through work or hobbies (coal, pitch, asphalt, petroleum), repeated trauma or injury to an area resulting in scars, older than age 50, male gender, and living in a geographic location near the equator or at high altitudes. Ways to prevent skin cancer are avoiding exposure to the sun, wearing a hat to protect the face, avoiding all sun lamps, and using a sunscreen with

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161. (2) Public glucose screening has been found to be an ineffective way to screen for diabetes unless based on health risk screening for those persons identified to be at risk or displaying symptoms. Safety and Infection Control

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a minimum of 15 sun protection factor (SPF) if exposure to the sun is unavoidable. Teaching clients how to recognize a potential problem involves inspecting the skin frequently; noting all birthmarks, freckles, and moles; and seeking medical assistance if any of the following are noted: change in color, change in shape, change in surface texture, change in size, change in the surrounding skin, or a new mole or a sore that does not heal. Health Promotion and Maintenance 169. (1) Health promotion is motivated by the desire to increase people’s well-being and health potential. The nurse promotes health by maximizing the client’s own strengths. Identification and analysis of the client’s strengths are a component of preventing illness, restoring health, and facilitating coping with disability or death. The nurse facilitates decisions about lifestyle that enhance one’s quality of life and encourage acceptance of responsibility for one’s own health. Health Promotion and Maintenance 170. (1) Gagging during the gag reflex test indicates that cranial nerves IX and X (the glossopharyngeal and vagus nerves) are intact. Health Promotion and Maintenance 171. (3) A child can have up to 20 temporary (deciduous or baby) teeth. The first tooth usually erupts by age 6 months and the last by age 30 months. All temporary teeth usually are shed between 6 and 13 years of age. Prevention and Early Detection of Disease 172. (3) The cardinal signs of respiratory problems and hypoxia are restlessness, diaphoresis, tachycardia, and cool skin. Bradycardia might occur much later in the process when the condition is severe. Eupnea is normal respirations in rate and depth. Physiological Adaptation 173. (2) The first three symptoms could be indicative of any of the conditions. The distinguishing symptom is the lack of breath sounds in the lower-right base, which is assessed when a portion of the lung has collapsed. Physiological Adaptation 174. (3) Choice 3 is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised and venous return to the heart is affected. The mediastinal shift is to the unaffected side. Choice 1 contains symptoms of pleurisy, and Choice 2 lists symptoms of bronchitis. Neither are emergencies. The client in Choice 4 should expect difficulty breathing after exercise when asthma is an existing condition and might need immediate attention if his rescue inhaler is ineffective. Physiological Adaptation 175. (2) The most common sign of cancer of the lung is a persistent cough that changes. Other signs are dyspnea, bloody sputum, and long-term pulmonary infection. Choice 1 is common with chronic obstructive pulmonary disease (COPD). Choice 3 is common with asthma. Choice 4 is common with tuberculosis. Physiological Adaptation 176. (4) The child has Fifth disease, a parvovirus flulike illness that is self-limiting but is contagious for two–three weeks. Safety and Infection Control 177. (1) Hepatitis A does not produce a carrier state. It is transmitted via contaminated water or food via the oral-fecal route and is not blood borne. Safety and Infection Control 178. (1) The three major sequential maturational crises affecting females are puberty, pregnancy, and menopause. These are life events that have been studied by many researchers and are considered the major events in a woman’s life. Puberty is the onset menarche. Pregnancy is a turning point in one’s life from which there is no return. Menopause is the cessation of menses. The nurse has the responsibility to assess, plan, implement appropriate concepts to facilitate effective functioning, and enhance growth and development. Choices 2, 3, and 4 are not sequential maturational crises. Psychosocial Integrity 179. (2) A maturational crisis occurs when an individual arrives at a new stage of development and must develop new coping strategies. Choice 1 arises from sources external to individuals. Choice 3 occurs when some event external to a person (floods, hurricanes) disrupts his or her coping behaviors. Choice 4 is not a crisis intervention. Psychosocial Integrity 180. (4) Thrombocytopenia is an abnormal decrease in the number platelets, which results in bleeding tendencies. Erythrocytosis is an abnormal increase in the number of circulating red blood cells. Leukocytosis is an increase in the number of white blood cells in the blood. Polycythemia is also an excess of red blood cells and is a synonym for erythrocytosis. With chemotherapy there is a decrease in red and white blood cells, not an increase. Physiological Adaptation

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181. (4) It is an early deceleration as a result of head compression, and at this time no action is necessary. Close observation of the mother and baby is needed. Physiological Adaptation 182. (1) Pain on movement and weight bearing indicates pressure on the nerves or muscles caused by the dislocation. Other symptoms of dislocation include an inability to bear weight and a shortening of the affected leg. Edema is not a primary sign of displacement. Physiological Adaptation 183. (2) Unless the client is first assessed for self-harm or suicide potential, the staff might not observe the necessary degree of vigilance needed in the client’s environment. Physical needs are the second most critical concern with a depressive client. Though the client may be encouraged to attend group therapy as part of the treatment plan, the client’s safety takes precedence. Response to medication takes time and is not an initial concern. Physiological Adaptation 184. (3) A crisis is an acute, time-limited state of disequilibrium resulting from a situational, developmental, or societal source of stress. Utilizing the nursing process, the nurse should assist clients to work through a crisis to its resolution and restore their precrisis level of functioning. Psychosocial Integrity 185. (3) The Transaction-Based Model is, according to R.S. Lazarus, a state that Stimulus theory and Response theory do not consider individual differences. He takes into account cognitive processes that intervene between the encounter and the reaction and the factors that affect the nature of this process. He includes mental and psychological components or responses as part of his concept of stress (Person—Environment Transactions). Psychosocial Integrity

187. (3) The least important factor (of those listed) during an emergency situation is the number of accompanying family members. Safety and Infection Control 188. (3) The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition. Safety and Infection Control 189. (2) Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizure and/or coma. Choices 1 and 3 are abnormal conditions that can cause bleeding, particularly in the third trimester. Choice 4 is a major obstetrical emergency that can cause bleeding internally and externally. Safety and Infection Control 190. (1) Padding distributes pressure so that bony prominences do not receive the brunt of pressure when a client pulls against the restraints. Pressure, especially over bony prominences, causes tissue damage due to ischemia. Safety and Infection Control 191. (3) Cooperation is more likely if the client and family understand the purpose of and expected gains from restraints. Well-meaning family members might release restraints if their purpose is not clear. Safety and Infection Control 192. (2) The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physician’s order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider. Safety and Infection Control 193. (1) A despondent friend, even though this could be a support to the grieving person, is in a state of despondency. Therefore, he or she might not do well with a grieving friend. Psychosocial Integrity 194. (3) The mother’s most prominent concern is likely to be what becomes of her son after she dies. Choice 1 is important but is not likely to be her most prominent concern. Choice 2 is also not likely to be her primary concern because the welfare of her son with schizophrenia is more important. Choice 4 is incorrect because Mrs. Owens has likely confronted and handled concerns about getting the physician to talk to her after 38 years of managing her son’s care. Psychosocial Integrity 195. (3) The client needs to learn how to communicate directly with his wife about her behavior. The nurse’s assistance enables him to practice a new skill and communicates confidence in his ability to confront this situation. Choices 1 and 2 inappropriately direct attention away from the client and toward his wife, who isn’t

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186. (3) Colon tumors tend to spread through the lymphatics and portal vein to the liver. Although metastasis to the other sites listed is possible, the liver is most likely the first to be affected. Physiological Adaptation

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present. Choice 4 implies that there might be a legitimate reason for the nurse to assume responsibility for something that rightfully belongs to the client. Instead of focusing on his problems, he’ll waste precious time convincing the nurse that he or she should do his work. Psychosocial Integrity 196. (4) This response answers the question honestly and nonjudgmentally and helps to preserve the client’s selfesteem. Choice 1 is an open and candid response but diminishes the client’s self-esteem. Choice 2 doesn’t answer the client’s question and is not helpful. Choice 3 increases the client’s anxiety because her inability to walk might be directly related to an unconscious psychological conflict that has not been resolved. Psychosocial Integrity 197. (1) The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept, including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention. Psychosocial Integrity 198. (4) If there are indications of a body image disturbance, the nursing care plan should include body disturbances, related to a functional or physical problem. The disturbance might be an anticipated one—that is, weight gain and pregnancy. Stressors can include a change in physical appearance, sexuality concerns, or an unrealistic ideal self. Psychosocial Integrity 199. (1) Objective anthropometric measurements such as triceps skinfold and mid-arm circumference (MAC), along with weight, are usually used to diagnose malnutrition. While all the other choices represent tests that might provide useful information, they also might be affected by variables other than malnutrition. Physiological Adaptation 200. (4) Leptin (recessive obesity gene—protein hormone) is expressed in fat cell coding for the protein that reacts to the percentage of fat cells in the body. Leptin is associated with increased energy expenditure and decreased food intake via hypothalamic control. Obese clients might have insensitivity or resistance to the effects of leptin. Leptin can affect other body hormones such as insulin. Genetic factors include leptin, uncoupling proteins, and the amount of brown/white fat in the body. Physiological Adaptation 201. (2) A client with renal insufficiency should not start a low CHO diet because it could result in an increased renal solute load. Clients who have renal disease (renal failure, endstage renal disease [ESRD], dialysis, and transplant) or liver disease (liver failure, hepatic encephalopathy, cirrhosis, transplant, and hepatitis) require some form of protein control in dietary patterns to prevent complications from an inability to handle protein solute load. Proteins used in the diet must be of high biologic value, and protein intake is usually weight based, starting at 0.8 g/kg of dry weight, depending on the client’s underlying clinical condition. Protein levels may be increased as necessary to account for metabolic response to dialysis and regeneration of liver tissue (1.5–2.0 g/kg/day). A minimum level of CHOs are needed in the diet (50–100 g/day) to spare protein. Vitamin and mineral supplements might be indicated with clients who have liver failure. The dietician is instrumental in calculating specific nutrient requirements for these clients and reviewing fluid intake and output, medication profile, and daily weight to monitor client outcomes in conjunction with dialysis technicians and nurses. Physiological Adaptation 202. (1) Herbal therapy is used to treat many common complaints and diseases. Physiological Adaptation 203. (2) 5-FU is an antieoplastic, antimetabolic drug that inhibits DNA synthesis and interferes with cell replication. It is given intravenously and acts systemically. It affects all rapidly growing cells, both malignant and normal. It is used as adjuvant therapy for treating cancer of the colon, rectum, stomach, breast, and pancreas. This drug has many side effects, including bone marrow depression, anorexia, stomatitis, nausea, and vomiting. Physiological Adaptation 204. (1) When taking estrogen, there is an increased risk of diabetes or hyperglycemia due to lowered glucose tolerance. It is true that monthly menses might return when taking combination hormones. The progestin is responsible for this. There is also a risk of gallbladder disease. It is also true that there is an increased risk of breast, cervical, and ovarian cancer with long-term hormone replacement therapy. Health Promotion and Maintenance 205. (4) Uterine bleeding on combination hormone replacement therapy, after 12 months of menses cessation, indicates an increased risk of carcinoma and should be reported to the physician immediately. Breast tenderness, weight gain, and fluid retention are all routine side effects of hormone replacement therapy. They should be noted in the record and reported to the physician, but they are not urgent. Health Promotion and Maintenance

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NCLEX-PN Practice Test 3 For each of the following questions, select the choice that best answers the question or completes the statement. 1. Which of the following statements by a client indicates adequate preparation for magnetic resonance imaging? 1. 2. 3. 4.

“I can leave my metal jewelry on during the test.” “I need to wear earplugs during the test.” “I can have the test even though I have a pacemaker.” “I can have the test even though I have an artificial hip.”

6. When a middle-age woman says to the nurse, “I’m really worried about menopause. When my mom went through it, she got really depressed.” the nurse’s best response is: 1. 2. 3. 4.

2. A client expresses anxiety about having magnetic resonance imaging performed. Which of the following is an appropriate response by the nurse? 1. 2. 3. 4.

“You can receive a sedative to help you relax during the test.” “There is absolutely nothing to worry about.” “There is no discomfort with this test, so don’t be anxious.” “The test won’t last long, so you can handle it.”

3. Which of the following is an indication for electroencephalography? 1. 2. 3. 4.

paralysis neuropathy seizure disorder myocardial infarction

4. When a client wishes to improve her appearance by removing excess skin from her face and neck, the nurse should provide teaching regarding which of the following procedures? 1. 2. 3. 4.

dermabrasion rhinoplasty blepharoplasty rhytidectomy

“It is a myth that women get depressed because of menopause.” “Menopause is a normal developmental process.” “It sounds like you are worried that you might become depressed during menopause.” “When women experience depression during menopause it is usually because of social stresses.”

7. When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours? 1. 2. 3. 4.

nausea and vomiting itching urinary retention somnolence

8. The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions? 1.

2. 3.

4.

“It is normal for your breasts to be tender. You should call the physician if you also have redness and fatigue.” “Because your baby was delivered vaginally, you might have to urinate more frequently.” “It is normal to run a low-grade temperature for a few days. If it is higher than 100° F, call your physician.” “Be sure to call your physician if your vaginal discharge becomes bright red.”

5. All of the following are clinical manifestations indicating male climacteric except: 1. 2. 3. 4.

hot flashes. loss of reproductive ability. headaches. heart palpitations.

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9. The parents of a 2-year-old child ask the nurse how they can teach their child to quit taking toys away from other children. Which of the following statements by the nurse offers the parents the best explanation of their child’s behavior? 1.

2. 3.

4.

“Your child is egocentric. Egocentricity is normal for 2-year-old children. He believes other children want him to have their toys.” “Your child is showing negativity. He doesn’t want other children to have the toys he wants.” “Your child is demonstrating magical thinking. He believes he can make the other children want him to play with their toys.” “Your child is engaging in domestic imitation. He is doing what he has seen other children do.”

10. Which of the following infant behaviors demonstrates the concept of object permanence? 1. 2. 3. 4.

The infant cries when his mother leaves the room. The infant looks at the floor to find a toy that he was playing with and dropped. The infant picks up another toy after the one he was playing with rolls under the couch. The infant participates in a game of patty-cake.

11. Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing’s syndrome? 1. 2. 3. 4.

providing safety measures to prevent falls taking medications as prescribed wearing a medical ID indicating Cushing’s syndrome having regular health assessments

12. Which of the following medications should be held 24–48 hours prior to an electroencephalogram (EEG)? 1. 2. 3. 4.

Lasix (furosemide) Cardizem (diltiazem) Lanoxin (digoxin) Dilantin (phenytoin)

13. Which of the following statements by a client indicates adequate understanding of preparation for electroencephalography? 1. 2. 3. 4.

14. A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for: 1. 2. 3. 4.

fluid volume excess. hyperkalemia. hypercalcemia. fluid volume deficit.

15. A physician orders a serum creatinine for a hospitalized client. The nurse should explain to the client and his family that this test: 1. 2. 3. 4.

is normal if the level is 4.0 to 5.5 mg/dl. can be elevated with increased protein intake. is a better indicator of renal function than the BUN. reflects the fluid volume status of a person.

16. One of the major functions of the kidneys in maintaining normal fluid balance is: 1. 2. 3. 4.

the manufacture of antidiuretic hormone. the regulation of calcium and phosphate balance. the regulation of the pH of the extracellular fluid. the control of aldosterone levels.

17. A nurse is caring for a client with an elevated cortisol level. The nurse can expect the client to exhibit symptoms of: 1. 2. 3. 4.

urinary excess. hyperpituitarism. urinary deficit. hyperthyroidism.

18. The anemias most often associated with pregnancy are: 1. 2. 3. 4.

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“I cannot eat or drink after midnight.” “I need to wash my hair before the test.” “I need to remove metal jewelry.” “I cannot take aspirin before the test.”

folic acid and iron deficiency. folic acid deficiency and thalassemia. iron deficiency and thalassemia. thalassemia and B12 deficiency.

NCLEX-PN Practice Test 3

19. Neural tube defects in the fetus have been primarily associated with which deficiency in the mother? 1. 2. 3. 4.

iron folic acid vitamin B12 vitamin E

20. Elderly persons with pernicious anemia should be instructed: 1. 2.

3. 4.

to increase their dietary intake of foods high in B12. that they do not need to return for follow-up for at least a month after initiation of treatment. that oral B12 is safer and less expensive than parenteral replacement. that diarrhea can be a transient side effect of B12 injections.

25. For which condition might a client’s antidiuretic hormone (ADH) level be increased? 1. 2. 3. 4.

26. Which of the following represents a normal serum potassium level? 1. 2. 3. 4.

1. 2. 3. 4.

peaches, eggs, beef cereals, kale, cheese red beans, enriched breads, squash legumes, green beans, eggs

22. The presence of which hormone in the urine is specifically indicative of pregnancy? 1. 2. 3. 4.

estrogen progesterone testosterone human chorionic gonadotropin

23. Increased cortisol levels might be found in a client with which condition?

1.

Cushing’s syndrome Addison’s disease renal failure congestive heart failure

24. Which of the following is not a function of parathyroid hormone? 1. 2. 3. 4.

moving calcium from bones to the bloodstream promoting renal tubular reabsorption of phosphorus promoting renal tubular reabsorption of calcium enhancing renal production of vitamin D metabolites

3. 4.

pernicious anemia is more common than folic acid deficiency. iron deficiency and folic acid deficiency can coexist. the alcohol interferes with iron absorption. oral vitamin replacement is contraindicated.

28. A female client complains to the nurse at the health department that she has fatigue, shortness of breath, and lightheadedness. Her history reveals no significant medical problems. She states that she is always on a fad diet without any vitamin supplements. Which tests should the nurse expect the client to have first? 1. 2. 3. 4.

peptic ulcer studies complete blood count, including hematocrit and hemoglobin genetic testing hemoglobin electrophoresis

29. The nurse should consider which of the following as a possible cause for the symptoms experienced by the client in Question 28? 1. 2. 3. 4.

iron deficiency folate deficiency peptic ulcer iron overload

30. What is pica? 1. 2. 3. 4.

dependency on alcohol increased iron in the diet the sickle cell trait eating ice

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1. 2. 3. 4.

1.5 mEq/L 3.0 mEq/L 4.0 mEq/L 6.0 mEq/L

27. In alcoholics with anemia:

2. 21. Which of the following should be included in a diet rich in iron?

diabetes mellitus diabetes insipidus hypothyroidism hyperthyroidism

Part II: NCLEX-PN Practice Tests

31. Which of the following viruses is most likely to be acquired through casual contact with an infected individual? 1. 2. 3. 4.

influenza virus herpes virus cytomegalovirus (CMV) human immunodeficiency virus (HIV)

32. A female prostitute enters a clinic for treatment of a sexually transmitted disease. This disease is the most prevalent STD in the United States. The nurse can anticipate that the woman has which of the following? 1. 2. 3. 4.

herpes chlamydia gonorrhea syphilis

33. Nurses should understand the chain of infection because it refers to: 1. 2. 3. 4.

the linkages between various forms of microorganisms. the sequence required for transmission of disease. the clustering of bacteria in a specific pattern. increasing virulence patterns among species of microorganisms.

34. Which of the following microorganisms is easily transmitted from client to client on the hands of health care workers? 1. 2. 3. 4.

mycobacterium tuberculosis clostridium tetani staphylococcus aureus human immunodeficiency virus

35. Which of the following blood pressure parameters indicates PIH? Elevation over a baseline of: 1. 2. 3. 4.

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30 mmHg systolic and/or 15 mmHg diastolic. 40 mmHg systolic and/or 20 mmHg diastolic. 10 mmHg systolic and/or 5 mmHg diastolic. 20 mmHg systolic and/or 20 mmHg diastolic.

36. When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy? 1. 2. 3. 4.

low-back pain urinary frequency GI distress malaise

37. When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration? 1. 2. 3. 4.

blood meconium hydramnios caput

38. With a breech presentation, the nurse must be particularly alert for which of the following? 1. 2. 3. 4.

quickening ophthalmia neonatorum pica prolapsed umbilical cord

39. Which of the following diseases places a client at risk for developing cirrhosis? 1. 2. 3. 4.

type I diabetes alcoholism leukemia glaucoma

40. Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis? 1. 2. 3. 4.

Confusion Latex Allergy Acute Pain Constipation

41. Which of the following is not a primary function of the kidneys? 1. 2. 3. 4.

blood pressure control vitamin D activation erythropoietin production reabsorbing waste products

NCLEX-PN Practice Test 3

42. A client with urinary tract calculi needs to avoid which of the following foods? 1. 2. 3. 4.

lettuce cheese apples broccoli

43. Which type of exercises might be prescribed to strengthen the pelvic floor muscles of a client with urinary incontinence? 1. 2. 3. 4.

Kegel resistance passive stretching

47. An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management? 1. 2. 3. 4.

inability to turn, cough, and breathe deeply inability to communicate pain inability to ambulate freely inability to use a bedside commode

48. A client is to have an enema to reduce flatus. The enema tube should be inserted: 1. 2. 3. 4.

4 inches. 6 inches. 2 inches. 8 inches.

44. A standard walker is used when clients: 1. 2. 3. 4.

have poor balance, cannot stand up, have weak arms, and have good hand strength. have poor balance, have a broken leg, or have experienced amputation. have poor balance, have cardiac problems, or cannot use crutches or a cane. have poor balance, have an autoimmune disease, or have weak arms.

45. Safety measures for using crutches must be taught to clients. Safety measures for the use of crutches include: 1. 2. 3. 4.

properly fitting crutches with rubber tips at the end that provide a four-point gait. properly fitting crutches, education in the appropriate gait, and strength in the arms. crutches that fit the way the client chooses and a gait chosen by client. both legs touching the floor for all gaits.

1. 2. 3. 4.

used for all clients who’ve had orthopedic surgery. used for all clients who are not able to stand and for extremity obese clients. used for all clients, both old and young, in a hospital setting. not an assistive device for special needs.

1. 2. 3. 4.

drink 1000 cc prior to the procedure to affect fluid loss. eat foods low in fat. empty his bladder prior to the procedure. assume the prone position.

50. A spinal change occurring with pregnancy that alters mobility is: 1. 2. 3. 4.

scoliosis. kyphosis. lordosis. ankylosing spondylitis.

51. Physical examination of a client regarding mobility status should: 1. 2. 3. 4.

begin with gait. be oriented to time, place, and person. begin with the Romberg test. begin with the Tandem Walk test.

52. The nurse is turning a client who has a new prosthetic hip. Which position should be avoided to prevent injury to the new prosthetic hip? 1. 2. 3. 4.

abduction of the hip adduction of the hip flexing the hip at 80° flexion flexing the hip at 90°

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46. The hydraulic lift (Hoyer lift) is:

49. A client with cirrhosis of the liver presents with ascites. The physician is to perform a parancentesis. For safety, the nurse should ask the client to:

Part II: NCLEX-PN Practice Tests

53. Nail and foot care are essential in meeting basic hygiene needs of clients. Important assessments by the nurse in this area include: 1. 2. 3. 4.

all body assessment, including the feet and nails. the essential lab work of the client. the nail beds and the tissue surrounding the nails. foot corns and calluses only.

56. When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is: 1.

2.

3. 54. For a client requiring total oral care, it is important for the nurse to: 1.

2. 3.

4.

assemble all equipment, assist the client to semi-Fowler’s position, and place a towel on his chest. place client in Fowler’s position, prepare the equipment, and tell the client what to do. assemble all equipment, place the client in a side-lying position, and place a towel under his chin. use gloves and clean the client’s mouth, including the tongue.

55. Client room environments should include: 1.

2. 3.

4.

a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)

4.

“Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse.” “Fertility couseling should be sought when you have not been able to conceive after 6–9 months of unprotected intercourse.” “The average time it takes someone your age to conceive is 51⁄2 months, so if you haven’t conceived by then, we can refer you.” “We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn’t happen within a year.”

57. When a couple experiencing infertility presents for a fertility workup, which of the following procedures should the nurse prepare the couple to have first? 1. 2. 3. 4.

hysterosalpingography semen analysis endometrial biopsy transvaginal ultrasound

58. Which of the following actions should a nurse take first for a client who has just vomited 300 cc of bright red blood? 1. 2. 3. 4.

Document the vomiting. Increase the IV fluids. Get a complete blood count. Check the blood pressure.

59. Which of the following statements indicates adequate dietary understanding in a client with constipation? 1. 2. 3. 4.

“I should decrease my intake of fluids.” “I should decrease my level of activity.” “I should increase my intake of apples.” “I should increase my intake of milk.”

60. Which cultural group has the highest incidence of inflammatory bowel disease (IBD)? 1. 2. 3. 4.

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Asians Caucasians Hispanics African Americans

NCLEX-PN Practice Test 3

61. Which of the following nursing diagnoses is most appropriate for a client with a new colostomy? 1. 2. 3. 4.

Excess Fluid Volume Risk for Aspiration Disturbed Body Image Urinary Retention

62. Which of the following foods can cause diarrhea when eaten by a client with an ileostomy? 1. 2. 3. 4.

eggs coffee fish garlic

63. In infants and children, the side effects of firstgeneration over-the counter (OTC) antihistamines, such as diphenhydramine (Benedryl) and hydroxyzine (Atarax), can include: 1. 2. 3. 4.

Reye’s syndrome. cholinergic effects. paradoxical CNS stimulation. nausea and diarrhea.

64. The nurse can promote relief of muscle pain, spasms, and tension by: 1. 2. 3. 4.

having the client continue his activities as usual. immobilizing the client. applying heat, cold, pressure, or vibration to the painful area. giving as much pain medication as needed to ease the muscle.

65. Nonpharmacological pain management involves all of the following except: hypnosis alone. psychological care, including support groups. physical and psychological modalities. pain-reducing drugs only.

66. The nurse is using Cognitive-Behavioral methods of pain control and knows that the these methods can be expected to do all the following except: 1. 2. 3. 4.

completely relieve all pain. provide benefit by restoring the client’s sense of self-control. help the client to control symptoms. help the client actively participate in his or her own care.

1. 2. 3. 4.

The client verbalizes knowledge of a maintenance diet. The client demonstrates assertiveness with family. The client verbalizes her body size accurately. The client demonstrates control of obsessive behaviors.

68. Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance? 1. 2. 3. 4.

high protein high carbohydrate low carbohydrate low protein

69. As part of the teaching plan for a client with type I diabetes mellitus, the nurse should include that carbohydrate needs might increase when: 1. 2. 3. 4.

an infection is present. there is an emotional upset. a large meal is eaten. active exercise is performed.

70. The NSAID that is comparable to morphine in efficacy is: 1. 2. 3. 4.

Feldene. Stodal. Toradol. Elavil.

71. Pain tolerance in an elderly client with cancer should: 1. 2. 3. 4.

Stay the same. Decrease. Increase. Cancer should have no effect on pain tolerance for an elderly client.

72. In administering NSAID adjunctive therapy to an elderly client with cancer, the nurse must monitor: 1. 2. 3. 4.

BUN and creatinine. creatinine and calcium. Hgb and Hct. BUN and CFT.

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1. 2. 3. 4.

67. Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?

Part II: NCLEX-PN Practice Tests

73. Appropriate care for a client with neutropenia includes: 1. 2. 3. 4.

plenty of fresh fruits and vegetables. a semi-private room. wearing a mask when out of the room. routine hand washing.

74. The PN is caring for a client with diabetes insipidus. The nurse can expect the lab work to show: 1. 2. 3. 4.

elevated urine osmolarity and elevated serum osmolarity. decreased urine osmolarity and decreased serum osmolarity. elevated urine osmolarity and decreased serum osmolarity. decreased urine osmolarity and elevated serum osmolarity.

75. If a client is suffering from thyroid storm, the PN can expect to find on assessment: 1. 2. 3. 4.

tachycardia and hyperthermia. bradycardia and hypothermia. a large goiter. a calm, quiet client.

76. The best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus is: 1. 2. 3. 4.

Impaired Skin Integrity. Knowledge Deficit: New Diabetes Diagnosis. Alteration in Nutrition: More than Body Requirements. Fluid Volume Deficit.

77. After group therapy, the female victim of intimatepartner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true? 1. 2. 3. 4.

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Victims of domestic violence are often the best predictors of their risk of harm. Victims of domestic violence often overestimate their safety risk. Victims of domestic violence are typically in a state of denial. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.

78. A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate? 1.

2. 3. 4.

“Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain.” “Often women become offended if asked about their safety in relationships.” “It is mandatory that all women be questioned about domestic violence.” “How would you feel to know that her partner is beating her and you didn’t ask?”

79. A client reports that someone is in the room and trying to kill him. The nurse’s best response is: 1. 2. 3. 4.

“No one is in your room. Let’s get you more medicine.” “I do not see anyone, but you seem to be very frightened.” “No one can hurt you here.” “Just tell the person to go away.”

80. The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should: 1. 2. 3. 4.

Have decreased anxiety. Talk to the nurse for 10 minutes. Sit quietly for 30 minutes. Develop an adaptive coping mechanism.

81. Which of the following services is not part of family consultation? 1. 2. 3. 4.

assisting with vocational rehabilitation providing information about the client’s illness teaching effective communication helping families solve problems

NCLEX-PN Practice Test 3

82. A family member of a client with a diagnosis of Schizophrenia asks about the prognosis. The nurse’s response is based on the knowledge that schizophrenia: 1. 2. 3. 4.

affects women more often than men. is usually diagnosed between the ages of 15 and 45. is a chronic, deteriorating disease with periods of remission. is diagnosed later in women due to a protective hormone effect.

83. A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has: 1. 2. 3. 4.

mild anxiety. moderate anxiety. severe anxiety. a panic attack.

84. The highest incident of child abuse occurs in children in which age group? 1. 2. 3. 4.

birth–3 years old 4–6 years old 6–10 years old more than 10 years old

1. 2.

3.

4.

“I think I was a lonely child because I could not tell anyone about my abuse.” “I am now aware of how deep-seated my anger is. Before I did not realize I was angry.” “The program has given me the courage to tell my mother how I felt about her role in my hurt.” “There are so many people just like me, who are just normal people that had bad things happen to them.”

1. 2. 3. 4.

retrograde ejaculation decreased plasma testosterone hypertrophy of testicles state of euphoria

87. When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is: 1.

2.

3.

4.

“Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes.” “If you haven’t been sexually active throughout your life, you will not be able to participate in sexual activity in old age.” “When intercourse isn’t possible, many of your sexual needs can be met through intimacy and touch.” “You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time.”

88. The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except: 1. 2. 3. 4.

disclose the information before the child knows or suspects. be comfortable with your sexual preference first. have the discussion in a quiet place where interruptions are unlikely. explain how your relationship with the child changes because of the discussion.

89. When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as? 1. 2. 3. 4.

polyandry soronal nonsororal sororate

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85. An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?

86. If a client has chronic renal failure, which of the following sexual complications is the client at risk of developing?

Part II: NCLEX-PN Practice Tests

90. Which of the following syndromes associated with incomplete lesions of the spinal cord is a result of damage to one-half of the spinal cord? 1. 2. 3. 4.

Brown-Séquard syndrome posterior cord syndrome central cord syndrome cauda equina syndrome

91. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia? 1. 2. 3. 4.

“I should raise him to a sitting position.” “I should check for a fecal impaction.” “I should look for a kink in the urinary catheter tubing.” “I should see whether symptoms worsen.”

92. Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury? 1. 2. 3. 4.

sudden onset of headache flushed face hypotension nasal congestion

93. Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management? 1. 2. 3. 4.

“I should avoid eating foods that produce gas.” “I should drink more fluids like coffee and cola.” “I should set a regular schedule for bowel movements.” “I should sit in an upright position for bowel movements.”

94. A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, “No woman will ever want to marry me now.” Which of the following responses by the nurse is most therapeutic? 1. 2. 3. 4.

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“Don’t worry. Maybe you’ll meet a paraplegic woman.” “There is someone for everyone in this world.” “You are still an attractive man, even though you can’t walk.” “Tell me more about your feelings on this issue.”

95. Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. The nurse who was not promoted tells a friend, “Oh, well, I really didn’t want the job anyway.” This is an example of: 1. 2. 3. 4.

rationalization. denial. projection. compensation.

96. The nurse who was not promoted tells another friend, “I knew I’d never get the job. The hospital administrator hates me.” If she actually believes this of the administrator, who, in reality, knows little of her, she is demonstrating: 1. 2. 3. 4.

compensation. reaction formation. projection. denial.

97. The Token Economy is a type of therapy that focuses on: 1. 2. 3. 4.

play therapy. behavior modification. milieu therapy. associative.

98. How does the ANA define the psychiatric nursing role? 1.

2. 3. 4.

a specialized area of nursing practice that employs theories of human behavior as its science and the powerful use of self as its art assisting the therapist to relieve the symptoms of clients to solve clients’ problems and give them the answers having a client committed to long-term therapy with the nurse

99. While admitting a client to an acute-care psychiatric unit, the nurse asks about substance abuse based on knowledge that: 1. 2. 3. 4.

psychiatric illness is more prevalent in addicted populations. people with psychiatric disorders are more prone to substance abuse. substance disorders are easily detected and diagnosed in acute-care psychiatric settings. undetected substance problems have no real effect on treatment of psychiatric disorders.

NCLEX-PN Practice Test 3

100. When planning care of a client who has a been diagnosed with Amphetamine Abuse, the nurse should use the knowledge that: 1. 2. 3. 4.

amphetamines increase energy by increasing dopamine levels at neural synapses. amphetamines have a low risk of tolerance or addiction. amphetamines produce a 10–20-second rush followed by a 2–4-hour high. addiction to barbiturates and amphetamines is rare because they have opposite effects.

101. A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do? 1. 2. 3. 4.

Consider it a normal finding. Check the system for leaks. Clamp the chest tube. Change the drainage system.

102. Which type of dressing is recommended to place over a site when a chest tube is removed by the physician? 1. 2. 3. 4.

transparent dressing colloidal dressing petrolatum gauze nonadherent dressing

103. A client begins bleeding from the site of a previous arterial blood gas draw on the right wrist. What should the nurse do first? 1. 2. 3. 4.

Check the blood count. Apply pressure to the site. Document the bleeding. Monitor the bleeding.

1. 2. 3. 4.

Open the airway. Give defibrillation. Check the pulse. Call for help.

1. 2. 3. 4.

5:1 1:5 15:2 2:15

106. The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should: 1.

2.

3.

4.

confront the staff member immediately and say, “You know that is not the treatment plan.” write an incident report to create a paper trail of the staff member’s failure to follow the planned program. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.

107. A client diagnosed with Borderline Personality Disorder frequently attempts to burn herself. The best intervention to facilitate behavior change is: 1. 2. 3.

4.

constantly observing the client to prevent self-harm. enlisting the client in defining and describing harmful behaviors. checking on the client every 15 minutes to ensure she is not engaging in harmful behavior. removing all items from the environment that the client could use to harm herself.

108. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechaie of the palate. The nurse should: 1. 2. 3. 4.

inquire about foods the child is eating. ask about the possibility of sexual abuse. request to see the type of bottle used for feedings. question the parent about objects the child plays with.

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104. A nurse walks into a client’s room to do an assessment and discovers that the client is unresponsive. The nurse shakes the client and calls his name, but he does not arouse. What should the nurse do next?

105. What is the appropriate ratio of cardiac compressions to ventilations in an adult client for one-person CPR?

Part II: NCLEX-PN Practice Tests

109. A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client? 1. 2. 3. 4.

prosecuting the perpetrator managing symptoms of anxiety and fear determining if the memories are real collaborating the client’s story

110. An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding: 1. 2. 3. 4.

internationally. in the state of Colorado only. in the continental United States. in the county of origination only.

111. A nursing advocate is one who: 1. 2.

3. 4.

makes decisions for others. encourages persons to make decisions for themselves and acts with or on behalf of the person to support those decisions. manages the care of others. is the legal representative for a person.

112. A case management clinical pathway for congestive heart failure might include all of the following except: 1. 2. 3. 4.

physician follow-up appointments with transportation. client education regarding medication use. a nutritional consult for diet review and accommodation. insurance review for reimbursement.

113. The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should: 1.

2.

3.

4.

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request that the family wait for its loved one in the client’s room and wait to resume the report until the family has left the desk area. request that a nursing assistant bring coffee for the family while it waits at the desk and continue with the report. request that the family have a seat in the station rather than stand while awaiting its loved one. request that the family wait for its loved one in the Emergency Department waiting room.

114. The nurse belongs to a professional nursing organization that provides social, educational, and political venues for nurses. The nurse has been active in this organization for almost two years, during which time she meets and works with nurses from several different nursing agencies and health care institutions to achieve a variety of goals, including obtaining advice regarding a personal career choice. This is an example of: 1. 2. 3. 4.

professional nurturing. networking. mentoring. collegiality.

115. A legal right to confidentiality of client information is waived when: 1. 2. 3. 4.

a court system subpoenas information. a family member requests health care information of a client. a living will takes effect. the client is declared incompetent by the legal system.

116. A gastroenterologist should be consulted for clients suffering from: 1. 2. 3. 4.

digestive system diseases. urinary system diseases. female reproductive system diseases. nervous system diseases.

117. A client has experienced a CVA with right hemiparesis and is ready for discharge from the hospital to a long-term care facility for rehab. To provide optimal continuity of care, the nurse should do all of the following except: 1. 2. 3. 4.

document current functional status. have the physician phone a report to the receiving facility. copy appropriate parts of the medical record for transport to the receiving facility. phone a report to the facility.

NCLEX-PN Practice Test 3

118. An example of a process standard on a med-surg unit is: 1. 2. 3. 4.

a procedure for changing IV tubing. a policy for staffing. the job description of the CEO (chief executive officer). a procedure for checking waveforms on a client being treated on an intra-aortic balloon pump.

122. The home health nurse has made a visit to an 85-year-old female client’s home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan? 1. 2.

119. Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection? 1. 2. 3. 4.

“Make it a stat delivery.” “Please do it as soon as you can after break.” “This client is delirious, and we’re worried about a urinary sepsis.” “Take this client to the bathroom now and collect a urine specimen from this voiding. Take the specimen to the lab immediately.”

120. Priorities to be considered intermediate are: 1. 2. 3. 4.

the nonemergency, non-life-threatening needs of the client. those tasks that can be delegated to assistive personnel. those tasks that can be performed at the end of the shift. those task that can be performed at any time.

1. 2. 3. 4.

The children should wear long sleeves and long pants while outside. Apply insect repellant containing DEET when the children are outside. Remove standing water from the property. All of the above.

4.

123. Issues addressed in ethics committees include all of the following except: 1. 2. 3. 4.

nonpayment of bills. euthanasia. starting or stopping treatment. use of feeding tubes.

124. How is the information documented on incident reports used? 1. 2. 3. 4.

to analyze risk categories to make sure procedures are in compliance with regulations to identify the educational needs of the staff all of the above

125. The only time that an individual may receive medical care without giving informed consent is: 1. 2. 3. 4.

when the durable power of attorney for health care is not available. in an emergency, life-or-death situation. when the physician is not available for discussion with the client. when they (clients) are not able to speak for themselves.

126. The acts enacted by states to provide immunity from liability to persons who provide emergency care at an accident scene are called: 1. 2. 3. 4.

Good Samaritan laws. HIPAA. Patient Self-Determination Act (PSDA). OBRA.

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121. A mother has come to the pediatric clinic concerned about the recent outbreak of West Nile Virus. The ages of her children are 5, 7, and 10. The mother has asked the nurse what she can do to prevent her children from contracting this illness. Which piece of information is best to provide the mother with?

3.

The client should remove all scatter rugs from the floor and minimize clutter. The client should not get up and move around the house. The client does not need to install a raised toilet and grab bar because she is able to walk on her own. The client should wear a robe and socks while walking in the house.

Part II: NCLEX-PN Practice Tests

127. Which of the following substances need to be assessed when completing a family health assessment? 1. 2. 3. 4.

coffee, tea, cola, and cocoa alcohol, tobacco, and illegal substances medicines prescribed by a physician all of the above

128. An appraisal of self-care practices involves an assessment of: 1. 2. 3. 4.

all diagnostic tests. home treatment practices, including nurse visits for the sick or disabled. the family’s capability to get health insurance. caregiving needs and the potential for strain.

129. Which of the following is one of the main goals for Healthy People 2010? 1. 2. 3. 4.

reduction of health care costs elimination of health disparities investigation of substance abuse determination of an acceptable morbidity rate

130. A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving? 1. 2. 3. 4.

primary prevention secondary prevention tertiary prevention health promotion

131. Which of the following developmental milestones for a 6-month-old child should be screened by the nurse during a routine office visit? 1. 2. 3. 4.

standing while holding something rolling over sitting up creeping

132. During the health screening of an adolescent, which finding by the nurse requires further teaching? 1. 2. 3. 4.

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The client started her first menses 2 years ago. The client states she is currently on birth control pills. The client states she recently lost 5 pounds. The client states she is experiencing growing pains.

133. A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following? 1. 2. 3. 4.

Immunizations may be started at any age. The recommended immunization schedule must be followed exactly. If a primary series of immunizations is interrupted, the series must be restarted. This child is at increased risk for reaction to the vaccines, when they are started.

134. Which of the following vaccines is a live virus? 1. 2. 3. 4.

varicella IPV DTaP hepatitis B

135. The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse’s actions: 1. 2. 3. 4.

help the client’s circadian rhythm. stimulate hormonal changes in the brain. decrease stimuli from the cerebral cortex. alert the hypothalamus in the brain.

136. Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the: 1. 2. 3. 4.

hypothalamus. thalamus. cortex. medulla.

137. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except: 1. 2. 3. 4.

the client reports no episodes of awakening during the night. the client falls asleep within 1 hour of going to bed. the client reports satisfaction with his amount of sleep. the client rates sleep as an 8 or more on the visual analog scale.

NCLEX-PN Practice Test 3

138. A month after receiving a blood transfusion, an immunocompromised client develops fever, liver abnormalities, a rash, and diarrhea. The nurse should suspect this client has: 1. 2. 3. 4.

nothing related to the blood transfusion. graft-versus-host disease (GVHD). myelosuppression. an allergic response to a recent medication.

139. An infection in a central venous access device is not eliminated by giving antibiotics through the catheter. How might bacterial glycocalyx contribute to this? 1. 2. 3. 4.

It protects the bacteria from antibiotic and immunologic destruction. Glycocalyx neutralizes the antibiotic, rendering it ineffective. It competes with the antibiotic for binding sites on the microbe. Glycocalyx provides nutrients for microbial growth.

140. Chemotherapeutic agents often produce a degree of myelosuppression including leukopenia. Leukopenia does not present immediately but is delayed several days or weeks because: 1. 2. 3. 4.

the client’s hemoglobin and hematocrit are normal. red blood cells are affected first. folic acid levels are normal. the current white cell count is not affected by chemotherapy.

1. 2. 3. 4.

increased therapeutic effects of Drug A. increased adverse effects of Drug B. decreased therapeutic effects of Drug A. decreased therapeutic effects of Drug B.

1. 2. 3. 4.

her response to being hospitalized the presence of a macular rash on her trunk her cardiac status the presence of polyarthritis and pain in her joints

143. A 21-year-old college student has just learned that she contracted genital herpes from her sexual partner. After completing the initial history and assessment, the nurse has data concerning areas pertinent to the disease. The data is likely to include all but which of the following? 1. 2. 3. 4.

voiding patterns characteristics of lesions vaginal discharge prior history of varicella

144. A client has been admitted in septic shock. Her nursing care plan includes the diagnosis High Risk for Injury (related to clotting disorder). Based on this diagnosis, all the following are appropriate entries in the nursing care plan except: 1. 2. 3.

4.

obtain an order for a stool softener. administer packed RBCs, if ordered. encourage the client to rinse her mouth with mouthwash and scrub her teeth with an oral sponge. dress venipuncture sites immediately to prevent infection.

145. A person using over-the-counter nasal decongestant drops who reports unrelieved and worsening nasal congestion should be instructed to: 1. 2. 3. 4.

switch to a stronger dose of the medication. discontinue the medication for a few weeks. continue taking the same medication, but use it more frequently. use a combination of medications for better relief.

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141. A client has been taking a drug (Drug A) that is highly metabolized by the cytochrome p-450 system. He has been on this medication for 6 months. At this time, he is started on a second medication (Drug B) that is an inducer of the cytochrome p-450 system. You should monitor this client for:

142. Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of “a sore throat about a month ago.” Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie’s condition?

Part II: NCLEX-PN Practice Tests

146. A client has a 10% dextrose in water IV solution running. He is scheduled to receive his antiepileptic drug, phenytoin (Dilantin), at this time. The nurse knows that the phenytoin: 1. 2. 3. 4.

is given after the D10W is finished. should be given at the time it is due in the medication port closest to the client. can be piggybacked into the D10W solution now. is incompatible with dextrose solutions.

147. The physician wants to know if a client is tolerating his total parenteral nutrition. Which of the following laboratory tests is likely to be ordered? 1. 2. 3. 4.

triglyceride level liver function tests a glucose tolerance test a complete blood count

150. The nurse is assessing an elder who the nurse suspects is being physically abused. The most important question for nurse to ask is: 1. 2. 3. 4.

151. A nurse notes that an elderly client suddenly does not keep appointments and is not wearing appropriate clothing. Which statement by the client raises the suspicion of financial abuse? 1. 2. 3. 4.

148. When planning intervention for a client during a crisis, which of the following outcomes is most appropriate? 1. 2. 3. 4.

The client should explore deep psychological problems. The client should express positive feelings about event. The client should identify needs that are threatened by the event. The client should use constructive coping mechanisms.

149. A man expresses surprise that his wife has become very withdrawn during hospitalization for pneumonia. Which response helps the husband understand how some people cope with hospitalization? 1.

2. 3. 4.

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“Hospitalization might cause a crisis. Has your wife had to cope with problems before this?” “Some people react that way. She will be more talkative when she feels better.” “Your wife might be feeling concern that she cannot fulfill her normal roles.” “This is typical behavior for someone who is as ill as your wife.”

“How much money do you keep around the house?” “Who provides your physical care?” “How close does your nearest relative live?” “What form of transportation do you use?”

“I am having difficulty paying for this new antibiotic the physician prescribed.” “I am a little short on cash since my daughter moved in to help me.” “I have not felt like shopping since the weather has gotten worse.” “People do not realize how difficult it is to make ends meet on a fixed income.”

152. A client needs to rapidly achieve a therapeutic plasma drug concentration of a medication. Rather than wait for steady state to be achieved, the physician might order: 1. 2. 3. 4.

a maintenance dose. a loading dose. a medication with no first-pass effect. the medication to be given intravenously.

153. In hanging a parenteral IV fluid that is to be infused by gravity, rather than with an infusion pump, the nurse notes that the IV tubing is available in different drop factors. Which tubing is a microdrop set? 1. 2. 3. 4.

15 drops per milliliter 60 drops per milliliter 20 drops per milliliter 10 drops per milliliter

154. The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client’s wishes regarding organ donation: 1. 2. 3. 4.

on the driver’s license of the client. in the client’s safety deposit box. in the client’s last will and testament. on the client’s insurance card.

NCLEX-PN Practice Test 3

155. An 85-year-old client is eligible for Medicarereimbursable home care services. Referral is contingent on meeting which of the following criteria? 1. 2. 3. 4.

homebound status, requiring skilled therapy care immediate previous hospitalization for acute care age requirement of nursing and social work support

156. The factor that most determines drug distribution is: 1. 2. 3. 4.

vascular perfusion of the tissue or organ. salt form. drug interactions. steady state.

157. Metformin (Glucophage) is administered to clients with type II diabetes mellitus. Metformin is an example of: 1. 2. 3. 4.

an antihyperglycemic agent. a hypoglycemic agent. an insulin analogue. a pancreatic alpha cell stimulant.

158. A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most? 1. 2.

1.

2.

3.

4.

Hyperactivity of the medium-sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest. Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways. Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production. Chloride is not being transported properly, producing excess absorption of water and sodium, and thick viscous mucus.

160. A client admitted to the medical nursing unit has classic symptoms of tuberculosis (TB) and tests positive on the purified protein derivative (PPD) skin test. Several months later, the nurse who cared for the client also tests positive on an annual TB skin test for work. The most likely course of treatment if the chest X-ray (CXR) is negative is to: 1. 2. 3. 4.

repeat a TB skin test in six months. treat the nurse with an anti-infective agent for six months. monitor for signs and symptoms within the next year. follow up in one year at the next annual physical with CXR only.

161. A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by: 1. 2. 3. 4.

pleurisy. pleural effusion. atelectasis. tuberculosis.

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3. 4.

temperature of 102° F and a productive cough arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg trachea deviating to the right barrel-chested appearance

159. A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse’s discussion with the client?

Part II: NCLEX-PN Practice Tests

162. One drug can alter the absorption of another drug. One drug increases intestinal motility. Which effect does this have on the second drug? 1. 2. 3. 4.

None; absorption of the second drug is not affected. The increased gut motility increases the absorption of the second drug. The absorption of the second drug cannot be predicted. Less of the second drug is absorbed.

167. After the client discusses her relationship with her father, the nurse says, “Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?” This is an example of: 1. 2. 3. 4.

verbalizing the implied. seeking consensual validation. encouraging evaluation. suggesting collaboration.

168. The best definition of communication is: 163. A client asks a nurse working in a dental office what type of drug the dentist uses to provide anesthesia during the extraction of the client’s wisdom teeth. The dentist uses an anesthetic gas, also known as laughing gas. This agent is: 1. 2. 3. 4.

nitrous oxide. nitrogen. nitric oxide. nitrogen dioxide.

164. Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)? 1. 2. 3. 4.

The hematocrit is adversely affected because of an increased vascular volume. AEDs affect immune modulators increasing the risk of infection. AEDs induce white blood cell reduction. A side effect of some AEDs is blood dyscrasia.

165. To manage time most effectively, the nurse responds to which of the following stimuli first: 1. 2. 3. 4.

the physician’s loud verbal direction. the nursing supervisor who is going to a meeting. unit staff leaving on a break. the care needs of the returning postoperative client just exiting the elevator.

166. People-related supervisory tasks include all of the following except: 1. 2. 3. 4.

coaching. encouraging. target setting. rewarding.

1. 2. 3. 4.

169. The nurse supporting a family who has just experienced a sudden and unexpected death needs to know: 1. 2. 3. 4.

that survivors have greater emotional turmoil and shock than when death is expected. that survivors have less emotional turmoil and shock than when death is expected. that survivors have the same emotional turmoil and shock as when death is expected. that survivors have little emotional turmoil and shock because they were not there.

170. A mother has just given birth to a baby who died soon after. The mother has been crying and states, “I can’t believe this has happened to me. I did everything right during this pregnancy.” How should the nurse respond to this mother? 1. 2. 3. 4.

Tell her she did nothing wrong; it was God’s will. Tell her she can have another baby. Tell her that her behavior is not going to solve anything. Tell her nothing and let her mourn this loss in the manner she chooses.

171. The difference between spirituality and religion is that spirituality is: 1. 2. 3. 4.

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the sending and receiving of messages. the effect of sending verbal messages. an ongoing, interactive form of transmitting transactions. the use of message variables to send information.

a belief about a higher power. an individual’s relationship with a higher power. organized worship. a belief in an invisible energy or ideal.

NCLEX-PN Practice Test 3

172. Spirituality affects a client’s life in all of the following areas except: 1. 2. 3. 4.

nutritional intake. ability to handle stress. sexual expression. genetic makeup.

173. How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher? 1. 2. 3. 4.

1 foot 2 feet 4 feet 6 feet

174. While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take? 1. 2. 3. 4.

Unplug the bed’s power source. Remove the client from the bed immediately. Notify the biomedical department at once. Turn off the oxygen.

175. After securing the client’s safety from a faulty electric bed, the nurse should take which action? 1. 2. 3. 4.

Discuss the matter with the client’s significant others. Document the incident in the client’s record in detail. Notify the physician. Prepare an incident report.

176. A client taking isotretinoin (Accutane) tells the nurse that she is pregnant. What should the nurse teach this client?

2. 3. 4.

Her pregnancy is threatened, and the fetus is at risk for teratogenesis. She has a reportable condition, and the pregnancy must be terminated. Accutane is a Category D drug, which means it is unsafe in pregnancy. Her pregnancy must be followed carefully by a genetic specialist.

1. 2. 3. 4.

Pregnancy tests might be unreliable while taking the drug. She must use a reliable form of birth control. She should not take the Category X drug on days she has intercourse. She must follow up with an endocrinologist.

178. The nurse seeks to assess the renal function of an elderly client who is about to receive a nephrotoxic medication. Which of the following labs provides the best indicator for renal function? 1. 2. 3. 4.

urinalysis creatinine and blood urea nitrogen chemistry of electrolytes creatinine clearance

179. The nurse sustains a needle puncture that requires HIV prophylaxis. Which of the following medication regimens should be used? 1. 2. 3. 4.

an antibiotic such as Metronidazole and a protease inhibitor (Saquinivir) two non-nucleoside reverse transcriptase inhibitors one protease inhibitor such as Nelfinavir two protease inhibitors

180. A client is taking the fluoroquinolone Ciprofloxin for acute prostatitis. After a few doses of the agent, he develops severe muscle pain. The most likely cause of the adverse reaction is: 1. 2. 3. 4.

electrolyte imbalance. impending tendon rupture. calcium deposits. antibiotic-associated colitis.

181. What is the primary goal of family education? 1. 2. 3. 4.

symptom reduction improved quality of life increased knowledge about mental illness improved caregiving skills

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1.

177. When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that:

Part II: NCLEX-PN Practice Tests

182. Acyclovir (Zovirax) is the agent of choice for which of the following infections? 1. 2. 3. 4.

HIV AIDS candida herpes

183. The client on Floxin must be alerted to which of the following adverse effects? 1. 2. 3. 4.

stunting of height in teens and young adults propensity of anovulatory uterine bleeding intractable diarrhea tendon rupture

184. Serum Vancomycin levels are taken to measure which of the following? 1. 2. 3. 4.

renal function therapeutic range trough levels antibiotic resistance

185. Which of the following is responsible for laws mandating the reporting of certain infections and diseases? 1. 2. 3. 4.

Centers for Disease Control and Prevention (CDC) individual state laws National Institute of Health Research (NIH) Health and Human Services (HHS)

186. A nurse who is assessing the health-related physical fitness of a client as part of a health assessment should focus on which of the following aspects of the assessment? 1. 2. 3. 4.

agility speed body composition risk factors

187. A nurse is trying to motivate a client toward more effective management of a therapeutic regimen. Which of the following actions by the nurse is most likely to be effective in increasing the client’s motivation? 1. 2. 3. 4.

determining whether the client has any family or friends living nearby developing a lengthy discharge plan and reviewing it carefully with the client teaching the client about the disorder at the client’s level of understanding making a referral to an area agency for client followup

188. Mr. Lee comes to the clinic with thick green drainage around his eyelids. The nurse examiner takes his history and performs a physical examination, beginning with an eye history. General information the nurse should seek is: 1. 2. 3. 4.

type of employment. burning or itchy sensation in the eyes. position of the eyelids. existence of floaters.

189. If Ms. Barrett’s distance vision is 20/30, which of the following statements is true? 1. 2. 3. 4.

The client can read from 20' what a person with normal vision can read at 30'. The client can read from 30' what a person with normal vision can read at 20'. The client can read the entire chart from 30'. The client can read the chart from 20' with the left eye and from 30' with the right eye.

190. The nurse is teaching a client about communicable diseases and explains that a portal of entry is: 1. 2. 3. 4.

a vector. a source, like contaminated water. food. the respiratory system.

191. Which of the following microorganisms are considered normal body flora? 1. 2. 3. 4.

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staphylococcus on the skin streptococcus in the nares candida albicans in the vagina pseudomonas in the blood

NCLEX-PN Practice Test 3

192. Which intervention should the nurse take first to assist a woman who states that she feels incompetent as the mother of a teenage daughter? 1. 2. 3.

4.

Recommend that she discipline her daughter more strictly and consistently. Make a list of things her husband can do to help her improve. Assist the mother to identify what she believes is preventing her success and what she can do to improve. Explore with the mother what the daughter can do to improve her behavior.

193. The mother of a newborn child is very upset. The child has a cleft lip and palate. The type of crisis this mother is experiencing is: 1. 2. 3. 4.

reactive. maturational. situational. adventitious.

194. A 26-year-old single woman is knocked down and robbed while walking her dog one evening. Three months later, she presents at the crisis clinic, stating that she cannot put this experience out of her mind. She complains of nightmares, extreme fear of being outside or alone, and difficulty eating and sleeping. What is the best response by the nurse? 1. 2.

3.

4.

195. A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse? 1. 2. 3. 4.

“You have nothing to worry about. You are in a safe place. Try to relax.” “Has anything happened recently or in the past that might have triggered these feelings?” “We have given you a medication that helps to decrease feelings of anxiety.” “Take some deep breaths and try to calm down.”

1. 2. 3. 4.

asking whether another individual wants to be her support person assuring her that the nursing triage group will be with her at all times telling her you will try to locate her family reinforcing the woman’s confidence in her own abilities to cope and maintain a sense of control

197. Signs of internal bleeding include all of the following except: 1. 2. 3. 4.

painful or swollen extremities. a tender, rigid abdomen. vomiting bile. bruising.

198. A newborn has been delivered. An Apgar score is given. What does this scoring system indicate? 1. 2. 3. 4.

heart rate, respiratory effort, color, muscle tone, reflex irritability heart rate, bleeding, cyanosis, edema bleeding, reflex, edema respiratory effort, heart rate, seizures

199. The nurse working with elderly clients should keep in mind that falls are most likely to happen to elderly who are: 1. 2. 3. 4.

in their 80s. living at home. hospitalized. living on only Social Security income.

200. The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered? 1. 2. 3. 4.

history of dizziness need for wheelchair due to reduced mobility weakness and fatigue noted when climbing stairs intact recent and remote memory

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“I will ask the physician to prescribe medication for you.” “That must have been a very difficult and frightening experience. It might be helpful to talk about it.” “In the future, you might walk your dog in a more populated area or hire someone else to take over this task.” “Have you thought of moving to a safer neighborhood?”

196. A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client’s needs at this time?

Part II: NCLEX-PN Practice Tests

201. The nurse should perform which intervention when a client is restrained? 1. 2. 3. 4.

Remove the restraints and provide skin care hourly. Document the condition of the client’s skin every 3 hours. Assess the restraint every 30 minutes. Tie the restraint to the side rails.

202. A client receives a cervical intracavity radium implant as part of her therapy. A common side effect of a cervical implant is: 1. 2. 3. 4.

creamy, pink-tinged vaginal drainage. stomatitis. constipation. xerostomia.

203. An appropriate question when assessing a client’s self-expectations about weight loss is: 1. 2. 3. 4.

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“What makes you think you can change your eating habits?” “How do you feel about losing weight?” “How important is it that you lose weight?” “What do you think is a realistic weekly weight loss for you?”

204. Which of the following statements should the nurse use to best describe a very low-calorie diet (VLCD) to a client? 1. 2. 3.

4.

“This diet can be used when there is close medical supervision.” “This is a long-term treatment measure that assists obese people who can’t lose weight.” “The VLCD consists of solid food items that are pureed to facilitate digestion and absorption.” “A VLCD contains very little protein.”

205. A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that: 1. 2. 3. 4.

Linens from the client’s bed should be double-bagged. Meals should be served on washable dishes. Extensive isolation rarely causes psychological problems. Paper trays and plastic utensils prevent disease transmission.

NCLEX-PN Practice Test 3

Answers and Explanations for Practice Test 3 For your reference, the appropriate review chapter is listed at the end of each answer explanation below. 1. (2) Due to the loud noises from the scanner moving to obtain images, earplugs need to be worn. No metal objects are allowed, including jewelry, pacemakers, and artificial joints. Reduction of Risk Potential 2. (1) This statement reassures the client that there is a solution for relief of his anxiety. The other responses minimize the client’s feelings. Reduction of Risk Potential 3. (3) Electroencephalography is indicated for assessing clients with a seizure disorder. Reduction of Risk Potential 4. (4) Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a face-lift. Dermabrasion involves the spraying of a chemical to cause light freezing of the skin, which is then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars, severe acne, and pigment from tattoos. Rhinoplasty is performed to improve the appearance of the nose and involves reshaping the nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids. Health Promotion and Maintenance 5. (2) The likelihood of fathering children does decrease with aging and decreased testosterone production, but men do not lose their ability to reproduce during the climacteric. Many men do not experience any physical symptoms of climacteric but some men do report hot flashes, headaches, and heart palpitations, among other symptoms. Health Promotion and Maintenance 6. (3) Choice 3 not only acknowledges the client’s fear but invites more disclosure and discussion. Reflective listening is very therapeutic and in this case acknowledges the woman’s unspoken fear that she might become depressed like her mother. When her fears have been acknowledged and she feels that the nurse understands, she will be more open to the teaching or interventions to follow. It is a myth that menopause causes depression, but to say that to this client does not acknowledge the fear she shared with the nurse and gives the impression the nurse doesn’t care about her concern. It closes down communication. It is also true that menopause is a normal developmental process. This can certainly be used in teaching but not to address her immediate concern; the client might feel the nurse doesn’t think her concern is appropriate because menopause is normal. If women experience depression during menopause, it is usually due to social stresses such as loss of loved ones, loss of roles, caregiver demands, and physical problems. Choice 4 is true but is a nontherapeutic response in this situation. Health Promotion and Maintenance 7. (2) A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4–7 hours after injection. Urinary retention is a side effect of postpartum epidural morphine but is not assessed as such within the first 3 hours. Somnolence is a rare side effect. Health Promotion and Maintenance

9. (1) Two-year-old children are very egocentric. They believe everything and everyone is concerned about them. They believe other children want them to have their toys. This is different than believing they can make other children want them to have all the toys, as in magical thinking, which normally occurs in preschool-age children. Toddlers are very negative, but this is expressed by refusal of requests made to them. Domestic imitation does occur in preschool-age children, but it refers to the imitation of household chores and roles performed by adults, not the imitation of other children. Health Promotion and Maintenance

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8. (4) The vaginal discharge after birth is called lochia, and it changes from red (rubra) to serosa (clear) on the third postpartum day. If it returns to red or contains clots, it could signal impending hemorrhage or infection and the physician should be notified. It is not normal for the breasts to be tender. If the breasts become engorged, they might be tender and the mother might need to be given additional instructions on breast care. Tenderness, redness, and fatigue are clinical manifestations of mastitis and should be reported to the physician. A woman should void in normal patterns and frequency after birth. Increased frequency is a sign of a urinary tract infection and should be reported to the physician. By the time of discharge, the woman’s temperature should be normal. Elevations should be reported to the physician. Health Promotion and Maintenance

Part II: NCLEX-PN Practice Tests

10. (2) Object permanence occurs when the infant learns that something/someone still exists even though they might not be able to see it/them. This develops between 9 and 10 months of age. If the infant cries when his mother leaves the room, it might be because he believes she is no longer in the house when he can’t see her. If an infant picks up another toy after the one he is playing with rolls under the couch and the infant fails to look for it, he believes the toy that rolled under the couch no longer exists. Patty-cake is a game infants engage in but, it has nothing to do with object permanence. An infant game that does show object permanence is peek-a-boo. In this game, an infant continues to hunt for a hidden face because he believes it is still there. Health Promotion and Maintenance 11. (3) All of the strategies listed are included in home care for the client with Cushing’s syndrome. Choice 3 is the best answer because wearing a medical ID is a visible sign that something is wrong and a constant reminder to the client that he or she has a loss of body function. Choice 1 might enhance body image because it prevents falls that could cause further injury and debilitation. Taking medications as prescribed should enhance body image because it decreases the symptoms present. Having regular health assessments indicates an enhanced body image because it signals the desire to take care of the body and keep it at its best. Health Promotion and Maintenance 12. (4) Anticonvulsants (such as Dilantin), tranquilizers, barbiturates, and other sedatives should be held 24–48 hours prior to an EEG. The other medications do not fall into these classifications. Reduction of Risk Potential 13. (2) The client needs to wash his hair to remove hair spray, cream, or oil that might interfere with attaching the electrodes to the scalp. Food or fluids do not need to be restricted, with the exception of caffeinated fluids. There is no restriction on metal objects. Aspirin is not a medication that needs to be held before the test (just anticonvulsants, tranquilizers, barbiturates, and other sedatives). Reduction of Risk Potential 14. (4) For a client with an elevated urine osmolarity, the nurse should assess the client for fluid volume deficit. Physiological Adaptation 15. (3) A serum creatinine level should be 0.7 to 1.5 mg/dl, and it does not vary with increased protein intake, so it is a better indicator of renal function than the BUN. Physiological Adaptation 16. (3) Major functions of the kidneys in maintaining normal fluid balance include regulation of extracellular fluid and osmolarity by selective retention and excretion of fluids, regulation of pH of the extracellular fluid by retention of hydrogen ions, and excretion of metabolic wastes and toxic substances. ADH is manufactured by the pituitary, and the parathyroid regulates calcium and phosphate balance. Physiological Adaptation 17. (3) High levels of cortisol can produce sodium and fluid retention and potassium deficit, thus creating urinary deficit. Physiological Adaptation 18. (1) Folic acid and iron deficiency anemia are the most common anemias, prevalent in women of childbearing age with 50% of pregnant women having this type of anemia. Iron deficiency anemia during pregnancy is a result (usually) of the increase in the plasma level during pregnancy but not in the constituent level. Also, if a woman has this type of anemia prepregnancy, it gets worse during pregnancy. Physiological Adaptation 19. (2) Folic acid is essential for the development of the neural tube and might prevent the defect or failure of the tube to close (congenital anomalies). Physiological Adaptation 20. (4) Pernicious anemia is a megaloblastic, macrocytic, normochronic anemia caused by a deficiency of the intrinsic factor produced by the stomach. This results in malabsorption of vitamin B12, which is necessary for DNA synthesis and maturation of RBC. Education should include side effects of Vitamin B12, which can include pain and burning at the injection site, peripheral vascular thrombosis, and transient diarrhea. Physiological Adaptation 21. (1) Home sources of iron that can be absorbed in the body include meat, poultry, and fish. In addition, these sources contain a factor that helps to enhance iron absorption of nonheme sources. Eating Vitamin C at the same time as iron sources also helps to promote iron absorption. High calcium intake in the diet promotes the absorption of iron because it helps to bind to phytates and thereby limits their effect. Physiological Adaptation 22. (4) Human chorionic gonadotropin is found in the urine during pregnancy and specifically indicates pregnancy. The other hormones do not. Reduction of Risk Potential

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23. (1) Cushing’s syndrome produces elevated cortisol levels. Addison’s disease produces decreased cortisol levels. The other conditions are not associated with cortisol levels. Reduction of Risk Potential 24. (2) Parathyroid hormone depresses renal tubular reabsorption of phosphorus. All of the other choices are functions of parathyroid hormone. Reduction of Risk Potential 25. (2) ADH level is increased in the client with nephrogenic diabetes insipidus. Reduction of Risk Potential 26. (3) Normal serum potassium levels fall in a range of 3.5–5.5mEq/L. The other choices listed fall below or above this range. Reduction of Risk Potential 27. (2) The ingestion of nonfood substances (alcohol) can lead to a clinical iron deficiency and might actually be the first sign of a problem. The client might substitute alcohol for a nutrition program that fosters a positive health habit. Physiological Adaptation 28. (2) The initial tests to determine the basis for her symptoms (considering her fad dieting) should be a complete blood count, urinalysis, blood sugar, and other tests. The decision about further testing is then made based on these results, her history, and other factors. Physiological Adaptation 29. (1) Due to her symptoms of fatigue, shortness of breath, lightheadedness, her gender, and her fad dieting, the cause is most likely iron deficiency. Physiological Adaptation 30. (4) Pica represents the ingestion of nonfood substances that leads to a clinical iron deficiency and might actually be the first sign of a problem. Clients eat a wide range of nonfood items, including ice, clay, dirt, and paste. Physiological Adaptation 31. (1) Influenza virus is transmitted through respiratory droplets. Herpes virus is transmitted by direct contact, and HIV is transmitted through blood and body fluids. Cytomeglaovirus is an opportunistic infection. Physiological Adaptation 32. (2) Epidemiological studies indicate that chlamydia is the most prevalent sexually transmitted disease in the United States. Physiological Adaptation 33. (2) Infection occurs in a predictable sequence requiring virulence, movement from a reservoir, and entry into a susceptible host. Physiological Adaptation 34. (3) Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by health care workers who fail to conduct routine hand washing between clients. Tuberculosis is almost always transmitted by the airborne route, and tetanus usually results from exposure to dirt. HIV is a weak virus that does not live long outside the body. Physiological Adaptation 35. (1) These are the accepted parameters for mild PIH. Mild preclampsia includes an increase in systolic blood pressure higher than 30 mmHg or an increase in diastolic blood pressure higher than 15 mmHg, noted on two readings taken 6 hours apart (or 140/90). Physiological Adaptation

37. (2) Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract. Physiological Adaptation 38. (4) Prolapsed umbilical cord is the descent of the umbilical cord into the vagina before the fetal presenting part and compression of the cord between the presenting part and the maternal pelvis, compromising or completely cutting off fetoplacental perfusion. This is an emergency situation; immediate delivery should be attempted to save the fetus. Physiological Adaptation 39. (2) Alcoholism places a client at risk for developing cirrhosis. None of the other choices are related to cirrhosis. Physiological Adaptation

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36. (2) Urinary frequency is least indicative of UTI during pregnancy because it is a common minor discomfort of pregnancy and is caused by pressure of the growing uterus on the bladder. As the uterus rises in the second trimester, there are no problems. Frequency returns in the third trimester when the uterus drops into the pelvic cavity. A UTI has the symptoms of frequency, back pain, supra pubic discomfort, and malaise and is diagnosed by laboratory findings. Physiological Adaptation

Part II: NCLEX-PN Practice Tests

40. (3) Acute Pain is most appropriate for the client experiencing acute pancreatitis. Physiological Adaptation 41. (4) All of the choices are functions of the kidneys except reabsorbing waste products. The kidneys excrete waste products. Physiological Adaptation 42. (2) The client with urinary tract calculi needs to avoid cheese, which has high calcium content. The other foods do not. Physiological Adaptation 43. (1) Kegel exercises might be prescribed to strengthen the pelvic floor muscles of a client with urinary incontinence. Physiological Adaptation 44. (3) A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward. Basic Care and Comfort 45. (2) In addition to the rubber tips on the ends of the crutches, the client needs to know the appropriate gait. Arm strength exercises are important, and it is critical that the client be fitted properly for the crutches. Basic Care and Comfort 46. (2) The hydraulic lift is used for safe transfer when a client is not able to stand or is too heavy for the health care workers to lift safely. Basic Care and Comfort 47. (2) The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client. Basic Care and Comfort 48. (1) Enema tubing must be passed beyond the internal sphincter. Two inches is not far enough to pass the internal sphincter. Both 6 and 8 inches are too far and might cause trauma to the bowel. Basic Care and Comfort 49. (3) When performing a parancentesis, the client must be sitting up to allow the fluid to settle to the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty. Basic Care and Comfort 50. (3) The spinal change occurring with pregnancy is lordosis. This occurs due to the weight of the enlarging uterus and the affect of gravity. Basic Care and Comfort 51. (1) Gait is usually assessed as the client walks into the room. Normal gait is smooth, flowing, and rhythmic without assistive devices. Basic Care and Comfort 52. (2) New prosthetic hips should have an abduction pillow in place to avoid adduction. Basic Care and Comfort 53. (3) The nail beds and the tissue surrounding the nails should be assessed for abnormal discoloration, lesions, paronychia (infection of tissue surrounding the nail), tissue dryness, breaks in the skin, pressure areas, or other abnormal appearances. Basic Care and Comfort 54. (3) Assemble all equipment first; place the client in a side-lying position so that fluid can easily flow out or pool in the side of the mouth for suctioning (to prevent aspiration); and then place a towel under the client’s chin and a curved basin against the chin. Gloves should be worn. Basic Care and Comfort 55. (2) Preparing a client’s room environment should include making the client’s bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client’s hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles. Basic Care and Comfort 56. (4) The guidelines for a fertility workup are to refer after the couple has not conceived after one year of unprotected intercourse. So, Choice 1 is technically correct, but it doesn’t consider the immediate need for the couple to have some counseling. Choice 4 is the best answer because it gives the couple guidance now and the referral at the appropriate time. If the woman is over the age of 35, an earlier referral, at six to nine months of unprotected intercourse, is appropriate. It is true that the average time it takes a 25-year-old woman to conceive is 5.3 months, but that does not address the concern the client is expressing. Choice 4 is still the most caring and correct answer. Couples conceive within the first month of unprotected intercourse 20% of the time. Health Promotion and Maintenance 57. (2) Because semen analysis is the least invasive of the tests listed and because in 35% of the cases the infertility is related to a male factor, semen analysis should be one of the first diagnostic tests performed.

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Hysterosalpingography fills the uterus and fallopian tubes with a radiopaque substance that can be seen with an X-ray. It demonstrates tubal patency or any distortion of the uterine cavity. Endometrial biopsy provides information about the effects of progesterone after ovulation and the endometrial receptivity. Transvaginal ultrasound is mostly used in the treatment of infertility. For diagnosis it allows the endocrinologist to evaluate the developing follicle, assess oocyte maturity, and diagnose luteal phase defects. All the tests listed in Choices 1, 3, and 4 are more invasive, require greater expertise to evaluate and treat, and are more costly. If the semen analysis is normal, the couple can expect to progress through these tests as well. Health Promotion and Maintenance 58. (4) The blood pressure should be checked first for a client who has just vomited 300 cc of bright red blood, to determine whether the client is hypotensive. The other actions can be taken later. Reduction of Risk Potential 59. (3) Apples are a source of high fiber, which decreases constipation. A constipated client needs to increase fluids and activity level. Milk is not a high-fiber food. Reduction of Risk Potential 60. (2) Caucasians have the highest incidence of inflammatory bowel disease (IBD). Reduction of Risk Potential 61. (3) Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy, due to the adjustments that need to be made with the physical alteration of a colostomy. The other diagnoses are not applicable. Reduction of Risk Potential 62. (2) Coffee might cause diarrhea in a client with an ileostomy. The other foods might cause odor. Reduction of Risk Potential 63. (3) Typically, first-generation OTC antihistamines have a sedating effect because of passage into the CNS. However, in some individuals, especially infants and children, paradoxical CNS stimulation occurs and is manifested by excitement, euphoria, restlessness, and confusion. For this reason, use of first-generation OTC antihistamines has declined and second-generation product use has increased. Reye’s syndrome is a systemic response to a virus. First-generation OTC antihistamines do not exhibit a cholinergic effect. Nausea and diarrhea are uncommon with first-generation OTC antihistamines. Pharmacological Therapies 64. (3) Superficial heat and cold, massage, pressure, or vibration can be applied to alleviate pain associated with muscle tension, pain, or spasms. Nonpharmacological Therapies 65. (4) All physical and psychosocial therapies can be used concurrently with drugs and other modalities to manage pain. These interventions can be carried out by the nurse with the client and family. Basic Care and Comfort 66. (1) These interventions (strategies) help the client in all areas of client well-being. Focusing on perception and thought, cognitive techniques are designed to influence how one interprets events and bodily sensations. Basic Care and Comfort 67. (3) Part of the problem for anorexic clients is an altered view of their body appearance (visualizing themselves as fat even when they are emaciated). Choice 1 involves a knowledge deficit. Choice 2 involves possible resolution of family-dynamic issues. Choice 4 involves psychological adaptation. Basic Care and Comfort

69. (4) Active exercise increases insulin sensitivity, thus lowering blood glucose levels. Additional carbohydrates might be needed to balance the usual insulin dose. All of the other choices increase blood glucose levels. Basic Care and Comfort 70. (3) Toradol is the first injectable NSAID equal to morphine in efficacy. Basic Care and Comfort 71. (2) There is potential for a lowered pain tolerance to exist with diminished adaptative capacity. Basic Care and Comfort 72. (1) Elder adults might be more at risk for gastric and renal toxicity, increasing among elder adults. Basic Care and Comfort 73. (3) When a client is neutropenic (one type of white blood cell), they lack the ability to fight off infection. The mask is to prevent exposure to any upper-respiratory infections. Fresh fruits, vegetables, and flowers can contain pathogens that might infect the neutropenic client. All foods must be thoroughly cooked and plants/flowers are

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68. (1) Clients with burns are hypermetabolic and require increased protein levels to maintain a positive nitrogen balance. Choices 2 and 3 are incorrect; carbohydrate levels do not help clients to meet this goal. Choice 4 is incorrect; a client with major burns requires a high-protein diet. Basic Care and Comfort

Part II: NCLEX-PN Practice Tests

not allowed. A neutropenic client needs a private room and carefully screened visitors—no one is to enter the room with any symptoms of an illness (runny nose, sneezing, nausea, and so on). Meticulous, frequent hand washing is called for. Physiological Adaptation 74. (4) In diabetes insipidus, the pituitary releases too much antidiuretic hormone (ADH) causing the client to produce a large amount of dilute (decreased osmolarity) urine and causing dehydration (elevated serum osmolarity). Choice 3 might be seen in a client with SIADH (syndrome of inappropriate ADH). Choices 1 and 2 generally don’t occur— urine and serum osmolarity typically move in opposite directions. Physiological Adaptation 75. (1) In thyroid storm, there is too much thyroxine, causing the client to go faster. Atrial fibrillation and palpitations are also frequently seen. Choices 2, 3, and 4 are associated with hypothyroidism. Physiological Adaptation 76. (2) Newly diagnosed diabetics need to learn about their disease, medications, glucose testing, possibly insulin injections, foot care, sick-day plans, and so forth. Choices 1 and 4 are diagnoses to prevent, but no evidence suggests that they exist at this point. Diabetics might have more or less nutrition than body requirements—type II is likely to be more, but type I is likely to be less. Physiological Adaptation 77. (1) Victims of domestic violence are often correct at predicting their risk of harm. However, the nurse should ensure that the client is expressing herself authentically and is not trying to convince the nurse that there is no immediate danger. Further, proper authorities, such as the police, should be alerted to this reportable offense. Psychosocial Integrity 78. (1) There is a correlation between vague symptoms, such as abdominal pain, and battered syndrome. The astute clinician should question any woman who presents with suspicious symptoms such as these. Rarely are women offended by a properly worded question, such as, “Do you feel safe in your present relationship?” Studies show an increase in case finding when such questions are asked. It is not mandatory that all women are assessed for violence, but it is prudent that all persons new to a clinician be assessed by at least the one question noted previously. Castigating or shaming the physician typically does not improve client outcomes and might make for a difficult working environment for the nurse. Tactless comments, like the one in Choice 4, are not collegial and should be avoided. Psychosocial Integrity 79. (2) It is important to acknowledges the client’s fear. The other responses deny the client’s perceptions. Psychosocial Integrity 80. (2) Outcome criteria need to be specific, measurable, and realistic. Talking for 10 minutes meets all of these conditions. It is not realistic to expect a severely anxious client to sit quietly for 30 minutes. The other statements are vague and not measurable. Psychosocial Integrity 81. (1) Family consultation does not involve vocational rehabilitation. It involves helping families deal with their feelings, focus, and find solutions. Choices 2, 3, and 4 are components of family consultation. Psychosocial Integrity 82. (3) Although all of the choices are true about schizophrenia, only Choice 3 answers the question asked. Psychosocial Integrity 83. (3) In severe anxiety, a client focuses on small or scattered details. The person is unable to solve problems. With mild anxiety, stimuli are readily perceived and processed, and the ability to learn and solve problems is enhanced. Moderate anxiety narrows the perceptual field, but the client notices things brought to his attention. During a panic attack, the person is disorganized and might be hyperactive or unable to speak or act. Psychosocial Integrity 84. (1) Children between birth and 3 years of age have the highest rates of victimization (at 16 per 1,000 children). Girls are slightly more likely to be victims than boys. Psychosocial Integrity 85. (2) Children who are abused learn to cope with the painful experiences by ignoring painful feelings and avoiding getting close to people. As adults, victims of abuse usually continue to repress feelings, avoid close interpersonal relationships, and frequently use alcohol or drugs to block painful memories. Long-term effects in adults might include criminal/violent behavior (for adult males), substance abuse, and a variety of social and emotional problems (including suicidal thoughts, anxiety, hostility, dissociation, and interpersonal difficulties). Psychosocial Integrity 86. (2) Untreated chronic renal failure causes decreased testosterone levels, atrophy of testicles, and decreased spermatogenesis. Retrograde ejaculation is not a complication of chronic renal failure. It is a complication of transurethral resection of the prostate. In chronic renal failure, the testicles atrophy; they do not hypertrophy. Chronic renal failure produces a state of depression, not euphoria. Health Promotion and Maintenance

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87. (1) To provide the best response, the nurse must identify what the elder is asking. Concern is being expressed about whether elders can engage in sexual activity. The most therapeutic response by the nurse is Choice 1. In this choice, the nurse acknowledges that elders can physically engage in sexual activity and have no psychological barriers to the same. All of the other choices contain facts but are not the best initial response. Choice 1 opens the conversation for the expression of further concerns about sexual issues. Choice 2 is true; past sexual function is predictive of sexual function in elder adults. An elder adult must have been sexually active as a younger adult to engage in intercourse in old age. This does not mean, however, that the elder adult cannot experience sexual intimacy in other ways. The need for intimacy is especially important for elder adults. If they have lost meaningful relationships or are having difficulty with intercourse, they might be able to experience intimacy through touch. As males age, they find it takes longer to achieve an erection, but that when it’s achieved, the erection lasts longer. In addition, elder males require direct stimulation to achieve an erection. Health Promotion and Maintenance 88. (4) Children of gay and lesbian parents should be reassured that their relationship with their parent will not change because of the discussion. Choices 1, 2, and 3 are all important aspects of the disclosure. As children grow, they might have additional questions. Preschool children might not understand the absence of a father or mother. Schoolage children might be troubled that their family isn’t like their friends’ families. Adolescents might become reluctant to discuss it or accept it even though they expressed acceptance at an earlier age. In general the earlier children are informed, the easier it is for them to accept and assimilate the information. Nurses need to be nonjudgmental and learn how to express and accept these differences so that they can keep the nurse-child-family relationship intact. Health Promotion and Maintenance 89. (2) The practice of polygamy refers to having multiple wives or husbands. When there are multiple wives who are sisters, the polygamy is designated as soronal. When the wives are not sisters it is nonsororal. Polyandry refers to multiple husbands and is rare. Some cultures practice a polygamy designated as sororate. Sororate polygamy specifies that a husband must marry his wife’s sister if she dies. These marriages are successive rather than concurrent. Health Promotion and Maintenance 90. (1) Brown-Séquard syndrome is a result of damage to one-half of the spinal cord. The other choices are also incomplete lesions of the spinal cord, but they have different defining characteristics. Reduction of Risk Potential 91. (4) If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a health care provider needs to be notified immediately. The remaining choices are correct; they are all ways to relieve autonomic dysreflexia. Reduction of Risk Potential 92. (3) Hypotension is not indicative of autonomic dysreflexia; rather, hypertension is a sign of autonomic dysreflexia. The remaining choices are symptoms of autonomic dysreflexia. Reduction of Risk Potential 93. (2) This statement is incorrect because caffeinated fluids, such as coffee and cola, stimulate fluid loss through urination. Instead, fluids such as water and fruit juices should be taken. The remaining choices indicate correct understanding of bowel management. Reduction of Risk Potential

95. (1) This is called the sour grapes form of rationalization. Rationalization is an unconscious form of self-deception in which excuses are made. Denial is an unconscious process that ignores the existence of the situation. Projection operates unconsciously and results in blaming behavior. Compensation is an attempt to make up for a perceived weakness by emphasizing a strong point. Psychosocial Integrity 96. (3) Projection results in unconsciously adopting blaming behavior. It attributes unacceptable attributes to other people. Compensation results in the nurse unconsciously attempting to emphasize a strong point in an attempt to make up for a perceived weakness. Reaction formation unconsciously adopts behavior that is opposite her actual feelings. Denial involves ignoring the existence of an unpleasant reality. Psychosocial Integrity 97. (2) Behavior modification gives positive feedback and rewards for appropriate behavior. Behavior modification requires negative behavior if it’s not destructive or life threatening. Psychosocial Integrity

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94. (4) This response is the most therapeutic because it allows the client to discuss his anxieties and fears with the nurse. The other responses do not allow for such a dialogue, so they are not as therapeutic. Reduction of Risk Potential

Part II: NCLEX-PN Practice Tests

98. (1) The ANA sets standards of practice for psychiatric and mental health nursing roles. Quality of care, performance appraisal, education, ethics, collaboration, and research are covered through the use of the Nursing Process. Psychosocial Integrity 99. (2) The failure to address substance abuse among clients with psychiatric disorders interferes with treatment effectiveness and contributes to relapse. Misdiagnosis of a psychiatric disorder, suboptimal pharmacological treatment, neglect of appropriate interventions, or an inappropriate referral might also occur. Psychosocial Integrity 100. (1) Amphetamines cause the release of norepinephrine and dopamine from storage vesicles into the synapse. The increased catecholamines at the receptors causes increased stimulation. Clear patterns of tolerance and withdrawal have not been described. Prolonged or excessive use of amphetamines can lead to psychosis. People use amphetamines for the feelings of euphoria, relief from fatigue, energy, and alertness. Overdose can cause seizures, cardiac arrhythmias, hypertension, and hyperthermia. When abstaining, the client might experience fatigue, depression, and irritability lasting for several weeks. Drug cravings are common and might lead to relapse. Psychosocial Integrity 101. (1) A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the waterseal, which indicates a leak. Reduction of Risk Potential 102. (3) Petrolatum gauze is recommended to place over a site when a chest tube is removed by the physician. This is because it forms an airtight seal, which the other choices do not. Reduction of Risk Potential 103. (2) If a client begins bleeding from the site of a previous arterial blood gas draw on the right wrist, the nurse should first apply pressure to the site. This prevents further bleeding. The remaining choices can be performed later. Reduction of Risk Potential 104. (4) The first step after determining unresponsiveness is to call for help. The remaining steps might be indicated afterward. Reduction of Risk Potential 105. (3) The appropriate ratio for adult CPR is 15 compressions to 2 ventilations. Reduction of Risk Potential 106. (3) It is essential that the treatment program be followed exactly for clients with antisocial personality disorder because they are very manipulative and attempt to divide staff. However, confronting the staff member in front of the client enhances the division of staff. Talking with the staff member in private allows the person to develop skills to work with this client population. Psychosocial Integrity 107. (2) The challenge when intervening with clients who might harm themselves is to maintain client safety while facilitating behavior change. Enlisting the client to identify the triggers for self-harm makes the client an active participant in treatment. Nurses are less judgmental when they understand the source of the behavior and can be sensitive to client feelings. Psychosocial Integrity 108. (2) Generally oral sex leaves little physical evidence. Injury to the soft palate (such as bruising, abrasions, and petechaie) and pharyngeal gonorrhea are the only signs. Infants are at risk for sexual abuse. Psychosocial Integrity 109. (2) At least 10% of victims of childhood sexual abuse have periods of complete amnesia about the abuse, followed by delayed recall. Controversial evidence suggests that people who have recovered memories have had part of those memories reconstructed by therapists. The nurse’s role is not to determine if the memories are real, but to help the client deal with the stress caused by the remembered abuse. Psychosocial Integrity 110. (2) Choices 1, 3, and 4 are incorrect. Advance directive protocols and documents are defined by each state. Coordinated Care 111. (2) Nurse advocates work with clients to provide information and assistance is decision-making. The decisions and care that occur from these decisions are based on the right of the client to self-determination and the work of the nurse advocate supports this right. Coordinated Care 112. (4) Clinical pathways include maps of care outcomes to be achieved prior to discharge or movement through a health care system. Insurance review for reimbursement is a function of an outside agency from the health care provider related to the amount of expected monetary compensation for services rendered to a client. Coordinated Care

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113. (1) To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client’s room, and the report should be resumed only after it can no longer hear what is said. Coordinated Care 114. (2) Networking involves the process of developing and using contacts throughout one’s professional career for information, advice, and support. Nurturing and mentoring are both examples of assistance to other colleagues in formal and informal relationships for support and career building. Collegiality is the professional camaraderie or rapport established among persons through shared experiences. Coordinated Care 115. (1) The legal right to confidentiality is waived when the court requires information to be given to the court for legal proceedings to occur (summonses, court orders, litigation information necessary for the court, subpoenas, and so on), when the state requires mandatory reporting of certain illnesses, when sharing information is necessary because a client has revealed an intent to harm himself or others, or when a client cannot make a safe and rational decision (competence). Coordinated Care 116. (1) A gastroenterologist cares for clients with digestive system diseases. A urologist cares for clients with urinary system diseases. A gynecologist cares for clients with female reproductive system diseases. A neurologist cares for clients with nervous system diseases. Coordinated Care 117. (2) It is the nurse’s responsibility to communicate the client’s condition and care plan to the receiving facility to support continuity of care. Documentation of the client’s baseline functional status is important for the receiving facility to work with in further goal setting. A copy of select portions of the medical record (according to facility policy) is another form of communication and supports continuity. A physician might be asked to be involved if there are specific medical needs or orders that she believe are important, but is generally not involved. Coordinated Care 118. (1) Process standards define the actions and behaviors required by staff to provide care. A procedure for changing IV tubing is a psychomotor skill that is applied to helping clients meet their goals. Coordinated Care 119. (4) Effective delegation depends on clear, concise direction that leaves no room for question or interpretation on the part of the one being delegated to. Nursing assistants have a limited understanding of medical conditions and terminology, and should not be relied on to prioritize such tasks. Coordinated Care 120. (1) Priorities designated as intermediate by the nurse are those that are not urgent. They do not affect the client’s immediate physiological status. This does not imply that they are not important or not necessary. Intermediate priorities might still require the skill level of an RN for completion. There might be specific time requirements for completion as well. Coordinated Care 121. (4) It is recommended that the children wear insect repellant containing DEET and long-sleeve shirts and long pants when they are outside. Removing standing water from areas around where the children play can help decrease the number of breeding mosquitoes. These are the only known methods of prevention at this time. Health Promotion and Maintenance

123. (1) Ethics committees do not deal with financial matters of payment. Euthanasia, starting or stopping treatment, and use of feeding tubes to maintain nutritional status are topics within the ethical scope of the committee’s function. Coordinated Care 124. (4) Risk management plays a vital role as an arm of quality monitoring and improvement programs. It utilizes information obtained from incident reports, as well as audits, committee minutes, service complaints, and clientsatisfaction questionnaires to perform all of the tasks identified. Safety and Infection Control

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122. (1) Rugs and clutter are a primary cause of falls in the home and should be eliminated if possible to decrease the risk of a fall. The elderly and those with gait issues are at an increased risk for a fall at home. The client should have a raised toilet seat and grab bars available in the bathroom to aid in movement in this potential slippery area of the home. Some clients find it difficult to rise up and down from the toilet and to get in and out of the shower. These items are all important in maintaining safety in the home. The client should not limit her movement within the home unless ordered by the physician. This decreases the ability of the client to perform activities of daily living and hinders the client’s return to a normal lifestyle after surgery. The client should not wear baggy clothing such as long robes, and the client should not wear socks on slippery floors. These items can cause the client to trip, slip, or fall. Health Promotion and Maintenance

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125. (2) Treatment may be given without consent in a life-threatening situation. Choices 1, 3, and 4 are incorrect. All attempts to notify a durable power of attorney for health care should be made. If unavailable, the physician assumes responsibility for treatment within facility protocol. The physician is obligated to have a discussion with the client in all non-life-threatening situations. If clients are not able to speak for themselves, their power of attorney for health care or responsible party is involved in the consent process. Coordinated Care 126. (1) The Good Samaritan laws protect providers of care in an emergency situation. HIPAA’s focus is confidentiality of information and right to privacy. The PSDA concerns a client’s autonomous decision-making. OBRA was passed in the late 1980s to promote nursing home reform due to quality issues. Coordinated Care 127. (4) When assessing drug, alcohol, and tobacco practices among family members, a thorough investigation of prescribed, over-the-counter and illegal substance-use practices should be made. Assessment of dietary practices should include the amount and types of food the family eats; the social behaviors associated with dietary practices; and the meal planning, shopping, and preparation practices of the family. Health Promotion and Maintenance 128. (4) Short-tem stressors impinging on a family include unemployment, being on welfare, the threat of termination, health, hospitalization, convalescence, depression, and suicidal thoughts. Long-term stressors impinging on the family include emotional distance, lack of communication in families (especially within marital relationships), continual geographical movement from one community to the next (so that no stable and sufficient social network is established), a spouse’s minimal participation in family life, and excessive and frequent drinking bouts. Family strengths include the presence of a social support system, interest in and capability to provide child care, motivation for employment, and financial self-sufficiency, self-care beliefs, values, health-seeking behaviors, and realistic goals and limitations. Health Promotion and Maintenance 129. (2) Healthy People 2010 has as its main goal elimination of health disparities among the U.S. population. Healthy People 2010 is a set of health objectives for the nation to achieve over the first decade of the twenty-first century and was developed by the Surgeon General’s office. Earlier editions of this report, Healthy People and Healthy People 2000: National Health Promotion and Disease Prevention Objectives established national health objectives and served as the basis for the development of state and community plans. Health Promotion and Maintenance 130. (2) This client is receiving secondary prevention. The current focus of health care is on preventive care. Leavell and Clark (1965) described the three levels of preventive care as primary, secondary, and tertiary. Secondary preventive care focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. Examples of activities at this level are carrying out direct nursing actions (for example, providing wound care, giving medications, exercising arms and legs), assessing children for normal growth and development, and encouraging regular medical and dental screenings and care. Primary preventive care is directed toward health promotion and specific protections against illness. Activities at this level might focus on individuals or groups. Examples of primary-level activities are immunizations, family-planning services, teaching breast self-examination, poison-control information, and accident-prevention education. Tertiary preventive care begins after an illness is diagnosed and treated and is aimed at helping rehabilitate clients and restore them to their maximum level of functioning. Health Promotion and Maintenance 131. (2) Rolling over occurs between 4 and 6 months of age. Sitting up occurs between 7 and 8 months, creeping between 9 and 10 months, and standing between 8 and 10 months. Health Promotion and Maintenance 132. (2) Because the client is on the pill, she requires further teaching regarding protection against STDs. The other findings are not abnormal for an adolescent. Health Promotion and Maintenance 133. (1) While a recommended immunization schedule exists, immunizations may be started at any age. An interrupted series may be continued and need not be restarted. There is no increased risk for reaction to vaccines due to delay. Health Promotion and Maintenance 134. (1) Varicella is a live virus, as is OPV. IPV is an inactivated polio vaccine. Health Promotion and Maintenance 135. (3) Reduction of environmental stimuli (particularly light and noise) from the cerebral cortex (which can be an area of arousal) facilitates sleep. Sleep occurs when there is a decreased input into this area. Basic Care and Comfort 136. (1) The hypothalamus, when injured, can cause fluctuations and disruptions in sleep patterns. Basic Care and Comfort

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137. (2) An expected outcome is that the client falls asleep shortly after going to bed. The stages of sleep are defined by 4 stages. By stage 3 or 4 (within a short period of time—usually 1 hour) the client is considered to be in the deep part of sleep. Basic Care and Comfort 138. (2) GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can occur within a month of the transfusion. Choices 1 and 4 are possible, but the nurse must remember that immunocompromised transfusion recipients are at risk for GVHD. Pharmacological Therapies 139. (1) Glycocalyx is a viscous polysaccharide or polypeptide slime that covers microbes. It enhances adherence to surfaces, resists phagocytic engulfment by the white blood cells, and prevents antibiotics from contacting the microbe. Glycocalyx does not have the effects described in Choices 2, 3, and 4. Pharmacological Therapies 140. (4) Time is required to clear circulating cells before the effect that chemotherapeutic drugs have on precursor cell maturation in the bone marrow becomes evident. Leukopenia is an abnormally low white blood cell count. Choices 1, 2, and 3 pertain to red blood cells. Pharmacological Therapies 141. (3) Drug B induces the cytochrome p-450 enzyme system of the liver, thus increasing the metabolism of Drug A. Therefore, Drug A is broken down faster and exerts decreased therapeutic effects. Drug A is metabolized faster, thus reducing, not increasing, its therapeutic effect. Inducing the cytochrome p-450 system does not increase the adverse effects of Drug B. Drug B induces the cytochrome p-450 system but is not metabolized faster. Thus, the therapeutic effects of Drug B are not decreased. Pharmacological Therapies 142. (3) Monitoring cardiac status is of the highest priority. Permanent cardiac damage can result from rheumatic fever. The second priority is assessing the client’s joints for the presence of polyarthritis and accompanying pain. Physiological Adaptation 143. (4) The other choices are common reasons for which clients with herpes seek care. Physiological Adaptation 144. (4) Firm, direct pressure should be applied to venipuncture sites for 3–7 minutes before final dressing because of the clotting abnormality. Septic shock is a systemic infection of the bloodstream producing clinical manifestations—warm, flushed skin; high urine output; tachycardia; edema; respiratory problems; restlessness; altered level of consciousness; life-threatening form of shock. Physiological Adaptation

146. (4) Phenytoin and dextrose will precipitate. Normal saline is used to flush before and after phenytoin administration. The administration of an antiepileptic drug cannot be delayed to maintain a therapeutic blood level. Pharmacological Therapies 147. (2) The liver is the primary organ for digestion. Liver function tests measure the blood level of enzymes produced by the liver: prothrombin time/partial prothrombin time, serum glutamic oxaloacetic and pyruvic transaminases, gamma glutamyl transpeptidase, albumin, and alkaline phosphatase. Choice 1 measures the body’s ability to clear triglycerides, the primary component of fats. Failure to clear triglycerides from the bloodstream indicates a problem with storage or the ingestion of too much fat. Choice 3 measures the blood glucose at intervals after a glucose-rich solution is ingested; it is used for diagnosing diabetes. Choice 4 is used to evaluate blood components. Pharmacological Therapies

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145. (2) Prolonged use of decongestant drops (3 to 5 days) can lead to rebound congestion, which is relieved by discontinuing the medication for 2 to 3 weeks. Nasal congestion results from dilation of nasal blood vessels due to infection, inflammation, or allergy. With this dilation, there is a transudation of fluid into the tissue spaces, resulting in swelling of the nasal cavity. Nasal decongestants (sympathomimetic amines) stimulate the alphaadrenergic receptors, producing vascular constriction (vasoconstriction) of the capillaries within the nasal mucosa. The result is shrinking of the nasal mucous membranes and a reduction in fluid secretion (runny nose). Decongestants can make a client jittery, nervous, or restless. These side effects decrease or disappear as the body adjusts to the drug. When nasal decongestants are used for longer than 5 days, instead of the nasal membranes constricting, vasodilation occurs, causing increased stuffy nose and nasal congestion. The nurse should emphasize the importance of limiting the use of nasal sprays and drops. As with any alpha-adrenergic drug (for example, decongestants), blood pressure and blood glucose levels can increase. These drugs are contraindicated and should only be used with extreme caution for clients with hypertension, cardiac disease, hyperthyroidism, and diabetes mellitus. Physiological Adaptation

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148. (4) The primary goal of crisis intervention is to relieve the symptoms of anxiety and foster constructive coping. Previous psychological issues might recur during crisis, but the focus is on short-term resolution of the current problem. At the end, the nurse credits a client for positive changes and helps him or her understand what was learned. This allows the client to use the learned coping mechanisms when new problems arise. Psychosocial Integrity 149. (1) Hospitalization might precipitate a crisis in either the client or family. Clients might become demanding or withdrawn. Family members might become demanding to help them cope with insecurity. Psychosocial Integrity 150. (2) The most common abuser is a caregiver living with the client. Research reveals that the spouse is currently the most common abuser, followed by an adult child. Psychosocial Integrity 151. (2) Elderly clients on fixed incomes have difficulty meeting new expenses, such as medicine. Signs of financial abuse include unexplained illnesses that are left untreated, an inability to pay rent or purchase clothes and food, and inaccurate knowledge about finances. Financial abuse is a form of elder abuse and requires investigation. Psychosocial Integrity 152. (2) A loading or priming dose rapidly establishes a therapeutic plasma drug level. It can be calculated by multiplying the volume of distribution by the desired plasma drug concentration. A maintenance dose maintains a therapeutic level after the loading dose. It takes five drug half-lives to achieve steady state if no loading dose is given. Choice 3 is similar to a maintenance dose. Intravenous administration provides excellent drug bioavailability, but one dose will not achieve a therapeutic plasma level. Pharmacological Therapies 153. (2) All microdrop sets are calculated to give 60 drops for each milliliter of IV fluid. Macrodrop sets are calculated to give 10, 15, or 20 drops for each milliliter of IV fluid. Pharmacological Therapies 154. (1) In most states, indication of organ donor status is found on the driver’s license. Evidence in a last will and testament or in a safety deposit box is not readily accessible for decision-making if the need arises. Insurance cards do not contain such information. Another source might be the client’s primary care physician’s health record documentation. Coordinated Care 155. (1) The requirements for Medicare-reimbursable home care services include the client being homebound and requiring a skilled service, such as PT/OT/ST/nursing/social work. Coordinated Care 156. (1) Drugs are distributed via the circulatory system. Adequate perfusion is necessary for distribution of a drug. Choices 2, 3, and 4 are not as dependent on adequate perfusion. Pharmacological Therapies 157. (1) This antihyperglycemic agent prevents hyperglycemia by reducing hepatic glucose output and decreasing glucose absorption from the gut. A hypoglycemic drug stimulates insulin production. Metformin is not a type of insulin. Metformin is not a stimulant of any pancreatic cell. Pharmacological Therapies 158. (3) A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices. Choice 1 is common with pneumonia. Values in Choice 2 are not alarming. Choice 4 is typical of someone with chronic obstructive pulmonary disease (COPD). A tension pneumothorax is a dangerous complication and a medical emergency where entering air cannot escape by the same route and pressure within the pleural cavity increases, resulting in complete collapse of the lung. A mediastinal shift to the unaffected side and a downward displacement of the diaphragm can be observed. Physiological Adaptation 159. (2) Larger-than-normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways. Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COPD). Physiological Adaptation 160. (2) Exposure with a positive TB skin test usually requires six months of prophylactic treatment unless contraindicated. The TB skin test should not be repeated; the results will always be positive. A CXR is usually not required annually in the event that the skin test was positive. TB is a type of pneumonia caused by the acid-fast bacillus, mycobacterium tuberculosis, and is contracted by airborne droplets that enter the lungs and multiply in the pulmonary alveoli. Nursing Assessment: (1) Assessment includes symptom analysis of type and progression of symptoms; color, consistency, and amount of sputum; knowledge of the disease; weight pattern; vital signs;

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description of any pain; palpable lymph nodes; breath sounds; and activity tolerance. (2) Diagnostic tests: a) CXR (shows dense lesions in the upper lobes, enlarged lymph nodes, and formation of large cavities); b) CBC (presence of leukocytosis); c) Fiberoptic bronchoscopy and bronchial washing (for obtaining culture specimens); d) Tuberculin skin test (positive at 5 to 9 mm for clients with abnormal CXR or HIV; positive at 10 to 15 mm for clients with high-risk factors such as intravenous [IV] drug use; residence in a long-term facility, high-incidence country; positive at 15 mm for all other people); e) Three early-morning sputum collections for acid-fast staining, culture and sensitivity positive for M. tuberculosis. Results can take up to 10 days. Physiological Adaptation 161. (1) Pleurisy is an inflammation of the pleura and is often accompanied by abrupt onset of pain. Symptoms of pleurisy are abrupt pain that is usually unilateral and localized to a specific portion of the chest. The pain is sharp, stabbing, and might radiate to the neck or shoulder. Pressure changes caused by breathing, movement, or coughing intensify the pain. Other symptoms might include fever, cough (dry, hacking), localized tenderness, diminished breath sounds, tachypnea, and pleural friction rub. Physiological Adaptation 162. (4) Because most oral mediations are absorbed in the intestine, increased motility moves the second drug through the system faster, thus decreasing the absorption time and the amount taken up by the intestine. Pharmacological Therapies 163. (1) Nitrous oxide produces analgesia and is often used for minor surgery and dental procedures that do not require loss of consciousness. It can also produce a mild euphoria in some clients. Nitrogen is a nonmetallic element that constitutes nearly four-fifths of the air by volume, occurring as a colorless, odorless, almost inert diatomic gas, N2, in various minerals and in all proteins. Nitric oxide is a potent vasodilator of vascular smooth muscle. It is produced from L arginine. Nitrogen dioxide is a poisonous brown gas, NO2, often found in smog and automobile exhaust fumes. Pharmacological Therapies 164. (4) Some AEDs cause aplastic anemia and megaloblastic anemia. Choices 1, 2, and 3 are not side effects of AEDs. Pharmacological Therapies 165. (4) While many environmental stimuli might compete for attention and time, the client care needs of complex or unstable clients and those requiring assessment and care must take priority. Coordinated Care 166. (3) Target-setting is the projection of goals or objectives to be accomplished and is considered to be a task-centered, supervisory responsibility. Coaching, encouraging, rewarding, evaluating, and facilitating are supervisory activities that are people related as they involve direct interaction with those doing the work. Coordinated Care 167. (2) Consensual validation is a technique used to check one’s understanding of what the client has said. Consensual validation is the process by which people come to agreement about the meaning and significance of specific symbols. Through this experience, individuals develop the ability to relate effectively. Psychosocial Integrity

169. (1) Sudden death produces greater emotional turmoil and shock in survivors than does a gradual, expected death. Survivors do not have time to engage in anticipatory grief. The most disturbing and unbalancing feature of sudden death is its unexpectedness. Psychosocial Integrity 170. (4) Perinatal loss is a great tragedy for the parents. A bereaved mother must resolve the crisis of perinatal loss in addition to the crisis of pregnancy. Such a loss is described as losing part of one’s self—loss of self-worth. The perinatal grief response must involve attachment and detachment as a part of the mourning process. Psychosocial Integrity 171. (2) Religion can be considered a system of beliefs, practices, and ethical values about a divine or superhuman power or powers worshipped as the creator(s) and ruler(s) of the universe. Spirituality is a belief in or relationship with some higher power, creative force, driving being, or infinite source of energy. Psychosocial Integrity 172. (4) Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy and does not have any effect on genetic makeup. Psychosocial Integrity

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168. (3) Communication is a personal, interactive system—a series of ever-changing, ongoing transactions in the environment. Transmissions are simultaneously received (decoded), sent (encoded), and influenced by the total of experiences and perceptions of the receivers and senders. Through communication and interaction with others, an individual develops a sense of identity and being. Communication is the basis of a person’s self-concept and the relationship of this self to another individual, to a group of people, and to the world. Psychosocial Integrity

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173. (4) The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger. Safety and Infection Control 174. (1) Shutting off the bed’s electricity should be the initial step. The nurse should not touch the client until the bed is checked for faulty grounding. An electrician should assess the equipment. Oxygen should be discontinued until the equipment is cleared. Safety and Infection Control 175. (4) After the situation is safe for the client, the nurse should record the occurrence on an incident form according to the agency protocol. Safety and Infection Control 176. (1) Accutane is a Category X drug, which means pregnancy is contraindicated due to teratogenesis associated with the medication. The pharmaceutical manufacturer should be notified of any pregnancy occurring while taking the drug, but reporting is voluntary. Choosing to terminate the pregnancy is a personal decision that requires full information. Consultation with a genetic specialist or OB physician is indicated. Safety and Infection Control 177. (2) Category X drugs have many practice limitations when prescribed and dispensed to women. For example, the prescription is valid for only seven days, and if not filled, it expires. The FDA provides a pregnancyprevention program for clients taking Isotretinoin (Accutane). Prior to prescribing a Category X drug, a pregnancy test should be performed. Safety and Infection Control 178. (4) Due to decreases in lean body mass, blood creatinine is not as good an indicator of the elderly client’s renal function as creatinine clearance. Urinalysis and blood urea nitrogen reflect hydration status and other clues to health but are not specific for renal function. The electrolytes might be deranged in renal failure but are not a direct correlation to the kidneys’ capability to eliminate waste. Therefore, the best lab for renal function in the elderly is thought to be creatinine clearance, which is a widely used test for glomerular filtration rate. Safety and Infection Control 179. (2) Unless there is drug resistance, the initial prophylaxis based on CDC recommendations is 2 NNRTIs. Safety and Infection Control 180. (2) An untoward, adverse drug reaction associated with the quinolones is tendon rupture. Electrolyte imbalance has not been associated with the group, and antibiotic-associated colitis is most common in augmentin and penicillin groups. Safety and Infection Control 181. (2) Improving quality of life is the primary goal of family education. Symptom reduction is a goal of psychoeducation, not family education. Increased knowledge about mental illness might accompany family education, but is not a goal of it. Improved quality of life and reduced family burden are the goals. Improved care-giving skills might accompany family education but are not a goal of it. Psychosocial Integrity 182. (4) Acyclovir is an antiviral effective in shortening the duration of infection in herpes. It is used in HIV and AIDS to treat opportunistic, viral infections but is not a primary AIDS drug. Candida is a fungus and is responsive to antifungal medication. Safety and Infection Control 183. (4) Floxin is a quinolone antibiotic used in respiratory infections and pelvic and reproductive infections. Rarely, quinolones can cause tendon sheath rupture, usually of the Achilles. At the first indication of tendon pain, the antibiotic should be discontinued. Safety and Infection Control 184. (2) Vancomycin levels are monitored to ensure therapeutic effects by peak level. Trough level is that level of wash out or lowest level of drug just prior to the next dose. The blood is taken approximately 2 hours after an IV infusion. Renal function is measured by creatinine and BUN or creatinine clearance and resistance by sensitivity. Safety and Infection Control 185. (2) Individual state laws mandate the reporting of infectious diseases. The list of reportable diseases varies from state to state and is overseen by state health departments. CDC reporting is voluntary and done via collaboration with state agencies. There are 58 emerging infectious diseases under surveillance by the CDC. Safety and Infection Control 186. (4) A health assessment should focus on possible risk factors of the client. A risk factor is something that increases a person’s chance for illness or injury. A health-risk appraisal is an assessment of the total person, including lifestyle and health behaviors. Health Promotion and Maintenance

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187. (3) For maximum effectiveness, teach the client about the disorder at the client’s level of understanding. Health Promotion and Maintenance 188. (1) Data belonging in a general health history of the eye includes employment, activities, allergies, medications, lenses, and protective devices used. Exposure to irritants and activity risks should be delineated. Routine care of eyes and eye devices should be explored. Health Promotion and Maintenance 189. (1) The numerator, which is always 20, is the distance in feet between the chart and the client. The denominator, which ranges from 10 to 200, indicates the distance at which a normal eye can read the chart. The eye chart the nurse uses is the Snellen chart, which assesses distance vision. Health Promotion and Maintenance 190. (4) The path by which a microorganism enters the body is the portal of entry. A vector is a carrier of disease, a source (like bad water or food) can be a reservoir of disease. Safety and Infection Control 191. (1) Of the choices given, only staphylococcus is considered a normal resident of the body. Safety and Infection Control 192. (3) The intervention priority with a mother who feels incompetent to parent a teenage daughter is to assist the mother to identify what she feels her crisis events are and to help her develop better coping skills and improve her mothering skills. With a teenager, the growth and development parameters have to be concentrated on self as well as acquiring an added event. Choices 1, 2, and 4 do not directly address the mother’s feelings of inadequacy. Psychosocial Integrity 193. (3) The arrival of the imperfect child that the mother had not envisioned places the mother in a situational crisis. Choice 1 is not an option. Choice 2 is an identified specific time period in normal development when anxiety and stress increase. Choice 4 is a crisis that occurs outside the person’s control so that the person has a disruption in social norms. Psychosocial Integrity 194. (2) Choice 2 gives the client support and an opportunity to discuss the experience. Choices 1, 3, and 4 do not validate her experience or permit discussion of her feelings. Psychosocial Integrity 195. (2) Choice 2 provides support, reassurance, and an opportunity to gain insight into the cause of the anxiety. Choice 1 dismisses the client’s feelings and offers false reassurance. Choices 3 and 4 do not allow the client to discuss his feelings, which he must do in order to understand and resolve the cause of his anxiety. Psychosocial Integrity 196. (1) Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her. Safety and Infection Control 197. (3) Vomiting bile is usually not a sign of internal bleeding. Signs of internal bleeding include painful or swollen extremities; a tender, rigid abdomen; and bruising. Safety and Infection Control 198. (1) The Apgar scoring system was put into place by Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, and reflex irritability at 1, 5, and sometimes 10 minutes after birth. Safety and Infection Control

200. (4) Intact recent and remote memory indicates that a client is not at risk for falls. Risk for falls can occur in elder clients, and the nurse should assess each client for the possibility of falls and take appropriate actions. Safety and Infection Control 201. (3) The minimum standard is to visually assess the restraint every 30 minutes. Documentation is typically performed per a checklist or flow sheet. The ends of the restraint are tied to a part of the bed that allows for position changes without unfastening them. Safety and Infection Control 202. (1) Creamy, pink-tinged vaginal drainage persists for 1 to 2 months after removal of a cervical implant. Diarrhea, not constipation, is usually a side effect of cervical implants. Stomatitis and xerostomia are local side effects of radiation to the mouth. Physiological Adaptation

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199. (3) Elder people are particularly prone to falling and incurring serious injury, especially in new situations and environments (such as the hospital). Safety and Infection Control

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203. (4) Nurses should assist clients to evaluate themselves and make behavior changes. Listening to clients, supporting clients’ strengths, assisting clients to look at themselves in totality, and encouraging clients to set attainable goals should be part of the nurse-client relationship. Psychosocial Integrity 204. (1) VLCDs are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality of protein, and has a minimum of carbohydrates to spare protein and prevent ketosis. Physiological Adaptation 205. (1) Linens should be double-bagged. Isolation refers to techniques used to prevent or to limit the spread of infection. Some form of isolation has been used for centuries, whether to protect a high-risk person from exposure to pathogens or to prevent the transmission of pathogens from an infected person to others. Special handling of articles and linen soiled by any body fluid is indicated. These articles should be placed in impervious bags before they are removed from the client’s bedside. Bagging in watertight containers is indicated to prevent exposure of personnel and contamination of the environment. The outside of the bag should not be contaminated when placing articles inside it. Each hospital and community agency has procedures for labeling and decontaminating exposed articles. Items that are visibly soiled with body substances should be rinsed and placed in plastic bags or clearly marked containers, often labeled “Contaminated.” If the outside of the bag becomes contaminated, placing that bag in another bag (double-bagging) is required. Safety and Infection Control

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