Silvestri1301-1400
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PN~Comp~Review-CD-1301-14001 PN Comprehensive Review CD Questions 1301-1400 {COMP: Equations/Formulas: 1303; questions: 1304?, 1310, 1373} 1301. A child with sickle cell anemia has vaso-occlusive pain. After noting that the child is of preschool age, the nurse plans to use which of the following methods to determine the adequacy of pain control methods? 1. Ask the child to point to pictures of faces (smiling to very sad) that best describe the pain 2. Ask the child to use a word descriptive rating scale (no, little, medium, large, worst pain) 3. Institute use of a patient-controlled analgesia (PCA) pump 4. Ask the child to use a numeric rating scale of 0 to 10 Answer: 1 Rationale: A child of preschool age has the cognitive ability to recognize happy and sad faces, and to correlate them with the level of pain experienced. Using descriptive words to communicate varying intensities of pain may be too complicated for some preschoolers (option 2). Some preschool children may not be able to count or understand the value of numbers in relation to other numbers (option 4). Children of preschool age are too young to control a PCA pump (option 3). Test-Taking Strategy: Use knowledge of growth and development and developmental stages to answer the question. With this in mind, eliminate each of the incorrect options and choose the one that is the simplest and easiest to teach and use. Review the concepts of growth and development if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 41, 140. 1302. A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains a copy of an x-ray report of the child’s: 1. Cervical spine 2. Hands 3. Heart 4. Chest and lungs Answer: 1 Rationale: Children with Down syndrome frequently have instability of the space between the first two cervical vertebrae. They require diagnostic studies (an x-ray of the cervical spine) to determine if this is present before participating in activities that put pressure on the head and neck, which could cause spinal cord compression. Options 2, 3, and 4 are not necessary. Test-Taking Strategy: First recall that children with Down syndrome have defects in almost all of their body systems. Next note the key words physical education. This tells you that the primary concern is possible injury. Use knowledge of Down syndrome and the process of elimination to prioritize which x-ray would be most important. This will direct you to option 1. The other body systems also require data collection via a health history, but do not require x-ray.
PN~Comp~Review-CD-1301-14002 Review care to the child with Down syndrome if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 338. Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 990.1303. {PLACE FIGURE HERE (Fig. 6)} Kee, J.,& Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, p. 337. A physician has prescribed vitamin K (AquaMEPHYTON) 2.5 mg intramuscularly. The nurse reads the label on the medication vial and administers how many milliliters to the client? Answer: 0.25 Rationale: Use the following formula for calculating the medication dose: Desired _________ × Volume = mL per dose Available 2.5 mg _____ × 1 mL = 0.25 mL 10 mg Test-Taking Strategy: Use the formula for the calculation of the correct dose. Recheck your work using a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, p. 337. Mosby’s medical, nursing, & allied health dictionary (6th ed.). (2002). St. Louis: Mosby, p. 1225. 1304. {PLACE FIGURE HERE (Fig. 7)} Mosby’s medical, nursing, & allied health dictionary (6th ed.). (2002). St. Louis: Mosby, p. 1225. A nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. The nurse contacts the physician and reports that the client is exhibiting: 1. Decorticate rigidity 2. Decerebrate rigidity 3. Flaccid quadriplegia 4. Opisthotonos
PN~Comp~Review-CD-1301-14003 Answer: 4 Rationale: Opisthotonos is a prolonged arching of the back with the head and heels bent backward. Opisthotonos indicates meningeal irritation. In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex. In decerebrate rigidity, the upper extremities are stiffly extended and adducted with internal rotation and pronation of the palms. The lower extremities are stiffly extended with plantar flexion. The teeth are clenched, and the back is hyperextended. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brainstem. Test-Taking Strategy: Note the position of the client and the arching of the back. Recalling that prolonged arching of the back occurs in opisthotonos will direct you to option 4. Also, noting the client’s diagnosis and recalling that this posture occurs in meningeal irritation will assist in answering the question. Review abnormal postures if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Mosby’s medical, nursing, & allied health dictionary (6th ed.). (2002). St. Louis: Mosby, p. 1225. 1305. A mother tells the pediatrician’s office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work. The nurse would explore with the mother which suggestion to decrease the children’s sense of isolation and fear? 1. Instruct the children never to cook 2. Let the children play in neighborhood homes 3. Have the children call the mother at work every hour 4. Find community after-school programs or activities Answer: 4 Rationale: In most communities, there are free or low-cost after-school programs or activities that would minimize the amount of time that school-age children are at home alone. These programs should include adult supervision, which is needed by school-aged children. Test-Taking Strategy: Use the process of elimination. The key words are sense of isolation and fear. With this in mind, evaluate each of the options from that perspective. Eliminate option 1 first because of the absolute word “never.” Eliminate option 3 next because it could be disruptive in the workplace; the mother should call the children instead. Choose option 4 over option 2 because it provides both structure and supervision, and does not contribute to possible tension with neighbors. Review safety measures in the home for children if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 272.
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1306. A nurse has reinforced teaching that was done with a school-aged child who was given a brace to wear for the treatment of scoliosis. The nurse interprets that the client has not fully understood the information presented if the child makes which statement? 1. “I will wear my brace under my clothes.” 2. “I will do back exercises at least 5 times a week.” 3. “I will wear my brace whenever I am not sleeping.” 4. “This brace will correct my curve.” Answer: 4 Rationale: Bracing can halt the progression of most curvatures, although it is not curative for scoliosis. The statements in options 1, 2, and 3 represent correct understanding on the part of the child. Test-Taking Strategy: Use the process of elimination and note the key words has not fully understood to answer the question. These words indicate a false response question and that you need to select the incorrect statement by the child. Noting the word “correct” in option 4 will direct you to this option. Review the key aspects of bracing for scoliosis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 330-332. 1307. An adolescent client with juvenile diabetes mellitus has a foot infection and is prescribed antibiotic therapy with an aminoglycoside. Before administration of the medication, the nurse collects data from the client and notes that the client has a hearing loss. The nurse should take which of the following actions next? 1. Suggest a peak and trough to ensure safe medication administration 2. Have the client drink extra water to avoid toxic side effects 3. Inform the registered nurse (RN) about the hearing loss 4. Give the medication but at half the ordered dose Answer: 3 Rationale: A preexisting hearing loss is a contraindication for the administration of aminoglycosides, because these medications can also cause ototoxicity and irreversible hearing loss. The nurse would report the findings to the RN to protect the client’s safety. The RN will in turn notify the physician. Options 1 and 2 are not beneficial because hearing loss has already occurred in this client. Nurses do not change medication orders independently. Test-Taking Strategy: Use the process of elimination. Knowing that the key side effects of aminoglycoside antibiotics are ototoxicity and nephrotoxicity help you limit your choices to options 3 and 4. Select option 3 because nurses do not change medication orders independently. Review the toxic effects of these types of antibiotics if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology
PN~Comp~Review-CD-1301-14005 Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 921. 1308. A nurse caring for an adolescent client recently diagnosed with bone cancer is monitoring the client for depression. To best recognize these symptoms in the adolescent, the nurse should recall that adolescents: 1. Are moody and often act-out 2. Like to stay up late but rarely have insomnia 3. Spend a great deal of time in self-reflection, so it is normal to withdraw 4. Like the unkempt look and are not concerned about their appearance Answer: 2 Rationale: The signs of depression include crying spells, insomnia, eating disorders, social isolation and withdrawal, serious acting-out behavior, feelings of hopelessness, unexplained physical symptoms, loss of interest in appearance, and giving away possessions. Option 2 is the only option that represents normal adolescent behavior. Test-Taking Strategy: Use knowledge of normal adolescent behavior and knowledge of the signs of depression to make your selection. Eliminate option 1 because of the word “often.” Eliminate option 4 next because of the absolute word “not.” Choose option 2 over option 3 because this option represents normal adolescent behavior. Review the signs of depression in the adolescent if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 347. 1309. An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse would plan to do which of the following as a first step in the prevention of future injury? 1. Have the client watch a video on the tragedies of improper firearm usage 2. Refer the client to a firearm safety class sponsored by the hospital 3. Explore the client’s knowledge of gun safety 4. Have the police take the client’s gun away Answer: 3 Rationale: One of the leading causes of accidental deaths in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data about a firearm safety history, which is done in option 3. Option 2 may then be indicated. Option 1 may or may not be effective at some point for this client. Option 4 is unreasonable. Test-Taking Strategy: Use the steps of the nursing process. Remember that the first step of the nursing process is data collection. Choose the option that collects data about the client’s knowledge base, which in this case is option 3. Review firearm safety in the adolescent if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance
PN~Comp~Review-CD-1301-14006 Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, pp. 623, 736, 828.1310. {PLACE FIGURE HERE (Fig. 8)} Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 217. A nurse measures a client’s body temperature with an oral mercury-in-glass thermometer. The nurse reads the temperature by placing the thermometer at eye level and noting the mercury level. The nurse determines that the client’s body temperature is which of the following if the mercury level is at the placement of the large arrow? 1. 98° F 2. 98.8° F 3. 100.5° F 4. 101° F Answer: 4 Rationale: When reading a thermometer to determine a client’s body temperature, the nurse places the thermometer at eye level and reads the mercury level. In this situation, the large arrow is at the 101° F level. Test-Taking Strategy: Note the placement of the large arrow. Recalling that each short line on the thermometer indicates 0.2° F and that each long line indicates 1° F will direct you to option 4. Review the procedure for reading a thermometer if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 217. 1311. A nurse determines that an adolescent client with diabetes mellitus needs further information about glycosylated hemoglobin levels and their purpose if the client made which statement when told that a level will be drawn? 1. “Most of my recent blood glucose levels were close to 170 mg/dl, so this result will probably be a little high.” 2. “Last time this test was taken the result was 13. I hope it will be lower this time.” 3. “I already had a complete blood cell (CBC) count drawn an hour ago, so this test is not necessary.” 4. “I have followed my diet these past three months so hopefully the test result will be OK.” Answer: 3 Rationale: Glycosylated hemoglobin reflects the average blood glucose levels during the previous 3 to 4 months. It assesses glucose control in the client with diabetes mellitus. Glucose molecules attach to the hemoglobin A molecules found in red blood cells (RBCs) and remain there for the lifetime of the RBCs, approximately 120 days. Test-Taking Strategy: Note the key words needs further information. These words indicate a false response question and that you need to select the incorrect client statement. Recalling the
PN~Comp~Review-CD-1301-14007 purpose of the glycosylated hemoglobin test will direct you to option 3. If you had difficulty with this question, review this test for monitoring diabetic control. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 728-729. 1312. An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3 AM. The nurse should first determine which of the following about the client? 1. His insurance status 2. Whether he ate his evening meal 3. Blood toxicology levels 4. Whether this is a change in his usual level of orientation Answer: 4 Rationale: The nurse should first determine whether this is a change in the client’s neurological status. The next item to determine would include when the client last ate. Blood toxicology levels may or may not be needed, but the physician would order these. Insurance information must be obtained at some point, but is not the priority from a clinical care viewpoint. Test-Taking Strategy: Use the process of elimination and knowledge about neurological data collection to answer this question. Note that the stem of the question contains the key word first. This tells you that more than one or all of the options are partially or totally correct. Focusing on the data in the question will direct you to option 4—neurological status. Review data collection related to neurological status if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 372. Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 142. 1313. An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client’s daughter. The daughter states that the client was “clear as a bell this morning.” The nurse determines from this piece of information that which of the following is unlikely to be the cause of the client’s disorientation? 1. Medication dosage error 2. Hypoglycemia 3. Alzheimer’s disease 4. Impaired circulation to the brain Answer: 3 Rationale: Alzheimer’s disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Medication use, hypoglycemia, and impaired cerebral circulation all require evaluation to determine if they play a
PN~Comp~Review-CD-1301-14008 role in causing the client’s current symptoms. Test-Taking Strategy: Use the process of elimination and note the key words clear as a bell this morning and unlikely. Eliminate options 1, 2, and 4 because they can all trigger an acute confusional state. Review the causes of disorientation and the characteristics of Alzheimer’s disease if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 140. 1314. An 80-year-old resident in a long-term care facility prepares to walk out into a rainstorm after saying, “My father is waiting to take me for a ride.” Which of the following would be an appropriate response by the nurse? 1. “I’m glad you told me that. Let’s have a cup of coffee and you can tell me about your father.” 2. “I need to place you in restraints.” 3. “How old are you? Your father must no longer be living.” 4. “I need you to sign a form before leaving.” Answer: 1 Rationale: The correct response acknowledges the client’s comment and feelings. Option 3 does not preserve the client’s dignity. Option 2 is inappropriate and is inconsistent with legal aspects of care based on the information given. Option 4 fails to protect the client from possible harm. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they do not protect the client and/or the client’s rights. Choose option 1 over option 3 because it addresses the client’s comment and feelings. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Communication and Documentation Content Area: Adult Health/Neurological Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1315. A nurse observes an outburst by a client with a history of schizophrenia, during which the client used extreme foul language. The nurse appropriately documents this occurrence by: 1. Documenting that the client is swearing loudly 2. Documenting that the client is having an outburst 3. Using quotation marks, placing dashes and lines in place of the profane words used by the client 4. Using quotation marks, exact words, and additional objective information about affect and nonverbal behavior Answer: 4 Rationale: Option 4 provides accurate, legally defensible information regarding the client’s behavior. Options 1 and 2 are not objective. Option 3 is incomplete documentation and is not legally defensible. Test-Taking Strategy: Use knowledge of basic principles of documentation to answer the
PN~Comp~Review-CD-1301-14009 question. Noting the key word objective in option 4 will direct you to this option. Review the principles of documentation if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 83. 1316. A nurse is told in the intershift report that a client has been appointed a legal guardian. The nurse looks for evidence of which of the following that supports that this in fact has occurred? 1. A physician’s order 2. A judicial decision in a court of law 3. Testimony of three neighbors 4. A licensed nurse’s observation of bizarre behavior Answer: 2 Rationale: Appointment of a guardian must be done through due legal process. It cannot be done by a physician’s order. Options 3 and 4 could support the decision that a legal guardian is necessary if the client is incompetent to make his or her own decisions, but they are not sufficient by themselves. Test-Taking Strategy: Use the process of elimination and focus on the issue—appointment of a legal guardian. Note the relationship between the words “legal” in the question and the word “law” in the correct option. Review information related to legal guardians if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 997. 1317. A female, older long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse would make which appropriate response to the client? 1. “Here I’ll taste the food for you.” 2. “It must be frightening to you. Has something made you feel that your food is poisoned?” 3. “Why do you think this way?” 4. “Your food is not poisoned. Our kitchen staff are nice people, and they are not allowed to poison people.” Answer: 2 Rationale: Option 2 validates the client’s feelings. Option 1 involves the nurse in the client’s delusion. Option 3 may place the client on the defensive and is not a facilitative technique. Option 4 is incorrect because the statement is defensive and therefore nontherapeutic. Test-Taking Strategy: Use therapeutic communication techniques. Remember, always focus on the client’s feelings first. This will direct you to option 2. Review these techniques if you had
PN~Comp~Review-CD-1301-140010 difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health References: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1318. A nurse is developing a nutritional plan for an assigned client. Which of the following is the most critical piece of data to collect before formulating the plan? 1. A dietary dairy 2. The presence of food allergies 3. Food preferences 4. Lack of a facilitative eating environment Answer: 2 Rationale: The presence of food allergies is critical to know before developing a nutritional plan. The items listed in the other options also provide good information, but are not as crucial as the presence of food allergies. Test-Taking Strategy: Use the process of elimination and note the key words most critical. This tells you that all of the options may be partially or totally correct, but that one of them is more important than the others. Use prioritizing skills, recalling the importance of allergies. Review the components of developing a nutritional plan if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1289. 1319. A nurse is assigned to care for a client who was agitated. Upon entering the room, the client screams, “Why don’t you just leave me alone?” The nurse makes which therapeutic response to the client? 1. “I can see that you are upset. I’ll be back in a few minutes to see how you are doing.” 2. “I am calling your doctor!” 3. “Why do you feel this way?” 4. “Don’t yell at me.” Answer: 1 Rationale: Option 1, the correct option, gives the client space and personal control. Option 2 is belittling, does not include the client, and does not provide a clear sense of direction. Option 3 may place the client on the defensive and is not a facilitative technique. Option 4 is confrontational, nonfacilitative, and imposes control by the nurse. Test-Taking Strategy: Use therapeutic communication techniques and note that the client is agitated. Remember, always focus on the client’s feelings first. This will direct you to option 1. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Application
PN~Comp~Review-CD-1301-140011 Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1320. A nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which of the following is inaccurate regarding depression and the older client? 1. Depression in an older person is rarely treatable 2. Depression in an older person is likely to have physical manifestations 3. Some indications of dementia may actually originate as depression 4. Suicide is a frequent cause of death among the older population Answer: 1 Rationale: Depression is treatable in an older client. The statements in options 2, 3, and 4 are accurate. Test-Taking Strategy: Use the process of elimination and note the key word inaccurate. The word “rarely” in option 1 provides a clue that this is the correct option. Review essential concepts of depression in the older client if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 152. 1321. A 74-year-old female resident with Alzheimer’s disease became very agitated when a group of children came to sing and dance at a long-term care facility, and the resident tried to take one of the children to her room. The nurse would use which of the following pieces of information when approaching the client about this behavior? 1. This resident probably had an unfortunate experience while singing and dancing during youth 2. This resident is a very dangerous individual 3. Individuals with Alzheimer’s disease are very likely to be potential child molesters 4. Individuals with Alzheimer’s disease have difficulty tolerating excess stimulation and changes in routine Answer: 4 Rationale: Clients with Alzheimer’s disease are likely to be intolerant of excess stimulation and changes in routine. There is not enough information in the question to verify the statements in options 1 and 2. Option 3 is an inaccurate statement. Test-Taking Strategy: Use the process of elimination. Focusing on the client’s diagnosis— Alzheimer’s disease—will direct you to option 4. Review the concepts related to this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 48, 140.
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1322. An older client is at risk for falls. When developing an individualized plan of care for this client, the nurse recalls that which concept is incorrect regarding maintenance of balance for the older client? 1. Older clients cannot think quickly enough to respond to emergencies 2. Many medications may have orthostatic hypotension as a side effect 3. Older clients tend to maintain a broad base of support, and thus change direction more slowly 4. Older clients often have slower neurological responses to stimuli Answer: 1 Rationale: It is not true that older clients cannot think quickly enough to respond to emergencies. That statement is a stereotypical generalization. The statements contained in the other options are true. Test-Taking Strategy: Use the process of elimination. Noting the key word incorrect will direct you to option 1. Review the physiological changes that occur in the older client if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 47, 123. 1323. In planning care for older clients in a long-term care facility, the nurse recalls that which of the following is accurate regarding sexuality and the older client? 1. Aberrant sexual behavior is to be expected among older males 2. Physical beauty is necessary for continued sexual activity in older persons 3. Although responses may be slower, sexual ability is present in later years of life 4. Most people do not engage in sexual activity after the age of 70 Answer: 3 Rationale: Option 3 represents a true statement about sexuality in the older client. Options 1, 2, and 4 indicate stereotypes with no foundation in fact. Test-Taking Strategy: Use the process of elimination and note the key word accurate. Eliminate option 1 because of the word “aberrant.” Eliminate options 2 and 4 because of the absolute words “necessary” and “not,” respectively. Review the concepts regarding sexuality and the older client if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 200. 1324. A nurse observes that a 68-year-old woman with Parkinson’s disease has very little facial expression. The nurse attributes this piece of data to which of the following? 1. Masklike faces are a component of Parkinson’s disease 2. Clients with Parkinson’s disease have diminished emotional involvement 3. Clients with Parkinson’s disease act very much like schizophrenics, in that they have very little affect
PN~Comp~Review-CD-1301-140013 4. The client does not want her emotional reaction to the disease to show Answer: 1 Rationale: A masked facial expression is typical of the client with Parkinson’s disease. Option 2 is not a true statement. Option 3 places a false interpretation on the client’s expression. There are no data to support the assumption provided in option 4. Test-Taking Strategy: Knowledge of the physical signs and symptoms associated with Parkinson’s disease is needed to answer this question. Remember, a masked facial expression is typical of the client with Parkinson’s disease. Review these signs and symptoms if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 48. 1325. A nurse is working with an older client and the client’s family about discharge following hospitalization. When initiating discussions with the group, the nurse understands that most older persons would prefer to live: 1. Independently, but close to their children 2. In long-term care facilities 3. With their children 4. Alone Answer: 1 Rationale: Most older people prefer to maintain their independence, while having the resource of children or family nearby to help in times of need. In general terms, the other options are not as favorably received by the older person, but this would also depend on the specific client and the specific situation. Test-Taking Strategy: Use knowledge of developmental stages of the older adult to answer the question. Remember, most older people prefer to maintain their independence. Review this content if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 11-12. 1326. An older client is taking multiple medications for a variety of health problems. The nurse would monitor the results of which most important laboratory test when evaluating adverse effects of medication therapy in the older adult? 1. Complete blood count 2. Arterial blood gases 3. Hemoglobin and hematocrit levels 4. Creatinine level Answer: 4 Rationale: Creatinine level should be most closely monitored because it relates to kidney function. Because many medications are excreted by the kidneys, that makes this the laboratory
PN~Comp~Review-CD-1301-140014 test of choice for ongoing monitoring. Option 3 is part of option 1, while arterial blood gases are not generally measured unless there is a specific problem with oxygenation. Test-Taking Strategy: Note that the issue relates to an older client and the organ at most risk when the client takes multiple medications. Because most medications are metabolized by the liver and excreted by the kidneys, you would look for a laboratory test that reflects either liver or kidney function. In this question, the correct option is an item related to the kidneys. Review the effects of medications on the body systems if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 208, 288. 1327. A nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad, because “his feet are always cold at night.” The nurse would incorporate which of the following concepts when formulating a response to the family member? 1. The resident has a right to procure and keep his own property 2. Heating pads are dangerous and are likely to cause fires 3. Older adults often have slower neurological response times and are therefore more at risk for burns 4. The long-term care facility strictly prohibits the use of heating pads Answer: 3 Rationale: Age-related changes in the older adult make the client more at risk for burns as a result of slower neurological response times. Option 1 ignores the client’s safety. Option 2 represents a general statement, but does not pertain to the individual safety of this client. Option 4 represents a bureaucratic response, and does not consider client needs. Test-Taking Strategy: The issue of the question is knowledge of the risks associated with the use of heating pads in the older client. Begin to answer the question by eliminating option 1, which ignores the safety of the client. Eliminate options 2 and 4 because they are general statements, and do not focus on the needs and risks of the individual client. Review age-related changes in the older adult if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 123-124. 1328. A nurse notes that an older client in a long-term care facility is receiving a daily dose of furosemide (Lasix). The nurse writes in the care plan to monitor which of the following parameters on a daily basis? 1. Weight 2. Radial pulse 3. Hemoglobin level 4. Serum creatinine level Answer: 1
PN~Comp~Review-CD-1301-140015 Rationale: Daily weight should be monitored because this reflects the fluid status of the client who is receiving a diuretic. Option 2 is a general assessment and does not directly relate to fluid balance. Options 3 and 4 are laboratory measurements that are not routinely ordered by the nurse, and would not be done on a daily basis in a long-term care facility. Test-Taking Strategy: Use the process of elimination, recalling that furosemide is a diuretic. Evaluate each of the options according to their ability to measure fluid status. Eliminate options 3 and 4 first, which are not ordered by the nurse. From the remaining options, select option 1 because it more directly correlates with fluid volume. Review the nursing interventions for the client on furosemide if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 480. 1329. A nurse has given a 77-year-old female client instructions on how to do active range-ofmotion (ROM) exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which of the following statements? 1. “If I don’t do this, that therapist gets really angry at me.” 2. “I’m doing this so I can go home soon.” 3. “It hurts, but things always have to hurt at my age.” 4. “I’m doing these exercises so I can begin to fasten my buttons and dress myself again.” Answer: 4 Rationale: Option 4 indicates that the client understands the purpose of the therapy and provides an incentive for the client to comply with the exercises. Option 1 is incorrect because it indicates imposition of staff values on the client, and is suggestive of possible abuse. Option 2 may or may not be true, and could relate to a number of factors other than use of the right hand. Option 3 is an inaccurate statement. Test-Taking Strategy: Use the process of elimination. Focusing on the issue of the question— the rationale for this procedure—will direct you to option 4. Review the purpose of active ROM exercises if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 258-260. 1330. A client with chronic atrial fibrillation is prescribed quinidine sulfate (Quinidex Extentabs) as maintenance therapy for dysrhythmia suppression. A nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instructions? 1. “I will stop taking the prescribed anticoagulant after starting this new medication.” 2. “I will take the medication with food if my stomach becomes upset.” 3. “I will avoid chewing the sustained-release tablets.”
PN~Comp~Review-CD-1301-140016 4. “I will take the dose at the same time each day.” Answer: 1 Rationale: Medication-specific teaching points for quinidine sulfate include the following: take the medication exactly as prescribed; do not chew the sustained-release tablets; take the medication with food if stomach upset occurs; wear a Medic-Alert bracelet or tag; and have periodic checks of heart rhythm and blood counts. The client should not stop taking a prescribed medication unless specifically ordered by the physician. Test-Taking Strategy: Note the key words need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Options 3 and 4 are general instructions for medication use and are therefore eliminated first. From the remaining options, remember that it is not usual practice to “stop taking” a “prescribed” medication. Review client teaching points related to this medication, if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Cardiovascular Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 918-919. 1331. A nurse has gathered data about each of the following items from an older client. The nurse understands that which of the following would not be a reliable indicator of fluid imbalance for a client in this age group? 1. Thirst 2. Appearance of oral mucosa 3. Skin turgor 4. Intake-output differences Answer: 1 Rationale: Thirst in the older adult is subjective, and is not always consistent with fluid balance. The appearance of oral mucosa, skin turgor, and the differences between intake and output are more reliable measures of fluid balance in the older adult. Test-Taking Strategy: Note the key words not be a reliable indicator and focus on the issue— fluid balance. Note that options 2, 3, and 4 are similar in that they are objective measures of fluid balance. Option 1 is subjective. Also, recall that the sensation of thirst declines with age. Review the interventions that will determine fluid balance in the older adult if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 213-214. 1332. A nurse is caring for a client with schizophrenia who states, “I decided not to take my medication because I realize that it really can’t help me. Only I can help me.” Which of the following nursing responses would be therapeutic? 1. “Only you can help?”
PN~Comp~Review-CD-1301-140017 2. “You decided not to take your medication?” 3. “Your doctor wants you to continue with this medication because it is helping you. Do you recall needing to be hospitalized because you stopped your medication?” 4. “If you can make this wise observation, you probably don’t need your medication any longer.” Answer: 3 Rationale: Noncompliance with antipsychotic medication is one of the chief reasons that clients with schizophrenia have relapses. The nurse teaches the schizophrenic client to identify the causes of relapse. In option 1, the nurse is employing restating, which, while therapeutic, is not useful to this client and to this client’s situation. In option 2, the nurse is again using restating. In option 4, the nurse is using an illogical, judgmental, and biased response, which is not therapeutic. Test-Taking Strategy: Use the process of elimination. Focus on the client’s diagnosis and use therapeutic communication techniques to direct you option 3. Review care to the client with schizophrenia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 1333. A nurse is told by a 72-year-old woman that she has begun to be incontinent of urine at night and now drinks no fluids after 6 PM. The nurse’s response would be guided by the knowledge that: 1. The client is the best judge of how much fluid she should drink or not drink 2. Incontinence is to be expected in old age 3. Older people do not need as much fluid intake as younger people 4. Incontinence at any age deserves urological attention Answer: 4 Rationale: Urinary incontinence requires evaluation as to the cause, so that appropriate treatment can be begun. Option 1 may generally be true, but may not apply since the development of this new problem. Options 2 and 3 are incorrect assumptions and represent stereotypical thinking. Test-Taking Strategy: Begin to answer this question by eliminating options 2 and 3, which are biased or stereotypical statements. To choose correctly between the remaining options, select option 4 because it relates to the issue of the question—the new onset of incontinence. Review expected and unexpected age-related changes if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 249. 1334. A nurse is communicating with an 80-year-old client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should: 1. Lower the voice pitch and face the client when speaking 2. Use sign language 3. Speak very loudly
PN~Comp~Review-CD-1301-140018 4. Put the mouth close to one ear when speaking Answer: 1 Rationale: The nurse should lower the pitch of the voice and face the client while speaking. Lower tones are heard better with hearing loss, and facing the client allows the client to pick up visual cues from the nurse’s face. Option 2 requires that both the client and the nurse understand sign language. Option 3 can be interpreted as hostility, while option 4 invades the client’s personal space. Test-Taking Strategy: Use the process of elimination and basic understanding of communication principles to answer the question. Remember, the nurse should lower the pitch of the voice and face the client while speaking. If this question was difficult, review care of the client with hearing loss. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Ear Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 147. 1335. A nurse is caring for an older client with a diagnosis of osteoarthritis. Which of the following would be least helpful for the client? 1. Gentle regular exercise 2. Increasingly vigorous and high-impact exercise 3. A warm bath or shower early in the day 4. An individualized program of pain medication administration Answer: 2 Rationale: Vigorous or high-impact exercise could be damaging to articulating surfaces within joints, and should be avoided by clients with osteoarthritis. The other options may be helpful in promoting joint mobility. Test-Taking Strategy: Use the process of elimination and note the key words least helpful. Evaluate each of the options in relation to their helpfulness to the client with impaired joint mobility. Review care to the client with osteoarthritis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 32. 1336. The nurse overhears the term “sundowning” used to describe the behavior of a client newly admitted to the nursing unit during the previous evening shift. The nurse interprets that this client most likely has a diagnosis of: 1. Acquired immunodeficiency syndrome 2. Alzheimer’s disease 3. Parkinson’s disease 4. Schizophrenia Answer: 2 Rationale: The term “sundowning” or “sundown syndrome” refers to a pattern of disorientation whereby the client is more oriented during the daytime hours and more disoriented at night. It is
PN~Comp~Review-CD-1301-140019 often seen in clients with Alzheimer’s disease. Test-Taking Strategy: To answer this question correctly, you must be familiar with this particular term and its use in the clinical context. Remember that “sundowning” refers to a pattern of disorientation whereby the client is more disoriented at night. If you had difficulty with this question, review the concepts related to chronic confusion and Alzheimer’s disease. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 139-140. 1337. A resident in a long-term care facility refuses a medication that has been ordered. The nurse takes appropriate action after considering which of the following? 1. The client cannot be forced to take the medication unless a legal guardianship is obtained and the guardian authorizes it 2. The client will probably take the medication if the physician personally administers each dose 3. The client can be forced to take the medication if the physician ordered it 4. The client has now become legally incompetent Answer: 1 Rationale: Option 1 is a true statement. The client has the right to refuse any medication ordered unless deemed incompetent in a court of law. Option 2 is an opinion not supported by fact. Options 3 and 4 are false statements. Test-Taking Strategy: Use the process of elimination. The issue of the client is the client’s right to participate or refuse an element of care, in this case medication therapy. Evaluate each of the options in terms of the clients’ rights. Review clients’ rights if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 20. 1338. A nurse notices a “paranoid stare” during a conversation with a client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which of the following actions by the nurse would be most beneficial? 1. Escort the client to a quiet room 2. Change the conversation to a less threatening subject 3. Allow the client to pace 4. Share the observation with the client and help the client to recognize feelings Answer: 4 Rationale: Sharing observations with the client may help them to recognize and acknowledge their feelings. Moving to a quiet room or changing the subject will not help the client to recognize their behaviors and feelings. Allowing the client to pace provides no assistance and may lead to the client becoming “out of control.” Test-Taking Strategy: Use the process of elimination. Eliminate option 3 because it provides no
PN~Comp~Review-CD-1301-140020 assistance, option 1 because it is punitive, and option 2 because it does not allow the client to deal with current issues. Remember to focus on the client’s feelings. Review care to the paranoid client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health References: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 187. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 413. 1339. A nurse working in a mental health unit hears that a client has been experiencing “flashbacks.” The nurse interprets that this client is exhibiting a sign of: 1. Anxiety 2. Schizophrenia 3. Agoraphobia 4. Posttraumatic stress disorder (PTSD) Answer: 4 Rationale: “Flashbacks” are the classic manifestation of PTSD. The other options are incorrect interpretations. Test-Taking Strategy: Use the process of elimination and note the key word flashbacks. Review of each option and recalling the manifestations that occur in each disorder will direct you to option 4. Review the manifestations that occur in each of these disorders if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 187. 1340. A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse plans to do which of the following initially with this client? 1. Explain the unit rules 2. Accept the client as a person and make them feel safe 3. Stabilize the client’s psychiatric needs 4. Orient the client to the unit Answer: 2 Rationale: The initial action is to make a confused and disoriented client feel safe. Orientation and explaining the unit rules are part of any admission process and do not meet the individual needs of this client. Stabilizing psychiatric needs is a long-term goal. Test-Taking Strategy: Focus on the issue—a confused and disoriented client. Use Maslow’s Hierarchy of Needs theory to direct you to option 2. Review care to the confused and disoriented client if you had difficulty with this question. Level of Cognitive Ability: Application
PN~Comp~Review-CD-1301-140021 Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 273. 1341. During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which of the following responses by the nurse would be therapeutic? 1. “I can see that you are upset about this. Let’s talk about this some more.” 2. “Why are you having so much trouble with maintaining realistic behavior?” 3. “Don’t worry so much.” 4. “Everything is going to be all right.” Answer: 1 Rationale: The correct response acknowledges the client’s feelings. The remaining options do not use therapeutic communication skills. Options 3 and 4 are clichés that do not acknowledge the client’s feelings. Option 2 is nontherapeutic and requires an explanation from the client. Test-Taking Strategy: Use therapeutic communication techniques to answer this question. Remembering to focus on the client’s feelings will direct you to option 1. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 1342. A nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. The nurse avoids including which of the following items on a list of suggestions to be given to the client? 1. Cut down on the amount of fats consumed in the diet 2. Use a heating pad on the legs to aid vasodilation 3. Walk each day to increase circulation to the legs 4. Be careful not to injure the legs or feet Answer: 2 Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further. Test-Taking Strategy: Focus on the client’s diagnosis and the key words limit disease progression and avoids. Recalling that the client is at risk for altered tissue integrity will direct you to option 2. Review client teaching points related to peripheral arterial disease if you had difficulty with this question. Level of Cognitive Ability: Application
PN~Comp~Review-CD-1301-140022 Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Cardiovascular Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 775. 1343. A client with depression reports to the nurse that she has not been sleeping or eating adequately. The nurse should plan to do which of the following to assist the client in meeting nutritional needs? 1. Provide meals as requested 2. Give the client a large fruit basket for snacking 3. Force foods to maintain minimum intake levels 4. Provide small, frequent meals Answer: 4 Rationale: A depressed client may eat small amounts of food rather than large amounts that may be overwhelming to them. If this client becomes overwhelmed, she may respond by withdrawing further. Option 1 may not be effective if the client is not motivated to eat. Option 2 is ineffective for the same reason. Option 3 violates client rights. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question— the best method of increasing intake with a depressed client. Recalling that depressed clients do not often feel like eating will assist in eliminating options 1 and 2. Choose correctly between the remaining options using either knowledge of nutrition or legal aspects of care. Review care to the client with depression if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health References: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, pp. 358-359. Varcarolis, E. (2002). Foundations of psychiatric mental health nursing (4th ed.). Philadelphia: W.B. Saunders, p. 468. 1344. A client who excessively uses alcohol and who is motivated to stop tells the nurse, “I know that there is a medication that can help people like me to quit drinking.” The nurse understands that this medication is: 1. Disulfiram (Antabuse) 2. Pyridoxine 3. Chlordiazepoxide (Librium) 4. Clonidine (Catapres) Answer: 1 Rationale: Disulfiram is a medication used for alcoholism and aids in the maintenance of sobriety. An adverse reaction occurs if the client drinks while taking this medication. The client should be motivated to stop drinking before being given this medication. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Specific knowledge regarding the medication used to maintain sobriety is needed to answer this question correctly. Remember, disulfiram is a medication used for
PN~Comp~Review-CD-1301-140023 alcoholism and aids in the maintenance of sobriety. If this question was difficult, review the actions and uses of disulfiram. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 300. 1345. A male phobic client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that “he cannot sing.” Which of the following responses by the nurse would be most therapeutic? 1. “Life is short! Enjoy it while you can.” 2. “You must go. You have no choice.” 3. “Perhaps you could just enjoy the music without singing.” 4. “Why don’t you really want to attend?” Answer: 3 Rationale: The correct response encourages the client to socialize and deflects the client’s attention away from the issue of singing. Option 1 uses a cliché, which is not therapeutic. Option 2 ignores client rights, while option 4 challenges the client. Test-Taking Strategy: Use therapeutic communication techniques. Option 3 is the only option that addresses the client’s concern. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 1346. A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse would appropriately remove the restraints when which of the following occurs? 1. When no acts of aggression are observed within 1 hour after release of two extremity restraints 2. When medication that has been administered has taken effect 3. When the nurse explores with the client the reasons for the attacking behavior 4. When the client apologizes and tells the nurse that it will never happen again Answer: 1 Rationale: The best indicator that the behavior is controlled is after the client is partially released from the restraints and exhibits no signs of aggression. This is also the best indicator of the client’s current physical behavior. Options 2, 3, and 4 are inaccurate indicators. Test-Taking Strategy: Use knowledge of legal and ethical issues involving restraints to answer this question. Also note the relationship between the word “aggressive” in the question and “aggression” in the correct option. Review the issues related to restraints if you had difficulty with this question.
PN~Comp~Review-CD-1301-140024 Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 262-263. 1347. A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client’s behavior is most consistent with: 1. Attention seeking 2. Desire to be accepted 3. Manipulation 4. Improvement Answer: 4 Rationale: The behavior exhibited by the client is most appropriate and demonstrates improvement. All clients have a desire to be accepted. Acting-out is attention-seeking behavior. There is no pattern of manipulation exhibited. Test-Taking Strategy: Use the process of elimination. Focusing on the data provided in the question will assist in directing you to option 4. Review the expected outcomes for the client with agoraphobia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 186. 1348. A nurse working the evening shift is assisting clients to get ready for sleep. A client diagnosed with obsessive-compulsive disorder becomes upset and agitated and asks the nurse to sit down and talk. Which of the following would be the best response of the nurse at this time? 1. “I can see that you’re upset. I’m willing to listen.” 2. “I don’t have time right now, but I’ll get someone else to talk to you.” 3. “No, we can’t talk right now; it is bedtime.” 4. “Try to get some sleep and we will talk in the morning.” Answer: 1 Rationale: The correct response acknowledges the client’s feelings and provides a forum for release of anxieties. The other options are incorrect because they do not use therapeutic communication techniques. Each of them contains a block to communication by putting the client’s feelings on hold. Test-Taking Strategy: Use therapeutic communication techniques. Select the option that acknowledges the client’s feelings and does not place the client’s issues on hold. This will direct you to option 1. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity
PN~Comp~Review-CD-1301-140025 Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 1349. A nurse is reviewing medications with a client receiving colchicine for the treatment of gout. The nurse determines that the medication is effective if the client reports a decrease in: 1. Blood glucose level 2. Blood pressure 3. Joint inflammation 4. Headaches Answer: 3 Rationale: Colchicine is classified as an anti-gout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in the affected joints, as well as a decrease in the number of gout attacks. Test-Taking Strategy: Use the process of elimination. Focusing on the diagnosis of the client will direct you to option 3. Review the action of colchicine if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 256. 1350. A nurse is preparing to admit a client diagnosed with obsessive-compulsive disorder (OCD) to the mental health unit. The nurse observes this client for behavior characteristic of one who is: 1. Extremely frightened 2. Inflexible and rigid 3. Suspicious and hostile 4. Flexible and adaptable Answer: 2 Rationale: Rigid and inflexible behaviors are characteristic of the client with OCD. Clients are not usually hostile unless they are prevented from performing the obsession or compulsion, because that is what decreases the anxiety. The other options are incorrect. Test-Taking Strategy: Use the process of elimination. Recalling that the client with OCD performs repetitive acts over and over as a means of decreasing anxiety will direct you to option 2. Review the characteristics of OCD if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 271.
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1351. A client cannot leave the house without checking the stove and the iron many times. The client is often late for appointments, and occasionally even misses engagements as a result of this behavior. The nurse interprets that this client’s symptoms are compatible with which of the following anxiety disorders? 1. Posttraumatic stress disorder 2. Obsessive-compulsive disorder 3. Generalized anxiety disorder 4. Phobias Answer: 2 Rationale: The repetitive behavior that interferes with activities of daily living and functioning is indicative of obsessive-compulsive disorder. This type of behavior is not part of the clinical picture for the disorders identified in options 1, 3, and 4. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and note the relationship between these data and option 2. Review the characteristics of obsessivecompulsive disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 187. 1352. A client has just been admitted to the mental health unit with a diagnosis of obsessivecompulsive disorder. The nurse observes the client for compulsive behavior that denotes repetition in: 1. Fears 2. Delusions 3. Thoughts 4. Actions Answer: 4 Rationale: A compulsion is a repetitive act, while an obsession is a repetitive thought. A phobia is a repetitive fear, while delusions are characteristic of schizophrenia. Test-Taking Strategy: Use the process of elimination and note the key word behavior. This tells you that the correct option is something observable by the nurse. This will direct you to option 4. Review the characteristics of obsessive-compulsive disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 186. 1353. A client in the mental health unit engages in repeated hand washing throughout the day. The nurse understands that these repetitive behaviors develop because the client is:
PN~Comp~Review-CD-1301-140027 1. Unconsciously attempting to control unpleasant thoughts or feelings 2. Unaware that they are performing the ritual 3. Consciously attempting to punish themselves or others 4. Responding to “the voices” telling them to perform rituals Answer: 1 Rationale: Repetitive acts are characteristic of clients who have obsessive-compulsive disorder. The rituals performed are an unconscious response that helps to divert and control the unpleasant thoughts or feelings in order to prevent acting on those feelings. The other interpretations are incorrect. Test-Taking Strategy: Knowledge regarding the characteristics of obsessive-compulsive disorder is required to answer this question. Remember, repetitive acts are characteristic of clients who have obsessive-compulsive disorder. Review these characteristics if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 187. 1354. A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma suffered 6 weeks ago. The nurse plans care knowing that which of the following is the priority action? 1. Refer the client for a psychiatric evaluation 2. Encourage the client to move the arms 3. Encourage the client to talk about feelings 4. Look for organic causes of the paralysis Answer: 4 Rationale: The first priority is to rule out any neurological disorders. After it has been determined that there is no physiological basis for the paralysis, then further psychiatric evaluation can be done. The client should be encouraged to talk about feelings, but this is not the priority option. Encouraging the client to move the arms has no beneficial effect in this situation. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to answer the question. Option 4 is the only option that relates to a physiological need. Review care to the client who experiences a physiological disorder as a result of emotional trauma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 225. 1355. A client with obsessive-compulsive disorder who continually cleans the bathroom becomes enraged with the roommate for using the bar of soap being used for cleaning. The client begins to yell and slaps the roommate. Which of the following actions should the nurse
PN~Comp~Review-CD-1301-140028 take first? 1. Restrain the client 2. Fill out an incident report 3. Remove both clients to a safe location 4. Call the hospital risk management department Answer: 3 Rationale: The first responsibility of the nurse is to provide for the safety of all clients. Only option 3 provides for the needs of both clients identified in the question. The other actions are either contraindicated (option 1), have lesser priority (option 2), or may not be indicated depending on the level of injury to the second client (option 4). Test-Taking Strategy: Use the process of elimination and note the key word first. The issue of the question is the appropriate method for dealing with an aggressive client. In this case, the umbrella (global) option is the one that is correct. Only the correct option provides for the needs of both clients identified in the question. Review methods of dealing with an aggressive client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 116, 261-262. 1356. A nurse is assigned to assist in the care of a client with obsessive-compulsive disorder. The nurse would place first priority on which of the following when planning care for this client? 1. Educate the client about self-care demands 2. Establish a trusting nurse-patient relationship 3. Monitor for obsessive-compulsive behavior 4. Demand active participation in care Answer: 2 Rationale: It is most important to establish a trusting relationship, which indicates to the client that the client is important. After a therapeutic relationship has been developed, other work can begin. The nurse should not demand anything from the client. Test-Taking Strategy: Use the process of elimination and note the key word first. Use knowledge of therapeutic communication skills and the nature of the nurse-client relationship to direct you to option 2. Review the importance of the nurse-client relationship if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 189. 1357. A nurse is preparing a care plan for the client with obsessive-compulsive disorder. The nurse should focus on which of the following as the primary means to accomplish work with this client?
PN~Comp~Review-CD-1301-140029 1. Group therapy 2. Recreational therapy 3. Medical diagnosis 4. Goals and objectives Answer: 4 Rationale: Goals and objectives are a mutual working tool between the client and the nurse. Options 1, 2, and 3 are not specific to the nurse-client working relationship. Test-Taking Strategy: Use the process of elimination and focus on the key word primary. Eliminate options 1, 2, and 3 because they relate to a medical rather than a nursing focus of care. Review the elements of the nurse-client relationship if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 190. 1358. A nurse employed in a mental health clinic is working with a client who has a somatization disorder. The nurse plans care recalling that the onset of symptoms in a somatization disorder is usually noted around age: 1. 10 2. 20 3. 30 4. 70 Answer: 3 Rationale: The average age for onset of somatization disorders is 30. The other ages listed are incorrect. Test-Taking Strategy: Knowledge regarding a somatization disorder is required to answer this question. Review the characteristics of this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 229. 1359. A client newly admitted to the mental health unit describes a recent history of emotional turmoil. The client exhibits physical symptoms and has some loss of physical functioning. The nurse determines that this client is exhibiting signs compatible with: 1. Posttraumatic stress disorder 2. Somatization disorder 3. Depression 4. Obsessive-compulsive disorder Answer: 2 Rationale: Emotional turmoil expressed in physical signs is a major symptom of somatization disorder. The other disorders listed are incorrect.
PN~Comp~Review-CD-1301-140030 Test-Taking Strategy: Focus on the data in the question. Recalling the characteristics associated with a somatization disorder will direct you to option 2. Review these characteristics if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 230. 1360. A nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month time period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. After reasoning that the client’s symptoms are compatible with a somatization disorder, the nurse recalls that obesity for this client most likely represents: 1. A form of functional coping 2. Satisfaction with self 3. Long-term lack of compliance with weight programs 4. Protection from the risk of intimacy Answer: 4 Rationale: A client who is obese after trauma such as that described in the question may be trying to portray themselves as “fat and unattractive.” This would allow the client to protect self from the danger of intimacy. Options 1 and 2 are incorrect. There are not enough data in the question to support option 3. Test-Taking Strategy: Use knowledge of somatization disorders and the effects of sexual abuse to answer this question. Begin by eliminating options 1 and 2 because of the words “functional” and “satisfaction,” respectively. From the remaining options, focusing on the data in the question will direct you to option 4. Review somatization disorders if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 231. 1361. A nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate? 1. Defend the delusional thinking 2. Develop a relationship to help reduce the frequency of the delusions 3. Relinquish the need for delusional thinking 4. Verbalize the reasons for delusional thinking Answer: 2 Rationale: Paranoid clients feel anxious and threatened because of a lack of trust. Increasing the ability to trust will help decrease delusional thinking. Defending the delusion is not therapeutic, while relinquishing the need for delusional thinking is not realistic at this point in time.
PN~Comp~Review-CD-1301-140031 Verbalizing the reasons for the delusion may also not be realistic in the short-term. Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question and noting the key words short-term goal will direct you to option 2. Review care of the client with delusions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 331. 1362. A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathology after a lengthy work-up. In planning care for this client, it is important that the nurse understands that the client is suffering from: 1. Somatization disorder 2. Hypochondriacal neurosis 3. Schizophrenia 4. Depression Answer: 1 Rationale: Somatization disorder is characterized by a long history of multiple problems with no organic cause. This characteristic is not found in clients with the other mental health disorders listed. Test-Taking Strategy: Focus on the data in the question. Knowledge of the characteristics of a somatization disorder will direct you to option 1. Review the characteristics of the disorders in the options if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, pp. 287-288. 1363. A client is tentatively diagnosed with ovarian cancer. The nurse gathers data about which late manifestation(s) of this disease? 1. Pelvic pain, anemia, and ascites 2. Normal bowel and bladder function 3. Vague lower abdominal discomfort 4. Mild digestive complaints Answer: 1 Rationale: Vague lower abdominal discomfort and mild digestive complaints are early symptoms. Bowel and bladder functions are also affected early on. Pelvic pain, anemia, and ascites are experienced late in the disease process. Early detection of this type of cancer is rare, which is why screening is so important. Test-Taking Strategy: Use the process of elimination. Noting the key word late will assist in directing you to option 1. Review the early and late manifestations of ovarian cancer if you had difficulty with this question.
PN~Comp~Review-CD-1301-140032 Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1080. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 960. 1364. A client with ovarian cancer is scheduled to receive chemotherapy with cisplatin (PlatinolAQ). The nurse assisting in caring for the client reviews the plan of care expecting to note which intervention? 1. Encourage a low-fat diet 2. Restrict fluids 3. Encourage fluids 4. Encourage a high-protein diet Answer: 3 Rationale: The client should receive prehydration before and during the infusion of this medication to minimize the risk of renal damage. Fluids are not restricted. Encouraging adequate dietary intake is appropriate, but a high-protein or low-fat diet is not necessary. Test-Taking Strategy: Use the process of elimination. Note that options 2 and 3 oppose each other, which indicates that one of these options is likely to be correct. Noting the client’s diagnosis and recalling that this medication is an antineoplastic will direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 369. 1365. A client receiving chemotherapy tells the nurse, “What will I ever do when my hair starts to fall out?” The appropriate response by the nurse would be to: 1. Tell her that people don’t pay attention to such things anymore 2. Offer to help her select a new hairstyle 3. Ignore the comment and change the subject 4. Encourage her to select a wig Answer: 4 Rationale: The nurse would encourage the client to select a wig. Selecting a wig before the hair falls out will enable the client to better match hair color and texture of the wig with her natural hair. A new hairstyle will not be beneficial to the client since the hair will fall out. Options 1 and 3 are nontherapeutic. Test-Taking Strategy: Use therapeutic communication techniques to eliminate options 1 and 3. From the remaining options, knowing that the hair will fall out will direct you to option 4. Review the interventions that will address the psychosocial issues of the client receiving chemotherapy if you had difficulty with this question.
PN~Comp~Review-CD-1301-140033 Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 386. 1366. A nurse has given a client with hepatitis instructions about postdischarge management during convalescence. The nurse determines that the client needs further teaching if the client states to: 1. Eat a high-carbohydrate, low-fat diet 2. Avoid alcohol and aspirin 3. Resume full activity level within 1 week 4. Take the prescribed amounts of vitamin K Answer: 3 Rationale: The client with hepatitis is easily fatigued and may require several weeks to resume full activity level. It is important for the client to get adequate rest so that the liver may heal. The client should take in a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as aspirin and alcohol. If the client has prolonged clotting times, vitamin K should be prescribed. Test-Taking Strategy: Note the key words needs further teaching. These words indicate a false response question and that you need to select the incorrect client statement. Use the process of elimination, focus on the issue, and note the time period of 1 week in option 3. Remember that fatigue is a troublesome problem in hepatitis and a lengthy period of convalescence is usually necessary. Review home care measures for the client with hepatitis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 233. 1367. A nurse has given discharge instructions to a client who has had ocular surgery of the right eye. The nurse determines that the client needs further instruction if the client states to: 1. Call the physician if a temperature of 99° F is present 2. Wear sunglasses during the day 3. Wear an eyeshield at night 4. Sleep on the back or left side Answer: 1 Rationale: The client is generally taught to report a temperature of 101° F or greater. The client should also report chills, pain unrelieved by medication, bleeding, foul-smelling drainage, or redness at the surgical site. The client should wear sunglasses during the day and an eyeshield at night to protect the eye. The client should lie on the back or the nonoperative side, unless otherwise instructed by the surgeon. Test-Taking Strategy: Begin to answer this question by eliminating options 2 and 3 first.
PN~Comp~Review-CD-1301-140034 Remember that options that are similar (in this case related to eye protection) are not likely to be correct. From the remaining options, note the key words needs further instruction. These words indicate a false response question and that you need to select the incorrect client statement, which will assist in directing you to option 1. Review home care measures following eye surgery if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1055. 1368. A client with glaucoma has suffered significant eye damage prior to diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client states that: 1. The family will drive the client when eye examinations are needed 2. Driving at dusk is not a problem 3. Nightlights have been placed in the hallways for night use 4. It is important to have periodic eye examinations Answer: 2 Rationale: The client who has adjusted to the impaired vision that may accompany glaucoma should take action to maintain safety in dim lighting. This includes moving carefully in dim lighting, using nightlights along paths traveled in the home at night, and avoidance of driving at dusk or dawn. Satisfactory adjustment is also indicated by recognition of the need for ongoing eye examinations, and the presence of a supportive family. Test-Taking Strategy: Use the process of elimination, noting the key words needs further assistance. These words indicate a false response question and that you need to select the incorrect client statement. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 1 and 4 first. From the remaining options, recall that vision is further impaired in dim lighting. This will direct you to option 2. Review client teaching points related to glaucoma if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Eye References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1944-1945. 1369. A client in the emergency department is diagnosed with Bell’s palsy. The nurse collecting data on this client expects to note which of the following? 1. Narrowing of the palpebral fissure 2. A lag in closing the eyelid 3. A symmetrical smile 4. Paroxysms of excruciating pain in the lips and cheek Answer: 2 Rationale: The facial drooping associated with Bell’s palsy makes it difficult for the client to
PN~Comp~Review-CD-1301-140035 close the eyelid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell’s palsy. Paroxysms of excruciating pain are seen with trigeminal neuralgia. Test-Taking Strategy: Use the process of elimination noting the key word palsy. Options 1 and 3 reflect findings opposite those that would be expected with Bell’s palsy. Excruciating pain is not noted in Bell’s palsy. Review the manifestations associated with Bell’s palsy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 643. 1370. A client has just been told by the physician of the diagnosis of breast cancer. The client responds, “Oh, no; does this mean I’m going to die?” The nurse interprets that the client’s initial reaction is one of: 1. Anxiety 2. Fear 3. Denial 4. Rage Answer: 2 Rationale: The client’s response is one of fear. The client has verbalized the object of fear (dying), which makes anxiety incorrect. There is no evidence of denial or rage in the client’s statement. Test-Taking Strategy: Focus on the issue of the question and the client’s statement. The client’s statement clearly identifies fear. Review psychosocial reactions related to a diagnosis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 278. 1371. A nurse inspects a decubitus ulcer on a client’s sacrum and notes that the ulcer has partialthickness skin loss and the formation of a blister. The nurse categorizes the ulcer as: 1. Stage I 2. Stage II 3. Stage III 4. Stage IV Answer: 2 Rationale: A stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss and the wound may appear as an abrasion, shallow crater, or a blister. A stage I ulcer is a reddened area that does not blanche, but has intact skin. Stage III and IV ulcers are those that involve full-thickness skin loss and full-thickness skin loss with necrosis or damage to muscle,
PN~Comp~Review-CD-1301-140036 bone, or supportive tissue, respectively. Test-Taking Strategy: Focus on the key words formation of a blister. Use knowledge of the different stages of pressure ulcer classification to answer this question. Review these various stages and their characteristics if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 273. 1372. A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse plans to maximize the effectiveness of this therapy by: 1. Rubbing the application into the skin 2. Applying a dry, sterile dressing over the affected area 3. Covering the application with a warm, moist dressing and an occlusive outer wrap 4. Placing the area under a heat lamp for 20 minutes Answer: 3 Rationale: The nurse can enhance penetration of topical corticosteroid therapy to the client with psoriasis by applying warm, moist heat and an occlusive outer wrap. The wrap may consist of a plastic film, glove, bootie, or a similar item. If large surface areas of skin are involved, the occlusive therapy may be limited to 12 hours per day to minimize local and systemic side effects. Test-Taking Strategy: Note the key word maximize. This implies that one option is better than the others for enhancing the effect of this therapy. Focusing on the client’s diagnosis and using principles related to warmth will direct you to option 3. Review treatment measures for psoriasis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Integumentary Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 78.1373. A nurse is counseling a client about decreasing the risk for cervical cancer. Select the items that the nurse would tell the client. ____Keep appointments for Papanicolaou smears at the frequency advised by the physician ____Seek prompt treatment for vaginitis ____Condoms are needed only if the client does not trust new partners ____Multiple sexual partners increase the risk Answer: Keep appointments for Papanicolaou smears at the frequency advised by the physician Seek prompt treatment for vaginitis Multiple sexual partners increase the risk Rationale: Condoms should be used for adequate protection, especially with new partners. Sexually transmitted diseases (that could be acquired without condom use) increase the client’s risk of cervical cancer. Multiple sexual partners also increase the risk. The client should adhere
PN~Comp~Review-CD-1301-140037 to guidelines for early detection of cervical cancer (Papanicolaou smear), and should seek prompt treatment of vaginitis and cervicitis if they occur. Test-Taking Strategy: Focus on the issue—to decrease the risk of cervical cancer. Knowledge of general measures to promote health guides you to answer correctly. Also note the absolute word “only” in the incorrect item. Review the risk factors associated with cervical cancer if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 354, 1072. 1374. A nurse has given instructions to the client with a cystocele about Kegel exercises. The nurse determines that the client has not fully understood the directions if the client states to: 1. Begin voiding and then stop the stream, holding residual urine for 1 hour 2. Stop and start the stream of urine several times during a voiding 3. Tighten perineal muscles for up to 10 seconds several times a day 4. Tighten perineal muscles for up to 5 minutes 3 or 4 times a day Answer: 1 Rationale: Kegel exercises strengthen the perineal floor and are useful in the prevention and management of cystocele, rectocele, and enterocele. There are several acceptable ways to perform Kegel exercises. These involve starting and stopping the flow of urine either once for up to 5 minutes, or several times during a single voiding for about 5 seconds. Because the muscles that control urination also are involved in defecation, these exercises can also be done once during defecation. Otherwise, they may be done by holding perineal muscles taut for up to 10 seconds several times a day, or for 5 minutes 3 to 4 times a day. Option 1 is not a correct method for performing Kegel exercises. Residual urine should not be held in the bladder for lengthy periods because it could promote urinary tract infection. Test-Taking Strategy: Focus on the issue and note the key words has not fully understood. These words indicate a false response question and that you need to select the incorrect client statement. General principles related to the prevention of urinary tract infections will direct you to option 1. Review the procedure for Kegel exercises if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 288. 1375. A client has been given a prescription for gemfibrozil (Lopid). The nurse plans to instruct the client to limit which of the following foods while taking this medication? 1. Fish 2. Beef 3. Spicy foods 4. Citrus products
PN~Comp~Review-CD-1301-140038 Answer: 2 Rationale: Gemfibrozil is a lipid-lowering agent. It is given as part of a therapeutic regimen that also includes dietary counseling, specifically the limitation of saturated fats and other fats in the diet. Test-Taking Strategy: Use the process of elimination, noting the key word limit. Recalling that gemfibrozil is a lipid-lowering agent will direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, pp. 656-657. 1376. A nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which of the following is the most appropriate action? 1. Check for blood return 2. Remove the IV 3. Apply a warm compress 4. Measure the area of infiltration Answer: 2 Rationale: Blanching, coolness, and edema at the IV site are all classic signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the most appropriate action is to remove the IV to prevent any further damage. The nurse should not depend solely on blood return for assurance that the cannula is in the vein because blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if the infiltrated solution is not damaging to the surrounding tissues. Measuring the area of infiltration should only be done after the IV has been removed so that further tissue damage is assessed. Test-Taking Strategy: Note the key words most appropriate. While all of the options may be appropriate, it is necessary to prioritize. The signs presented in the question identify infiltration. Infiltration indicates that the IV needs to be removed. Review the signs of infiltration and the appropriate interventions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, pp. 446-448. 1377. A nurse would monitor for which of the following laboratory results as indicating an adverse reaction in the client with endometrial cancer who is receiving chemotherapy? 1. White blood cell count 7000/mm3 2. Blood urea nitrogen 20 mg/dl 3. Hemoglobin 12.5 g/dl 4. Platelet count 20,000/mm3
PN~Comp~Review-CD-1301-140039 Answer: 4 Rationale: A normal platelet count ranges from 150,000/mm3 to 400,000/mm3. A platelet count of 20,000/mm3 places the client at severe risk for bleeding. All of the other values are within normal limits. Test-Taking Strategy: Use the process of elimination and knowledge of normal blood studies. Option 4 is the only value that is not normal. Review the risks associated with chemotherapy and these normal laboratory values if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 382. 1378. A nurse determines that a client with a history of which of the following is most at risk of endometrial cancer? 1. Estrogen replacement therapy 2. Steroid replacement therapy 3. Occupational exposure to carcinogens 4. Surgical interventions Answer: 1 Rationale: Endometrial cancer is related to the hormone estrogen because estrogen is the primary stimulant of endometrial proliferation. Surgical interventions, environmental exposure to carcinogens, and steroid replacement therapy are not considered to be risk factors for endometrial cancer. Test-Taking Strategy: Specific knowledge of the risk factors for endometrial cancer is needed to answer this question. Note the correlation also between the word “endometrial” in the question and the word “estrogen” in the correct option. Review these risk factors if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1071. 1379. A client with endometrial cancer is receiving doxorubicin (Adriamycin), an antineoplastic agent. The nurse would specifically collect data about which of the following? 1. Hematological laboratory values 2. Level of orientation 3. Pupillary response to light 4. Neuromuscular reflexes Answer: 1 Rationale: Because of bone marrow suppression during therapy with antineoplastic agents, hematological laboratory values should be monitored closely. The incorrect options all reflect neurological symptoms, which are not the issue with this medication.
PN~Comp~Review-CD-1301-140040 Test-Taking Strategy: Use the process of elimination. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 2, 3, and 4 because they reflect neurological data. Review the effects of doxorubicin if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 294. 1380. A nurse is caring for a client with cancer receiving chemotherapy who has developed stomatitis. The nurse plans to give mouth care by using oral care agents and devices: 1. That are the preference of the nurse 2. Based on the grade of stomatitis 3. That the client requests 4. That are readily available Answer: 2 Rationale: Interventions used to treat stomatitis are based on the varying degrees of the disorder. The incorrect options do not focus on the individual needs of the client with this complication of cancer chemotherapy. Test-Taking Strategy: Use the process of elimination and focus on the client’s problem. This will direct you to option 2. Review care to the client with stomatitis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 671. 1381. A client with cancer has undergone a total abdominal hysterectomy and has a Foley catheter in place during the immediate postoperative period. The nurse would expect to note which of the following types of urinary drainage immediately following this surgery? 1. Blood-tinged 2. Colorless 3. Purulent 4. Bright red Answer: 1 Rationale: Because of the handling of the bladder during surgery, the urine is likely to be bloodtinged. Option 2 would indicate overhydration. Option 3 indicates infection. Option 4 would indicate active bleeding. Test-Taking Strategy: Use the process of elimination and note the key words immediately following. Use general knowledge of postsurgical urinary drainage and the effects of surgical manipulation to direct you to option 1. Review the expected findings following this surgery if you had difficulty with this question. Level of Cognitive Ability: Analysis
PN~Comp~Review-CD-1301-140041 Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1070. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, pp. 1674, 1840. 1382. A nurse is caring for a client immediately following a total abdominal hysterectomy. The nurse anticipates that which of the following will be the priority in the first 24 hours following surgery? 1. Pain 2. Lack of information about recovery 3. Changes in body image 4. Inability to cope with stressors Answer: 1 Rationale: The client who has had surgery is most likely to be faced with greater or lesser amounts of pain in the first 24 hours after surgery, depending on the effectiveness of pain control measures. The other priorities are of lesser importance during this timeframe, and could increase in importance later in recovery. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to answer the question. Option 1 is the only option that addresses a physiological need. Remember that physiological needs are the priority. Review care to the client following a total abdominal hysterectomy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Clients Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1069-1070. 1383. A nurse is caring for a client with a skin infection who is receiving amoxicillin (Amoxil) 500 mg every 8 hours. Which of the following would indicate to the nurse that the client is experiencing a frequent side effect related to the medication? 1. Severe abdominal cramps 2. Vaginal drainage 3. Fever 4. Severe watery diarrhea Answer: 2 Rationale: Amoxicillin (Amoxil) is a type of penicillin. Frequent side effects include gastrointestinal disturbances, headache, and oral or vaginal candidiasis. Less common but more harmful adverse reactions that can occur include superinfection, such as potentially fatal antibiotic-associated colitis, which results from altered bacterial balance. Symptoms would include abdominal cramps, severe watery diarrhea, and fever. Test-Taking Strategy: Focus on the key words frequent side effect. This will assist in eliminating options 1 and 4. From the remaining options, recall that antibiotics can alter the normal vaginal
PN~Comp~Review-CD-1301-140042 flora to assist in directing you to option 2. If you had difficulty with this question, review the frequent side effects associated with the use of this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 60. 1384. A nurse is caring for a client with glaucoma who is receiving acetazolamide (Diamox) daily. Which of the following would indicate to the nurse that the client is experiencing an adverse reaction related to the medication? 1. Diarrhea 2. Lacrimation 3. Low back pain and dysuria 4. Irritability Answer: 3 Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity can occur and are manifested by dark-colored urine and stools, pain in the lower back, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression may also occur. Test-Taking Strategy: Focus on the key words adverse reaction in the stem of the question. Remembering that acetazolamide is nephrotoxic and hepatotoxic will assist in directing you to the correct option. Review the adverse effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Eye Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 10. 1385. A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when: 1. Suctioning is required frequently 2. Excessive secretions are suctioned from the tracheostomy 3. The client’s skin and mucous membranes are light pink in color 4. Aspiration of gastric contents occurs Answer: 4 Rationale: Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 3 are not signs of this complication. Test-Taking Strategy: Use knowledge of anatomy and medical terminology to assist you in answering this question. A fistula is an artificial opening. The term “tracheoesophageal” indicates trachea to esophagus. This will direct you to option 4. Review the signs of
PN~Comp~Review-CD-1301-140043 tracheoesophageal fistula if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1779. 1386. A nurse is assigned to care for a client with a Sengstaken-Blakemore tube. The nurse would suspect that the client has which diagnosis? 1. Gastritis 2. Esophageal varices 3. Bowel obstruction 4. Small bowel tumor Answer: 2 Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. Test-Taking Strategy: Use the process of elimination. Recalling that this tube is used for the client with ruptured esophageal varices will direct you to option 2. Review the purpose and use of this tube if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1345. 1387. A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. Following deflation of the balloon, the nurse would monitor the client most closely for which of the following? 1. Swelling of the abdomen 2. Bloody diarrhea 3. Hematemesis 4. An elevated temperature and an increase in blood pressure Answer: 3 Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis and ruptured esophageal varices. It has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, noted by vomiting of blood (hematemesis). Test-Taking Strategy: Use the process of elimination. Recalling that the esophageal balloon exerts pressure on the ruptured esophageal varices to stop the bleeding will direct you to option
PN~Comp~Review-CD-1301-140044 3. Review care to the client with a Sengstaken-Blakemore tube if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1345. 1388. A nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the laboratory results of the client and notes that the calcium level is extremely low. The nurse would expect to note which of the following on data collection of the client? 1. Positive Trousseau’s sign 2. Negative Chvostek’s sign 3. Unresponsive pupils 4. Hyperactive bowel sounds Answer: 1 Rationale: Hypoparathyroidism is related to a lack of parathyroid hormone secretion or to a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit positive Chvostek’s and Trousseau’s signs, which indicate potential tetany. Options 2, 3, and 4 are not related to the presence of hypocalcemia. Test-Taking Strategy: Use the process of elimination. Recalling that a positive Chvostek’s and Trousseau’s sign would be noted in this disorder will direct you to option 1. Review the findings in hypoparathyroidism and hypocalcemia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 470. 1389. A nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which of the following specific signs of this complication would be included on the list? 1. Decreased urine output 2. Profuse sweating 3. Increased thirst 4. Shakiness Answer: 3 Rationale: The classic signs of hyperglycemia include polydipsia, polyuria, and polyphagia. Profuse sweating and shakiness would be noted in a hypoglycemic condition. Test-Taking Strategy: Use the process of elimination. Remembering the “three P’s”—polyuria, polydipsia, and polyphagia—will assist in directing you to the correct option. Review the signs of hyperglycemia if you had difficulty with this question. Level of Cognitive Ability: Application
PN~Comp~Review-CD-1301-140045 Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1292. 1390. A nurse is caring for a 14-year-old child who was hospitalized and placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child’s needs? 1. Allow the child to have their hair dyed if the parent agrees 2. Allow the child to play loud music in the hospital room 3. Let the child wear own clothing when friends visit 4. Allow the child to keep the shades closed and the room darkened at all times Answer: 3 Rationale: Adolescents need to identify with their peers and have a strong need to belong to a group. They like to dress like the group and wear similar hairstyles, which are different from their parents. Because Crutchfield traction uses skeletal pins, hair dye is not appropriate. The child should be allowed to wear their own clothes to feel a sense of belonging to the group. Loud music may disturb others in the hospital. The child’s request for a darkened room is indicative of a possible problem with depression that may need further evaluation and intervention. Test-Taking Strategy: Use the process of elimination and focus on the issues—Crutchfield traction and a 14-year-old-child. Knowledge regarding Crutchfield traction and its limitations as well as growth and development concepts in the adolescent will direct you to option 3. Review growth and development and care to the child in Crutchfield traction if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 894. 1391. A nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. The priority data would include which of the following? 1. The client’s fear related to the use of crutches 2. The client’s understanding of the need for increased mobility 3. The client’s vital signs, muscle strength, and previous activity level 4. The client’s feelings about the restricted mobility Answer: 3 Rationale: Vitals signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine if the client has enough strength for crutch walking and if muscle strengthening exercises are necessary. Knowledge of the previous activity level will provide information related to the tolerance of activity. Options 1, 2, and 4 are also important but physiological needs take precedence over psychosocial needs.
PN~Comp~Review-CD-1301-140046 Test-Taking Strategy: Note the key word priority in the stem of the question. Use Maslow’s Hierarchy of Needs theory to prioritize. Remember that physiological needs take precedence over psychosocial needs. This should easily direct you to option 3. Review nursing interventions related to teaching a client about crutch walking if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 948-949. 1392. A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, the client is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern that he/she will not be able to continue the tube feedings at home. Which of the following nursing responses would be appropriate at this time? 1. “Do you want to stay in the nursing home a few more days?” 2. “Have you discussed your feelings with your doctor?” 3. “Tell me more about your concerns with your diet after going home.” 4. “You need to talk to your doctor about these findings.” Answer: 3 Rationale: A client often has fears about leaving the secure, cared-for environment of the health care facility. This client has a fear about not being able to care for self at home, and not being able to handle the tube feedings at home. An open communication statement such as “tell me more about” often leads to valuable information about the client and the client’s concerns. Options 1, 2, and 4 are nontherapeutic statements. Test-Taking Strategy: Use therapeutic communication techniques. Focus on the client’s feelings. Options 2 and 4 place the client’s feelings on hold. Option 1 is a close-ended statement. Option 3 focuses on the client’s feelings. Remember to address the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1393. A client who sustained an inhalation injury from a fire arrives in the emergency department. On data collection of the client, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing: 1. Anxiety 2. Fear 3. Hypoxia 4. Pain Answer: 3
PN~Comp~Review-CD-1301-140047 Rationale: After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after an inhalation injury and may occur after an electrical injury. Test-Taking Strategy: Use the process of elimination and knowledge regarding this type of burn injury to assist in answering the question. Use the ABCs—airway, breathing, and circulation— to assist in directing you to option 3. If you had difficulty with this question, review assessment of the client with a burn injury. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 516. 1394. A client is brought to the emergency department immediately following a smoke inhalation injury. The initial nursing action would be to prepare the client to receive: 1. Pain medication 2. Oxygen via nasal cannula 3. 100% humidified oxygen by face mask 4. Endotracheal intubation Answer: 3 Rationale: If the client sustains a smoke inhalation injury, the client is immediately treated with 100% humidified oxygen delivered by face mask. Endotracheal intubation is needed if the client exhibits respiratory stridor, which indicates airway obstruction. Test-Taking Strategy: Note the key word initial in the stem of the question. There are no data in the question that indicate the client would require endotracheal intubation. Use the ABCs— airway, breathing, and circulation—to assist in directing you to option 3. Review care to the client who sustained a burn injury if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 516. 1395. An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. On data collection of the client, which of the following would indicate that the client sustained a respiratory injury as a result of the burn? 1. Clear breath sounds 2. Use of accessory muscles for breathing 3. Fear and anxiety 4. Complaints of pain Answer: 2 Rationale: Clinical indicators in a burn client that would indicate respiratory injury include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs.
PN~Comp~Review-CD-1301-140048 Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing. Although anxiety may be a sign of hypoxemia, anxiety along with bradycardia, dysrhythmias, and lethargy would most likely indicate a concern related to a respiratory injury. Abnormal breath sounds and abnormal arterial blood gas values would also be noted. Test-Taking Strategy: Use the process of elimination. Note the issue—a respiratory injury. Focusing on the finding related to a respiratory problem will direct you to option 2. If you had difficulty with this question, review the findings in the client with a burn injury that may indicate a respiratory condition. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 521. 1396. A nurse is preparing a plan of care for a client in skeletal leg traction with an overbed frame. Which of the following nursing interventions would be included in the plan of care to best assist the client with positioning in bed? 1. Encourage the client to pull self up by pushing with the unaffected leg on the bed mattress 2. Use the assistance of four nurses to reposition the client 3. Place a draw sheet under the client for pulling the client up in bed 4. Place a trapeze on the bed to provide a means for the client to lift the hips off the bed Answer: 4 Rationale: The nurse can best assist the client in skeletal traction with repositioning by providing a trapeze on the bed for the client’s use. Encouraging the client to pull self up by pushing with the unaffected leg on the bed mattress may cause skin breakdown on the unaffected heel area. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote the means of repositioning by the client. Test-Taking Strategy: Focus on the key words to best assist the client with positioning. Eliminate options 2 and 3 first because they are similar. Next eliminate option 1 because this action may cause an alteration in skin integrity. If you had difficulty with this question, review care to the client in skeletal traction. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1480. 1397. A nurse is caring for a client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client’s alignment in bed and notes that proper alignment is maintained. Which of the following actions should the nurse take next? 1. Medicate the client 2. Provide pin care 3. Notify the registered nurse
PN~Comp~Review-CD-1301-140049 4. Remove 2 pounds of weight from the traction Answer: 3 Rationale: A client who complains of severe pain may need realignment or may have traction weights ordered that are too heavy. The nurse realigns the client and if ineffective, notifies the registered nurse who will then contact the physician. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction without a specific order to do so. Providing pin care is unrelated to the problem as described. Test-Taking Strategy: Note the key words severe left leg pain in the question. This should indicate to you that a problem exists. Recalling the causes of severe pain in a client in skeletal traction and noting that the question addresses that the nurse has already assured that the client is in proper alignment should assist in directing you to option 3. If you had difficulty with this question, review the complications associated with skeletal traction. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1480. 1398. A nurse is caring for a client who has a cast applied to the left lower leg. On data collection of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which of the following nursing interventions is appropriate? 1. Massage the skin at the edges of the cast 2. Contact the physician 3. Place a small face cloth in the cast around the edges of the cast 4. Petal the cast edges with adhesive tape Answer: 4 Rationale: If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. Massaging the skin will not eliminate the problem. Placing a small face cloth in the cast around the edges of the cast is not appropriate. It is not necessary to contact the physician. Test-Taking Strategy: Focus on the issue of the question and use the process of elimination. Eliminate option 3 first because this action is inappropriate. Next eliminate option 2 because this action is unnecessary. Option 1 will not alleviate the problem, which leaves option 4 as the correct option. If you had difficulty with this question, review care to the client with an extremity cast. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1481. 1399. A nurse is reinforcing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents
PN~Comp~Review-CD-1301-140050 understand these measures if the parents state which of the following? 1. “We will be sure to give our child a Fleet enema every day to prevent constipation.” 2. “We will make sure that our child participates in physical activity every day.” 3. “We will provide comfort measures to reduce any crying periods by our child.” 4. “We will encourage our child to cough every few hours on a daily basis.” Answer: 3 Rationale: A warm bath, avoidance of upright positioning, and comfort measures to reduce crying are all simple measures to reduce a hernia. Coughing and crying increase the strain on the hernia. Likewise, enemas of any type would increase the strain on the hernia. Test-Taking Strategy: Use the process of elimination and focus on the issue. The issue of the question is an appropriate action that will reduce a hernia. Options 1, 2, and 4 all increase pressure and strain on the hernia site. Review nursing measures for a hernia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 478. 1400. A nurse is assisting in developing a plan of care for a newborn infant with spina bifida (meningomyelocele type). The nurse includes data collection measures in the plan to monitor for increased intracranial pressure (ICP). Which of the following will best detect the presence of an increase in ICP? 1. Monitoring blood pressure for signs of hypotension 2. Monitoring for signs of dehydration 3. Monitoring urine for specific gravity 4. Monitoring the anterior fontanelle for bulging Answer: 4 Rationale: A bulging or taut anterior fontanelle would indicate the presence of increased ICP. Blood pressure is difficult to assess during the newborn period and is not the best indicator of increased ICP. Urine concentration is also not well developed in the newborn stage of development. Monitoring for signs of dehydration will not provide data related to increased ICP. Test-Taking Strategy: Focus on the issue of the question—monitoring for increased ICP. Use the process of elimination and knowledge regarding the findings in the newborn infant that would indicate the presence of increased ICP. Review these data collection techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 432.
PN~Comp~Review-CD-1301-14002 Review care to the child with Down syndrome if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 338. Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 990.
PN~Comp~Review-CD-1301-14003 Answer: 4 Rationale: Opisthotonos is a prolonged arching of the back with the head and heels bent backward. Opisthotonos indicates meningeal irritation. In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex. In decerebrate rigidity, the upper extremities are stiffly extended and adducted with internal rotation and pronation of the palms. The lower extremities are stiffly extended with plantar flexion. The teeth are clenched, and the back is hyperextended. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brainstem. Test-Taking Strategy: Note the position of the client and the arching of the back. Recalling that prolonged arching of the back occurs in opisthotonos will direct you to option 4. Also, noting the client’s diagnosis and recalling that this posture occurs in meningeal irritation will assist in answering the question. Review abnormal postures if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Mosby’s medical, nursing, & allied health dictionary (6th ed.). (2002). St. Louis: Mosby, p. 1225. 1305. A mother tells the pediatrician’s office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work. The nurse would explore with the mother which suggestion to decrease the children’s sense of isolation and fear? 1. Instruct the children never to cook 2. Let the children play in neighborhood homes 3. Have the children call the mother at work every hour 4. Find community after-school programs or activities Answer: 4 Rationale: In most communities, there are free or low-cost after-school programs or activities that would minimize the amount of time that school-age children are at home alone. These programs should include adult supervision, which is needed by school-aged children. Test-Taking Strategy: Use the process of elimination. The key words are sense of isolation and fear. With this in mind, evaluate each of the options from that perspective. Eliminate option 1 first because of the absolute word “never.” Eliminate option 3 next because it could be disruptive in the workplace; the mother should call the children instead. Choose option 4 over option 2 because it provides both structure and supervision, and does not contribute to possible tension with neighbors. Review safety measures in the home for children if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 272.
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1306. A nurse has reinforced teaching that was done with a school-aged child who was given a brace to wear for the treatment of scoliosis. The nurse interprets that the client has not fully understood the information presented if the child makes which statement? 1. “I will wear my brace under my clothes.” 2. “I will do back exercises at least 5 times a week.” 3. “I will wear my brace whenever I am not sleeping.” 4. “This brace will correct my curve.” Answer: 4 Rationale: Bracing can halt the progression of most curvatures, although it is not curative for scoliosis. The statements in options 1, 2, and 3 represent correct understanding on the part of the child. Test-Taking Strategy: Use the process of elimination and note the key words has not fully understood to answer the question. These words indicate a false response question and that you need to select the incorrect statement by the child. Noting the word “correct” in option 4 will direct you to this option. Review the key aspects of bracing for scoliosis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 330-332. 1307. An adolescent client with juvenile diabetes mellitus has a foot infection and is prescribed antibiotic therapy with an aminoglycoside. Before administration of the medication, the nurse collects data from the client and notes that the client has a hearing loss. The nurse should take which of the following actions next? 1. Suggest a peak and trough to ensure safe medication administration 2. Have the client drink extra water to avoid toxic side effects 3. Inform the registered nurse (RN) about the hearing loss 4. Give the medication but at half the ordered dose Answer: 3 Rationale: A preexisting hearing loss is a contraindication for the administration of aminoglycosides, because these medications can also cause ototoxicity and irreversible hearing loss. The nurse would report the findings to the RN to protect the client’s safety. The RN will in turn notify the physician. Options 1 and 2 are not beneficial because hearing loss has already occurred in this client. Nurses do not change medication orders independently. Test-Taking Strategy: Use the process of elimination. Knowing that the key side effects of aminoglycoside antibiotics are ototoxicity and nephrotoxicity help you limit your choices to options 3 and 4. Select option 3 because nurses do not change medication orders independently. Review the toxic effects of these types of antibiotics if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology
PN~Comp~Review-CD-1301-14005 Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 921. 1308. A nurse caring for an adolescent client recently diagnosed with bone cancer is monitoring the client for depression. To best recognize these symptoms in the adolescent, the nurse should recall that adolescents: 1. Are moody and often act-out 2. Like to stay up late but rarely have insomnia 3. Spend a great deal of time in self-reflection, so it is normal to withdraw 4. Like the unkempt look and are not concerned about their appearance Answer: 2 Rationale: The signs of depression include crying spells, insomnia, eating disorders, social isolation and withdrawal, serious acting-out behavior, feelings of hopelessness, unexplained physical symptoms, loss of interest in appearance, and giving away possessions. Option 2 is the only option that represents normal adolescent behavior. Test-Taking Strategy: Use knowledge of normal adolescent behavior and knowledge of the signs of depression to make your selection. Eliminate option 1 because of the word “often.” Eliminate option 4 next because of the absolute word “not.” Choose option 2 over option 3 because this option represents normal adolescent behavior. Review the signs of depression in the adolescent if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 347. 1309. An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse would plan to do which of the following as a first step in the prevention of future injury? 1. Have the client watch a video on the tragedies of improper firearm usage 2. Refer the client to a firearm safety class sponsored by the hospital 3. Explore the client’s knowledge of gun safety 4. Have the police take the client’s gun away Answer: 3 Rationale: One of the leading causes of accidental deaths in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data about a firearm safety history, which is done in option 3. Option 2 may then be indicated. Option 1 may or may not be effective at some point for this client. Option 4 is unreasonable. Test-Taking Strategy: Use the steps of the nursing process. Remember that the first step of the nursing process is data collection. Choose the option that collects data about the client’s knowledge base, which in this case is option 3. Review firearm safety in the adolescent if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance
PN~Comp~Review-CD-1301-14006 Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, pp. 623, 736, 828.
PN~Comp~Review-CD-1301-14007 purpose of the glycosylated hemoglobin test will direct you to option 3. If you had difficulty with this question, review this test for monitoring diabetic control. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 728-729. 1312. An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3 AM. The nurse should first determine which of the following about the client? 1. His insurance status 2. Whether he ate his evening meal 3. Blood toxicology levels 4. Whether this is a change in his usual level of orientation Answer: 4 Rationale: The nurse should first determine whether this is a change in the client’s neurological status. The next item to determine would include when the client last ate. Blood toxicology levels may or may not be needed, but the physician would order these. Insurance information must be obtained at some point, but is not the priority from a clinical care viewpoint. Test-Taking Strategy: Use the process of elimination and knowledge about neurological data collection to answer this question. Note that the stem of the question contains the key word first. This tells you that more than one or all of the options are partially or totally correct. Focusing on the data in the question will direct you to option 4—neurological status. Review data collection related to neurological status if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 372. Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 142. 1313. An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client’s daughter. The daughter states that the client was “clear as a bell this morning.” The nurse determines from this piece of information that which of the following is unlikely to be the cause of the client’s disorientation? 1. Medication dosage error 2. Hypoglycemia 3. Alzheimer’s disease 4. Impaired circulation to the brain Answer: 3 Rationale: Alzheimer’s disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Medication use, hypoglycemia, and impaired cerebral circulation all require evaluation to determine if they play a
PN~Comp~Review-CD-1301-14008 role in causing the client’s current symptoms. Test-Taking Strategy: Use the process of elimination and note the key words clear as a bell this morning and unlikely. Eliminate options 1, 2, and 4 because they can all trigger an acute confusional state. Review the causes of disorientation and the characteristics of Alzheimer’s disease if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 140. 1314. An 80-year-old resident in a long-term care facility prepares to walk out into a rainstorm after saying, “My father is waiting to take me for a ride.” Which of the following would be an appropriate response by the nurse? 1. “I’m glad you told me that. Let’s have a cup of coffee and you can tell me about your father.” 2. “I need to place you in restraints.” 3. “How old are you? Your father must no longer be living.” 4. “I need you to sign a form before leaving.” Answer: 1 Rationale: The correct response acknowledges the client’s comment and feelings. Option 3 does not preserve the client’s dignity. Option 2 is inappropriate and is inconsistent with legal aspects of care based on the information given. Option 4 fails to protect the client from possible harm. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they do not protect the client and/or the client’s rights. Choose option 1 over option 3 because it addresses the client’s comment and feelings. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Communication and Documentation Content Area: Adult Health/Neurological Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1315. A nurse observes an outburst by a client with a history of schizophrenia, during which the client used extreme foul language. The nurse appropriately documents this occurrence by: 1. Documenting that the client is swearing loudly 2. Documenting that the client is having an outburst 3. Using quotation marks, placing dashes and lines in place of the profane words used by the client 4. Using quotation marks, exact words, and additional objective information about affect and nonverbal behavior Answer: 4 Rationale: Option 4 provides accurate, legally defensible information regarding the client’s behavior. Options 1 and 2 are not objective. Option 3 is incomplete documentation and is not legally defensible. Test-Taking Strategy: Use knowledge of basic principles of documentation to answer the
PN~Comp~Review-CD-1301-14009 question. Noting the key word objective in option 4 will direct you to this option. Review the principles of documentation if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 83. 1316. A nurse is told in the intershift report that a client has been appointed a legal guardian. The nurse looks for evidence of which of the following that supports that this in fact has occurred? 1. A physician’s order 2. A judicial decision in a court of law 3. Testimony of three neighbors 4. A licensed nurse’s observation of bizarre behavior Answer: 2 Rationale: Appointment of a guardian must be done through due legal process. It cannot be done by a physician’s order. Options 3 and 4 could support the decision that a legal guardian is necessary if the client is incompetent to make his or her own decisions, but they are not sufficient by themselves. Test-Taking Strategy: Use the process of elimination and focus on the issue—appointment of a legal guardian. Note the relationship between the words “legal” in the question and the word “law” in the correct option. Review information related to legal guardians if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 997. 1317. A female, older long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse would make which appropriate response to the client? 1. “Here I’ll taste the food for you.” 2. “It must be frightening to you. Has something made you feel that your food is poisoned?” 3. “Why do you think this way?” 4. “Your food is not poisoned. Our kitchen staff are nice people, and they are not allowed to poison people.” Answer: 2 Rationale: Option 2 validates the client’s feelings. Option 1 involves the nurse in the client’s delusion. Option 3 may place the client on the defensive and is not a facilitative technique. Option 4 is incorrect because the statement is defensive and therefore nontherapeutic. Test-Taking Strategy: Use therapeutic communication techniques. Remember, always focus on the client’s feelings first. This will direct you to option 2. Review these techniques if you had
PN~Comp~Review-CD-1301-140010 difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health References: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1318. A nurse is developing a nutritional plan for an assigned client. Which of the following is the most critical piece of data to collect before formulating the plan? 1. A dietary dairy 2. The presence of food allergies 3. Food preferences 4. Lack of a facilitative eating environment Answer: 2 Rationale: The presence of food allergies is critical to know before developing a nutritional plan. The items listed in the other options also provide good information, but are not as crucial as the presence of food allergies. Test-Taking Strategy: Use the process of elimination and note the key words most critical. This tells you that all of the options may be partially or totally correct, but that one of them is more important than the others. Use prioritizing skills, recalling the importance of allergies. Review the components of developing a nutritional plan if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1289. 1319. A nurse is assigned to care for a client who was agitated. Upon entering the room, the client screams, “Why don’t you just leave me alone?” The nurse makes which therapeutic response to the client? 1. “I can see that you are upset. I’ll be back in a few minutes to see how you are doing.” 2. “I am calling your doctor!” 3. “Why do you feel this way?” 4. “Don’t yell at me.” Answer: 1 Rationale: Option 1, the correct option, gives the client space and personal control. Option 2 is belittling, does not include the client, and does not provide a clear sense of direction. Option 3 may place the client on the defensive and is not a facilitative technique. Option 4 is confrontational, nonfacilitative, and imposes control by the nurse. Test-Taking Strategy: Use therapeutic communication techniques and note that the client is agitated. Remember, always focus on the client’s feelings first. This will direct you to option 1. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Application
PN~Comp~Review-CD-1301-140011 Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1320. A nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which of the following is inaccurate regarding depression and the older client? 1. Depression in an older person is rarely treatable 2. Depression in an older person is likely to have physical manifestations 3. Some indications of dementia may actually originate as depression 4. Suicide is a frequent cause of death among the older population Answer: 1 Rationale: Depression is treatable in an older client. The statements in options 2, 3, and 4 are accurate. Test-Taking Strategy: Use the process of elimination and note the key word inaccurate. The word “rarely” in option 1 provides a clue that this is the correct option. Review essential concepts of depression in the older client if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 152. 1321. A 74-year-old female resident with Alzheimer’s disease became very agitated when a group of children came to sing and dance at a long-term care facility, and the resident tried to take one of the children to her room. The nurse would use which of the following pieces of information when approaching the client about this behavior? 1. This resident probably had an unfortunate experience while singing and dancing during youth 2. This resident is a very dangerous individual 3. Individuals with Alzheimer’s disease are very likely to be potential child molesters 4. Individuals with Alzheimer’s disease have difficulty tolerating excess stimulation and changes in routine Answer: 4 Rationale: Clients with Alzheimer’s disease are likely to be intolerant of excess stimulation and changes in routine. There is not enough information in the question to verify the statements in options 1 and 2. Option 3 is an inaccurate statement. Test-Taking Strategy: Use the process of elimination. Focusing on the client’s diagnosis— Alzheimer’s disease—will direct you to option 4. Review the concepts related to this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 48, 140.
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1322. An older client is at risk for falls. When developing an individualized plan of care for this client, the nurse recalls that which concept is incorrect regarding maintenance of balance for the older client? 1. Older clients cannot think quickly enough to respond to emergencies 2. Many medications may have orthostatic hypotension as a side effect 3. Older clients tend to maintain a broad base of support, and thus change direction more slowly 4. Older clients often have slower neurological responses to stimuli Answer: 1 Rationale: It is not true that older clients cannot think quickly enough to respond to emergencies. That statement is a stereotypical generalization. The statements contained in the other options are true. Test-Taking Strategy: Use the process of elimination. Noting the key word incorrect will direct you to option 1. Review the physiological changes that occur in the older client if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 47, 123. 1323. In planning care for older clients in a long-term care facility, the nurse recalls that which of the following is accurate regarding sexuality and the older client? 1. Aberrant sexual behavior is to be expected among older males 2. Physical beauty is necessary for continued sexual activity in older persons 3. Although responses may be slower, sexual ability is present in later years of life 4. Most people do not engage in sexual activity after the age of 70 Answer: 3 Rationale: Option 3 represents a true statement about sexuality in the older client. Options 1, 2, and 4 indicate stereotypes with no foundation in fact. Test-Taking Strategy: Use the process of elimination and note the key word accurate. Eliminate option 1 because of the word “aberrant.” Eliminate options 2 and 4 because of the absolute words “necessary” and “not,” respectively. Review the concepts regarding sexuality and the older client if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 200. 1324. A nurse observes that a 68-year-old woman with Parkinson’s disease has very little facial expression. The nurse attributes this piece of data to which of the following? 1. Masklike faces are a component of Parkinson’s disease 2. Clients with Parkinson’s disease have diminished emotional involvement 3. Clients with Parkinson’s disease act very much like schizophrenics, in that they have very little affect
PN~Comp~Review-CD-1301-140013 4. The client does not want her emotional reaction to the disease to show Answer: 1 Rationale: A masked facial expression is typical of the client with Parkinson’s disease. Option 2 is not a true statement. Option 3 places a false interpretation on the client’s expression. There are no data to support the assumption provided in option 4. Test-Taking Strategy: Knowledge of the physical signs and symptoms associated with Parkinson’s disease is needed to answer this question. Remember, a masked facial expression is typical of the client with Parkinson’s disease. Review these signs and symptoms if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 48. 1325. A nurse is working with an older client and the client’s family about discharge following hospitalization. When initiating discussions with the group, the nurse understands that most older persons would prefer to live: 1. Independently, but close to their children 2. In long-term care facilities 3. With their children 4. Alone Answer: 1 Rationale: Most older people prefer to maintain their independence, while having the resource of children or family nearby to help in times of need. In general terms, the other options are not as favorably received by the older person, but this would also depend on the specific client and the specific situation. Test-Taking Strategy: Use knowledge of developmental stages of the older adult to answer the question. Remember, most older people prefer to maintain their independence. Review this content if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 11-12. 1326. An older client is taking multiple medications for a variety of health problems. The nurse would monitor the results of which most important laboratory test when evaluating adverse effects of medication therapy in the older adult? 1. Complete blood count 2. Arterial blood gases 3. Hemoglobin and hematocrit levels 4. Creatinine level Answer: 4 Rationale: Creatinine level should be most closely monitored because it relates to kidney function. Because many medications are excreted by the kidneys, that makes this the laboratory
PN~Comp~Review-CD-1301-140014 test of choice for ongoing monitoring. Option 3 is part of option 1, while arterial blood gases are not generally measured unless there is a specific problem with oxygenation. Test-Taking Strategy: Note that the issue relates to an older client and the organ at most risk when the client takes multiple medications. Because most medications are metabolized by the liver and excreted by the kidneys, you would look for a laboratory test that reflects either liver or kidney function. In this question, the correct option is an item related to the kidneys. Review the effects of medications on the body systems if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 208, 288. 1327. A nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad, because “his feet are always cold at night.” The nurse would incorporate which of the following concepts when formulating a response to the family member? 1. The resident has a right to procure and keep his own property 2. Heating pads are dangerous and are likely to cause fires 3. Older adults often have slower neurological response times and are therefore more at risk for burns 4. The long-term care facility strictly prohibits the use of heating pads Answer: 3 Rationale: Age-related changes in the older adult make the client more at risk for burns as a result of slower neurological response times. Option 1 ignores the client’s safety. Option 2 represents a general statement, but does not pertain to the individual safety of this client. Option 4 represents a bureaucratic response, and does not consider client needs. Test-Taking Strategy: The issue of the question is knowledge of the risks associated with the use of heating pads in the older client. Begin to answer the question by eliminating option 1, which ignores the safety of the client. Eliminate options 2 and 4 because they are general statements, and do not focus on the needs and risks of the individual client. Review age-related changes in the older adult if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 123-124. 1328. A nurse notes that an older client in a long-term care facility is receiving a daily dose of furosemide (Lasix). The nurse writes in the care plan to monitor which of the following parameters on a daily basis? 1. Weight 2. Radial pulse 3. Hemoglobin level 4. Serum creatinine level Answer: 1
PN~Comp~Review-CD-1301-140015 Rationale: Daily weight should be monitored because this reflects the fluid status of the client who is receiving a diuretic. Option 2 is a general assessment and does not directly relate to fluid balance. Options 3 and 4 are laboratory measurements that are not routinely ordered by the nurse, and would not be done on a daily basis in a long-term care facility. Test-Taking Strategy: Use the process of elimination, recalling that furosemide is a diuretic. Evaluate each of the options according to their ability to measure fluid status. Eliminate options 3 and 4 first, which are not ordered by the nurse. From the remaining options, select option 1 because it more directly correlates with fluid volume. Review the nursing interventions for the client on furosemide if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 480. 1329. A nurse has given a 77-year-old female client instructions on how to do active range-ofmotion (ROM) exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which of the following statements? 1. “If I don’t do this, that therapist gets really angry at me.” 2. “I’m doing this so I can go home soon.” 3. “It hurts, but things always have to hurt at my age.” 4. “I’m doing these exercises so I can begin to fasten my buttons and dress myself again.” Answer: 4 Rationale: Option 4 indicates that the client understands the purpose of the therapy and provides an incentive for the client to comply with the exercises. Option 1 is incorrect because it indicates imposition of staff values on the client, and is suggestive of possible abuse. Option 2 may or may not be true, and could relate to a number of factors other than use of the right hand. Option 3 is an inaccurate statement. Test-Taking Strategy: Use the process of elimination. Focusing on the issue of the question— the rationale for this procedure—will direct you to option 4. Review the purpose of active ROM exercises if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 258-260. 1330. A client with chronic atrial fibrillation is prescribed quinidine sulfate (Quinidex Extentabs) as maintenance therapy for dysrhythmia suppression. A nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instructions? 1. “I will stop taking the prescribed anticoagulant after starting this new medication.” 2. “I will take the medication with food if my stomach becomes upset.” 3. “I will avoid chewing the sustained-release tablets.”
PN~Comp~Review-CD-1301-140016 4. “I will take the dose at the same time each day.” Answer: 1 Rationale: Medication-specific teaching points for quinidine sulfate include the following: take the medication exactly as prescribed; do not chew the sustained-release tablets; take the medication with food if stomach upset occurs; wear a Medic-Alert bracelet or tag; and have periodic checks of heart rhythm and blood counts. The client should not stop taking a prescribed medication unless specifically ordered by the physician. Test-Taking Strategy: Note the key words need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Options 3 and 4 are general instructions for medication use and are therefore eliminated first. From the remaining options, remember that it is not usual practice to “stop taking” a “prescribed” medication. Review client teaching points related to this medication, if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Cardiovascular Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 918-919. 1331. A nurse has gathered data about each of the following items from an older client. The nurse understands that which of the following would not be a reliable indicator of fluid imbalance for a client in this age group? 1. Thirst 2. Appearance of oral mucosa 3. Skin turgor 4. Intake-output differences Answer: 1 Rationale: Thirst in the older adult is subjective, and is not always consistent with fluid balance. The appearance of oral mucosa, skin turgor, and the differences between intake and output are more reliable measures of fluid balance in the older adult. Test-Taking Strategy: Note the key words not be a reliable indicator and focus on the issue— fluid balance. Note that options 2, 3, and 4 are similar in that they are objective measures of fluid balance. Option 1 is subjective. Also, recall that the sensation of thirst declines with age. Review the interventions that will determine fluid balance in the older adult if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 213-214. 1332. A nurse is caring for a client with schizophrenia who states, “I decided not to take my medication because I realize that it really can’t help me. Only I can help me.” Which of the following nursing responses would be therapeutic? 1. “Only you can help?”
PN~Comp~Review-CD-1301-140017 2. “You decided not to take your medication?” 3. “Your doctor wants you to continue with this medication because it is helping you. Do you recall needing to be hospitalized because you stopped your medication?” 4. “If you can make this wise observation, you probably don’t need your medication any longer.” Answer: 3 Rationale: Noncompliance with antipsychotic medication is one of the chief reasons that clients with schizophrenia have relapses. The nurse teaches the schizophrenic client to identify the causes of relapse. In option 1, the nurse is employing restating, which, while therapeutic, is not useful to this client and to this client’s situation. In option 2, the nurse is again using restating. In option 4, the nurse is using an illogical, judgmental, and biased response, which is not therapeutic. Test-Taking Strategy: Use the process of elimination. Focus on the client’s diagnosis and use therapeutic communication techniques to direct you option 3. Review care to the client with schizophrenia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 1333. A nurse is told by a 72-year-old woman that she has begun to be incontinent of urine at night and now drinks no fluids after 6 PM. The nurse’s response would be guided by the knowledge that: 1. The client is the best judge of how much fluid she should drink or not drink 2. Incontinence is to be expected in old age 3. Older people do not need as much fluid intake as younger people 4. Incontinence at any age deserves urological attention Answer: 4 Rationale: Urinary incontinence requires evaluation as to the cause, so that appropriate treatment can be begun. Option 1 may generally be true, but may not apply since the development of this new problem. Options 2 and 3 are incorrect assumptions and represent stereotypical thinking. Test-Taking Strategy: Begin to answer this question by eliminating options 2 and 3, which are biased or stereotypical statements. To choose correctly between the remaining options, select option 4 because it relates to the issue of the question—the new onset of incontinence. Review expected and unexpected age-related changes if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 249. 1334. A nurse is communicating with an 80-year-old client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should: 1. Lower the voice pitch and face the client when speaking 2. Use sign language 3. Speak very loudly
PN~Comp~Review-CD-1301-140018 4. Put the mouth close to one ear when speaking Answer: 1 Rationale: The nurse should lower the pitch of the voice and face the client while speaking. Lower tones are heard better with hearing loss, and facing the client allows the client to pick up visual cues from the nurse’s face. Option 2 requires that both the client and the nurse understand sign language. Option 3 can be interpreted as hostility, while option 4 invades the client’s personal space. Test-Taking Strategy: Use the process of elimination and basic understanding of communication principles to answer the question. Remember, the nurse should lower the pitch of the voice and face the client while speaking. If this question was difficult, review care of the client with hearing loss. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Ear Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 147. 1335. A nurse is caring for an older client with a diagnosis of osteoarthritis. Which of the following would be least helpful for the client? 1. Gentle regular exercise 2. Increasingly vigorous and high-impact exercise 3. A warm bath or shower early in the day 4. An individualized program of pain medication administration Answer: 2 Rationale: Vigorous or high-impact exercise could be damaging to articulating surfaces within joints, and should be avoided by clients with osteoarthritis. The other options may be helpful in promoting joint mobility. Test-Taking Strategy: Use the process of elimination and note the key words least helpful. Evaluate each of the options in relation to their helpfulness to the client with impaired joint mobility. Review care to the client with osteoarthritis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 32. 1336. The nurse overhears the term “sundowning” used to describe the behavior of a client newly admitted to the nursing unit during the previous evening shift. The nurse interprets that this client most likely has a diagnosis of: 1. Acquired immunodeficiency syndrome 2. Alzheimer’s disease 3. Parkinson’s disease 4. Schizophrenia Answer: 2 Rationale: The term “sundowning” or “sundown syndrome” refers to a pattern of disorientation whereby the client is more oriented during the daytime hours and more disoriented at night. It is
PN~Comp~Review-CD-1301-140019 often seen in clients with Alzheimer’s disease. Test-Taking Strategy: To answer this question correctly, you must be familiar with this particular term and its use in the clinical context. Remember that “sundowning” refers to a pattern of disorientation whereby the client is more disoriented at night. If you had difficulty with this question, review the concepts related to chronic confusion and Alzheimer’s disease. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 139-140. 1337. A resident in a long-term care facility refuses a medication that has been ordered. The nurse takes appropriate action after considering which of the following? 1. The client cannot be forced to take the medication unless a legal guardianship is obtained and the guardian authorizes it 2. The client will probably take the medication if the physician personally administers each dose 3. The client can be forced to take the medication if the physician ordered it 4. The client has now become legally incompetent Answer: 1 Rationale: Option 1 is a true statement. The client has the right to refuse any medication ordered unless deemed incompetent in a court of law. Option 2 is an opinion not supported by fact. Options 3 and 4 are false statements. Test-Taking Strategy: Use the process of elimination. The issue of the client is the client’s right to participate or refuse an element of care, in this case medication therapy. Evaluate each of the options in terms of the clients’ rights. Review clients’ rights if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 20. 1338. A nurse notices a “paranoid stare” during a conversation with a client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which of the following actions by the nurse would be most beneficial? 1. Escort the client to a quiet room 2. Change the conversation to a less threatening subject 3. Allow the client to pace 4. Share the observation with the client and help the client to recognize feelings Answer: 4 Rationale: Sharing observations with the client may help them to recognize and acknowledge their feelings. Moving to a quiet room or changing the subject will not help the client to recognize their behaviors and feelings. Allowing the client to pace provides no assistance and may lead to the client becoming “out of control.” Test-Taking Strategy: Use the process of elimination. Eliminate option 3 because it provides no
PN~Comp~Review-CD-1301-140020 assistance, option 1 because it is punitive, and option 2 because it does not allow the client to deal with current issues. Remember to focus on the client’s feelings. Review care to the paranoid client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health References: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 187. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 413. 1339. A nurse working in a mental health unit hears that a client has been experiencing “flashbacks.” The nurse interprets that this client is exhibiting a sign of: 1. Anxiety 2. Schizophrenia 3. Agoraphobia 4. Posttraumatic stress disorder (PTSD) Answer: 4 Rationale: “Flashbacks” are the classic manifestation of PTSD. The other options are incorrect interpretations. Test-Taking Strategy: Use the process of elimination and note the key word flashbacks. Review of each option and recalling the manifestations that occur in each disorder will direct you to option 4. Review the manifestations that occur in each of these disorders if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 187. 1340. A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse plans to do which of the following initially with this client? 1. Explain the unit rules 2. Accept the client as a person and make them feel safe 3. Stabilize the client’s psychiatric needs 4. Orient the client to the unit Answer: 2 Rationale: The initial action is to make a confused and disoriented client feel safe. Orientation and explaining the unit rules are part of any admission process and do not meet the individual needs of this client. Stabilizing psychiatric needs is a long-term goal. Test-Taking Strategy: Focus on the issue—a confused and disoriented client. Use Maslow’s Hierarchy of Needs theory to direct you to option 2. Review care to the confused and disoriented client if you had difficulty with this question. Level of Cognitive Ability: Application
PN~Comp~Review-CD-1301-140021 Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 273. 1341. During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which of the following responses by the nurse would be therapeutic? 1. “I can see that you are upset about this. Let’s talk about this some more.” 2. “Why are you having so much trouble with maintaining realistic behavior?” 3. “Don’t worry so much.” 4. “Everything is going to be all right.” Answer: 1 Rationale: The correct response acknowledges the client’s feelings. The remaining options do not use therapeutic communication skills. Options 3 and 4 are clichés that do not acknowledge the client’s feelings. Option 2 is nontherapeutic and requires an explanation from the client. Test-Taking Strategy: Use therapeutic communication techniques to answer this question. Remembering to focus on the client’s feelings will direct you to option 1. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 1342. A nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. The nurse avoids including which of the following items on a list of suggestions to be given to the client? 1. Cut down on the amount of fats consumed in the diet 2. Use a heating pad on the legs to aid vasodilation 3. Walk each day to increase circulation to the legs 4. Be careful not to injure the legs or feet Answer: 2 Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further. Test-Taking Strategy: Focus on the client’s diagnosis and the key words limit disease progression and avoids. Recalling that the client is at risk for altered tissue integrity will direct you to option 2. Review client teaching points related to peripheral arterial disease if you had difficulty with this question. Level of Cognitive Ability: Application
PN~Comp~Review-CD-1301-140022 Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Cardiovascular Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 775. 1343. A client with depression reports to the nurse that she has not been sleeping or eating adequately. The nurse should plan to do which of the following to assist the client in meeting nutritional needs? 1. Provide meals as requested 2. Give the client a large fruit basket for snacking 3. Force foods to maintain minimum intake levels 4. Provide small, frequent meals Answer: 4 Rationale: A depressed client may eat small amounts of food rather than large amounts that may be overwhelming to them. If this client becomes overwhelmed, she may respond by withdrawing further. Option 1 may not be effective if the client is not motivated to eat. Option 2 is ineffective for the same reason. Option 3 violates client rights. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question— the best method of increasing intake with a depressed client. Recalling that depressed clients do not often feel like eating will assist in eliminating options 1 and 2. Choose correctly between the remaining options using either knowledge of nutrition or legal aspects of care. Review care to the client with depression if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health References: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, pp. 358-359. Varcarolis, E. (2002). Foundations of psychiatric mental health nursing (4th ed.). Philadelphia: W.B. Saunders, p. 468. 1344. A client who excessively uses alcohol and who is motivated to stop tells the nurse, “I know that there is a medication that can help people like me to quit drinking.” The nurse understands that this medication is: 1. Disulfiram (Antabuse) 2. Pyridoxine 3. Chlordiazepoxide (Librium) 4. Clonidine (Catapres) Answer: 1 Rationale: Disulfiram is a medication used for alcoholism and aids in the maintenance of sobriety. An adverse reaction occurs if the client drinks while taking this medication. The client should be motivated to stop drinking before being given this medication. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Specific knowledge regarding the medication used to maintain sobriety is needed to answer this question correctly. Remember, disulfiram is a medication used for
PN~Comp~Review-CD-1301-140023 alcoholism and aids in the maintenance of sobriety. If this question was difficult, review the actions and uses of disulfiram. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 300. 1345. A male phobic client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that “he cannot sing.” Which of the following responses by the nurse would be most therapeutic? 1. “Life is short! Enjoy it while you can.” 2. “You must go. You have no choice.” 3. “Perhaps you could just enjoy the music without singing.” 4. “Why don’t you really want to attend?” Answer: 3 Rationale: The correct response encourages the client to socialize and deflects the client’s attention away from the issue of singing. Option 1 uses a cliché, which is not therapeutic. Option 2 ignores client rights, while option 4 challenges the client. Test-Taking Strategy: Use therapeutic communication techniques. Option 3 is the only option that addresses the client’s concern. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 1346. A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse would appropriately remove the restraints when which of the following occurs? 1. When no acts of aggression are observed within 1 hour after release of two extremity restraints 2. When medication that has been administered has taken effect 3. When the nurse explores with the client the reasons for the attacking behavior 4. When the client apologizes and tells the nurse that it will never happen again Answer: 1 Rationale: The best indicator that the behavior is controlled is after the client is partially released from the restraints and exhibits no signs of aggression. This is also the best indicator of the client’s current physical behavior. Options 2, 3, and 4 are inaccurate indicators. Test-Taking Strategy: Use knowledge of legal and ethical issues involving restraints to answer this question. Also note the relationship between the word “aggressive” in the question and “aggression” in the correct option. Review the issues related to restraints if you had difficulty with this question.
PN~Comp~Review-CD-1301-140024 Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 262-263. 1347. A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client’s behavior is most consistent with: 1. Attention seeking 2. Desire to be accepted 3. Manipulation 4. Improvement Answer: 4 Rationale: The behavior exhibited by the client is most appropriate and demonstrates improvement. All clients have a desire to be accepted. Acting-out is attention-seeking behavior. There is no pattern of manipulation exhibited. Test-Taking Strategy: Use the process of elimination. Focusing on the data provided in the question will assist in directing you to option 4. Review the expected outcomes for the client with agoraphobia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 186. 1348. A nurse working the evening shift is assisting clients to get ready for sleep. A client diagnosed with obsessive-compulsive disorder becomes upset and agitated and asks the nurse to sit down and talk. Which of the following would be the best response of the nurse at this time? 1. “I can see that you’re upset. I’m willing to listen.” 2. “I don’t have time right now, but I’ll get someone else to talk to you.” 3. “No, we can’t talk right now; it is bedtime.” 4. “Try to get some sleep and we will talk in the morning.” Answer: 1 Rationale: The correct response acknowledges the client’s feelings and provides a forum for release of anxieties. The other options are incorrect because they do not use therapeutic communication techniques. Each of them contains a block to communication by putting the client’s feelings on hold. Test-Taking Strategy: Use therapeutic communication techniques. Select the option that acknowledges the client’s feelings and does not place the client’s issues on hold. This will direct you to option 1. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity
PN~Comp~Review-CD-1301-140025 Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 1349. A nurse is reviewing medications with a client receiving colchicine for the treatment of gout. The nurse determines that the medication is effective if the client reports a decrease in: 1. Blood glucose level 2. Blood pressure 3. Joint inflammation 4. Headaches Answer: 3 Rationale: Colchicine is classified as an anti-gout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in the affected joints, as well as a decrease in the number of gout attacks. Test-Taking Strategy: Use the process of elimination. Focusing on the diagnosis of the client will direct you to option 3. Review the action of colchicine if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 256. 1350. A nurse is preparing to admit a client diagnosed with obsessive-compulsive disorder (OCD) to the mental health unit. The nurse observes this client for behavior characteristic of one who is: 1. Extremely frightened 2. Inflexible and rigid 3. Suspicious and hostile 4. Flexible and adaptable Answer: 2 Rationale: Rigid and inflexible behaviors are characteristic of the client with OCD. Clients are not usually hostile unless they are prevented from performing the obsession or compulsion, because that is what decreases the anxiety. The other options are incorrect. Test-Taking Strategy: Use the process of elimination. Recalling that the client with OCD performs repetitive acts over and over as a means of decreasing anxiety will direct you to option 2. Review the characteristics of OCD if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 271.
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1351. A client cannot leave the house without checking the stove and the iron many times. The client is often late for appointments, and occasionally even misses engagements as a result of this behavior. The nurse interprets that this client’s symptoms are compatible with which of the following anxiety disorders? 1. Posttraumatic stress disorder 2. Obsessive-compulsive disorder 3. Generalized anxiety disorder 4. Phobias Answer: 2 Rationale: The repetitive behavior that interferes with activities of daily living and functioning is indicative of obsessive-compulsive disorder. This type of behavior is not part of the clinical picture for the disorders identified in options 1, 3, and 4. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and note the relationship between these data and option 2. Review the characteristics of obsessivecompulsive disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 187. 1352. A client has just been admitted to the mental health unit with a diagnosis of obsessivecompulsive disorder. The nurse observes the client for compulsive behavior that denotes repetition in: 1. Fears 2. Delusions 3. Thoughts 4. Actions Answer: 4 Rationale: A compulsion is a repetitive act, while an obsession is a repetitive thought. A phobia is a repetitive fear, while delusions are characteristic of schizophrenia. Test-Taking Strategy: Use the process of elimination and note the key word behavior. This tells you that the correct option is something observable by the nurse. This will direct you to option 4. Review the characteristics of obsessive-compulsive disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 186. 1353. A client in the mental health unit engages in repeated hand washing throughout the day. The nurse understands that these repetitive behaviors develop because the client is:
PN~Comp~Review-CD-1301-140027 1. Unconsciously attempting to control unpleasant thoughts or feelings 2. Unaware that they are performing the ritual 3. Consciously attempting to punish themselves or others 4. Responding to “the voices” telling them to perform rituals Answer: 1 Rationale: Repetitive acts are characteristic of clients who have obsessive-compulsive disorder. The rituals performed are an unconscious response that helps to divert and control the unpleasant thoughts or feelings in order to prevent acting on those feelings. The other interpretations are incorrect. Test-Taking Strategy: Knowledge regarding the characteristics of obsessive-compulsive disorder is required to answer this question. Remember, repetitive acts are characteristic of clients who have obsessive-compulsive disorder. Review these characteristics if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 187. 1354. A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma suffered 6 weeks ago. The nurse plans care knowing that which of the following is the priority action? 1. Refer the client for a psychiatric evaluation 2. Encourage the client to move the arms 3. Encourage the client to talk about feelings 4. Look for organic causes of the paralysis Answer: 4 Rationale: The first priority is to rule out any neurological disorders. After it has been determined that there is no physiological basis for the paralysis, then further psychiatric evaluation can be done. The client should be encouraged to talk about feelings, but this is not the priority option. Encouraging the client to move the arms has no beneficial effect in this situation. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to answer the question. Option 4 is the only option that relates to a physiological need. Review care to the client who experiences a physiological disorder as a result of emotional trauma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 225. 1355. A client with obsessive-compulsive disorder who continually cleans the bathroom becomes enraged with the roommate for using the bar of soap being used for cleaning. The client begins to yell and slaps the roommate. Which of the following actions should the nurse
PN~Comp~Review-CD-1301-140028 take first? 1. Restrain the client 2. Fill out an incident report 3. Remove both clients to a safe location 4. Call the hospital risk management department Answer: 3 Rationale: The first responsibility of the nurse is to provide for the safety of all clients. Only option 3 provides for the needs of both clients identified in the question. The other actions are either contraindicated (option 1), have lesser priority (option 2), or may not be indicated depending on the level of injury to the second client (option 4). Test-Taking Strategy: Use the process of elimination and note the key word first. The issue of the question is the appropriate method for dealing with an aggressive client. In this case, the umbrella (global) option is the one that is correct. Only the correct option provides for the needs of both clients identified in the question. Review methods of dealing with an aggressive client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 116, 261-262. 1356. A nurse is assigned to assist in the care of a client with obsessive-compulsive disorder. The nurse would place first priority on which of the following when planning care for this client? 1. Educate the client about self-care demands 2. Establish a trusting nurse-patient relationship 3. Monitor for obsessive-compulsive behavior 4. Demand active participation in care Answer: 2 Rationale: It is most important to establish a trusting relationship, which indicates to the client that the client is important. After a therapeutic relationship has been developed, other work can begin. The nurse should not demand anything from the client. Test-Taking Strategy: Use the process of elimination and note the key word first. Use knowledge of therapeutic communication skills and the nature of the nurse-client relationship to direct you to option 2. Review the importance of the nurse-client relationship if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 189. 1357. A nurse is preparing a care plan for the client with obsessive-compulsive disorder. The nurse should focus on which of the following as the primary means to accomplish work with this client?
PN~Comp~Review-CD-1301-140029 1. Group therapy 2. Recreational therapy 3. Medical diagnosis 4. Goals and objectives Answer: 4 Rationale: Goals and objectives are a mutual working tool between the client and the nurse. Options 1, 2, and 3 are not specific to the nurse-client working relationship. Test-Taking Strategy: Use the process of elimination and focus on the key word primary. Eliminate options 1, 2, and 3 because they relate to a medical rather than a nursing focus of care. Review the elements of the nurse-client relationship if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 190. 1358. A nurse employed in a mental health clinic is working with a client who has a somatization disorder. The nurse plans care recalling that the onset of symptoms in a somatization disorder is usually noted around age: 1. 10 2. 20 3. 30 4. 70 Answer: 3 Rationale: The average age for onset of somatization disorders is 30. The other ages listed are incorrect. Test-Taking Strategy: Knowledge regarding a somatization disorder is required to answer this question. Review the characteristics of this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 229. 1359. A client newly admitted to the mental health unit describes a recent history of emotional turmoil. The client exhibits physical symptoms and has some loss of physical functioning. The nurse determines that this client is exhibiting signs compatible with: 1. Posttraumatic stress disorder 2. Somatization disorder 3. Depression 4. Obsessive-compulsive disorder Answer: 2 Rationale: Emotional turmoil expressed in physical signs is a major symptom of somatization disorder. The other disorders listed are incorrect.
PN~Comp~Review-CD-1301-140030 Test-Taking Strategy: Focus on the data in the question. Recalling the characteristics associated with a somatization disorder will direct you to option 2. Review these characteristics if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 230. 1360. A nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month time period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. After reasoning that the client’s symptoms are compatible with a somatization disorder, the nurse recalls that obesity for this client most likely represents: 1. A form of functional coping 2. Satisfaction with self 3. Long-term lack of compliance with weight programs 4. Protection from the risk of intimacy Answer: 4 Rationale: A client who is obese after trauma such as that described in the question may be trying to portray themselves as “fat and unattractive.” This would allow the client to protect self from the danger of intimacy. Options 1 and 2 are incorrect. There are not enough data in the question to support option 3. Test-Taking Strategy: Use knowledge of somatization disorders and the effects of sexual abuse to answer this question. Begin by eliminating options 1 and 2 because of the words “functional” and “satisfaction,” respectively. From the remaining options, focusing on the data in the question will direct you to option 4. Review somatization disorders if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 231. 1361. A nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate? 1. Defend the delusional thinking 2. Develop a relationship to help reduce the frequency of the delusions 3. Relinquish the need for delusional thinking 4. Verbalize the reasons for delusional thinking Answer: 2 Rationale: Paranoid clients feel anxious and threatened because of a lack of trust. Increasing the ability to trust will help decrease delusional thinking. Defending the delusion is not therapeutic, while relinquishing the need for delusional thinking is not realistic at this point in time.
PN~Comp~Review-CD-1301-140031 Verbalizing the reasons for the delusion may also not be realistic in the short-term. Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question and noting the key words short-term goal will direct you to option 2. Review care of the client with delusions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 331. 1362. A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathology after a lengthy work-up. In planning care for this client, it is important that the nurse understands that the client is suffering from: 1. Somatization disorder 2. Hypochondriacal neurosis 3. Schizophrenia 4. Depression Answer: 1 Rationale: Somatization disorder is characterized by a long history of multiple problems with no organic cause. This characteristic is not found in clients with the other mental health disorders listed. Test-Taking Strategy: Focus on the data in the question. Knowledge of the characteristics of a somatization disorder will direct you to option 1. Review the characteristics of the disorders in the options if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, pp. 287-288. 1363. A client is tentatively diagnosed with ovarian cancer. The nurse gathers data about which late manifestation(s) of this disease? 1. Pelvic pain, anemia, and ascites 2. Normal bowel and bladder function 3. Vague lower abdominal discomfort 4. Mild digestive complaints Answer: 1 Rationale: Vague lower abdominal discomfort and mild digestive complaints are early symptoms. Bowel and bladder functions are also affected early on. Pelvic pain, anemia, and ascites are experienced late in the disease process. Early detection of this type of cancer is rare, which is why screening is so important. Test-Taking Strategy: Use the process of elimination. Noting the key word late will assist in directing you to option 1. Review the early and late manifestations of ovarian cancer if you had difficulty with this question.
PN~Comp~Review-CD-1301-140032 Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1080. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 960. 1364. A client with ovarian cancer is scheduled to receive chemotherapy with cisplatin (PlatinolAQ). The nurse assisting in caring for the client reviews the plan of care expecting to note which intervention? 1. Encourage a low-fat diet 2. Restrict fluids 3. Encourage fluids 4. Encourage a high-protein diet Answer: 3 Rationale: The client should receive prehydration before and during the infusion of this medication to minimize the risk of renal damage. Fluids are not restricted. Encouraging adequate dietary intake is appropriate, but a high-protein or low-fat diet is not necessary. Test-Taking Strategy: Use the process of elimination. Note that options 2 and 3 oppose each other, which indicates that one of these options is likely to be correct. Noting the client’s diagnosis and recalling that this medication is an antineoplastic will direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 369. 1365. A client receiving chemotherapy tells the nurse, “What will I ever do when my hair starts to fall out?” The appropriate response by the nurse would be to: 1. Tell her that people don’t pay attention to such things anymore 2. Offer to help her select a new hairstyle 3. Ignore the comment and change the subject 4. Encourage her to select a wig Answer: 4 Rationale: The nurse would encourage the client to select a wig. Selecting a wig before the hair falls out will enable the client to better match hair color and texture of the wig with her natural hair. A new hairstyle will not be beneficial to the client since the hair will fall out. Options 1 and 3 are nontherapeutic. Test-Taking Strategy: Use therapeutic communication techniques to eliminate options 1 and 3. From the remaining options, knowing that the hair will fall out will direct you to option 4. Review the interventions that will address the psychosocial issues of the client receiving chemotherapy if you had difficulty with this question.
PN~Comp~Review-CD-1301-140033 Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 386. 1366. A nurse has given a client with hepatitis instructions about postdischarge management during convalescence. The nurse determines that the client needs further teaching if the client states to: 1. Eat a high-carbohydrate, low-fat diet 2. Avoid alcohol and aspirin 3. Resume full activity level within 1 week 4. Take the prescribed amounts of vitamin K Answer: 3 Rationale: The client with hepatitis is easily fatigued and may require several weeks to resume full activity level. It is important for the client to get adequate rest so that the liver may heal. The client should take in a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as aspirin and alcohol. If the client has prolonged clotting times, vitamin K should be prescribed. Test-Taking Strategy: Note the key words needs further teaching. These words indicate a false response question and that you need to select the incorrect client statement. Use the process of elimination, focus on the issue, and note the time period of 1 week in option 3. Remember that fatigue is a troublesome problem in hepatitis and a lengthy period of convalescence is usually necessary. Review home care measures for the client with hepatitis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 233. 1367. A nurse has given discharge instructions to a client who has had ocular surgery of the right eye. The nurse determines that the client needs further instruction if the client states to: 1. Call the physician if a temperature of 99° F is present 2. Wear sunglasses during the day 3. Wear an eyeshield at night 4. Sleep on the back or left side Answer: 1 Rationale: The client is generally taught to report a temperature of 101° F or greater. The client should also report chills, pain unrelieved by medication, bleeding, foul-smelling drainage, or redness at the surgical site. The client should wear sunglasses during the day and an eyeshield at night to protect the eye. The client should lie on the back or the nonoperative side, unless otherwise instructed by the surgeon. Test-Taking Strategy: Begin to answer this question by eliminating options 2 and 3 first.
PN~Comp~Review-CD-1301-140034 Remember that options that are similar (in this case related to eye protection) are not likely to be correct. From the remaining options, note the key words needs further instruction. These words indicate a false response question and that you need to select the incorrect client statement, which will assist in directing you to option 1. Review home care measures following eye surgery if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1055. 1368. A client with glaucoma has suffered significant eye damage prior to diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client states that: 1. The family will drive the client when eye examinations are needed 2. Driving at dusk is not a problem 3. Nightlights have been placed in the hallways for night use 4. It is important to have periodic eye examinations Answer: 2 Rationale: The client who has adjusted to the impaired vision that may accompany glaucoma should take action to maintain safety in dim lighting. This includes moving carefully in dim lighting, using nightlights along paths traveled in the home at night, and avoidance of driving at dusk or dawn. Satisfactory adjustment is also indicated by recognition of the need for ongoing eye examinations, and the presence of a supportive family. Test-Taking Strategy: Use the process of elimination, noting the key words needs further assistance. These words indicate a false response question and that you need to select the incorrect client statement. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 1 and 4 first. From the remaining options, recall that vision is further impaired in dim lighting. This will direct you to option 2. Review client teaching points related to glaucoma if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Eye References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1944-1945. 1369. A client in the emergency department is diagnosed with Bell’s palsy. The nurse collecting data on this client expects to note which of the following? 1. Narrowing of the palpebral fissure 2. A lag in closing the eyelid 3. A symmetrical smile 4. Paroxysms of excruciating pain in the lips and cheek Answer: 2 Rationale: The facial drooping associated with Bell’s palsy makes it difficult for the client to
PN~Comp~Review-CD-1301-140035 close the eyelid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell’s palsy. Paroxysms of excruciating pain are seen with trigeminal neuralgia. Test-Taking Strategy: Use the process of elimination noting the key word palsy. Options 1 and 3 reflect findings opposite those that would be expected with Bell’s palsy. Excruciating pain is not noted in Bell’s palsy. Review the manifestations associated with Bell’s palsy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 643. 1370. A client has just been told by the physician of the diagnosis of breast cancer. The client responds, “Oh, no; does this mean I’m going to die?” The nurse interprets that the client’s initial reaction is one of: 1. Anxiety 2. Fear 3. Denial 4. Rage Answer: 2 Rationale: The client’s response is one of fear. The client has verbalized the object of fear (dying), which makes anxiety incorrect. There is no evidence of denial or rage in the client’s statement. Test-Taking Strategy: Focus on the issue of the question and the client’s statement. The client’s statement clearly identifies fear. Review psychosocial reactions related to a diagnosis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 278. 1371. A nurse inspects a decubitus ulcer on a client’s sacrum and notes that the ulcer has partialthickness skin loss and the formation of a blister. The nurse categorizes the ulcer as: 1. Stage I 2. Stage II 3. Stage III 4. Stage IV Answer: 2 Rationale: A stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss and the wound may appear as an abrasion, shallow crater, or a blister. A stage I ulcer is a reddened area that does not blanche, but has intact skin. Stage III and IV ulcers are those that involve full-thickness skin loss and full-thickness skin loss with necrosis or damage to muscle,
PN~Comp~Review-CD-1301-140036 bone, or supportive tissue, respectively. Test-Taking Strategy: Focus on the key words formation of a blister. Use knowledge of the different stages of pressure ulcer classification to answer this question. Review these various stages and their characteristics if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 273. 1372. A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse plans to maximize the effectiveness of this therapy by: 1. Rubbing the application into the skin 2. Applying a dry, sterile dressing over the affected area 3. Covering the application with a warm, moist dressing and an occlusive outer wrap 4. Placing the area under a heat lamp for 20 minutes Answer: 3 Rationale: The nurse can enhance penetration of topical corticosteroid therapy to the client with psoriasis by applying warm, moist heat and an occlusive outer wrap. The wrap may consist of a plastic film, glove, bootie, or a similar item. If large surface areas of skin are involved, the occlusive therapy may be limited to 12 hours per day to minimize local and systemic side effects. Test-Taking Strategy: Note the key word maximize. This implies that one option is better than the others for enhancing the effect of this therapy. Focusing on the client’s diagnosis and using principles related to warmth will direct you to option 3. Review treatment measures for psoriasis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Integumentary Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 78.
PN~Comp~Review-CD-1301-140037 to guidelines for early detection of cervical cancer (Papanicolaou smear), and should seek prompt treatment of vaginitis and cervicitis if they occur. Test-Taking Strategy: Focus on the issue—to decrease the risk of cervical cancer. Knowledge of general measures to promote health guides you to answer correctly. Also note the absolute word “only” in the incorrect item. Review the risk factors associated with cervical cancer if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 354, 1072. 1374. A nurse has given instructions to the client with a cystocele about Kegel exercises. The nurse determines that the client has not fully understood the directions if the client states to: 1. Begin voiding and then stop the stream, holding residual urine for 1 hour 2. Stop and start the stream of urine several times during a voiding 3. Tighten perineal muscles for up to 10 seconds several times a day 4. Tighten perineal muscles for up to 5 minutes 3 or 4 times a day Answer: 1 Rationale: Kegel exercises strengthen the perineal floor and are useful in the prevention and management of cystocele, rectocele, and enterocele. There are several acceptable ways to perform Kegel exercises. These involve starting and stopping the flow of urine either once for up to 5 minutes, or several times during a single voiding for about 5 seconds. Because the muscles that control urination also are involved in defecation, these exercises can also be done once during defecation. Otherwise, they may be done by holding perineal muscles taut for up to 10 seconds several times a day, or for 5 minutes 3 to 4 times a day. Option 1 is not a correct method for performing Kegel exercises. Residual urine should not be held in the bladder for lengthy periods because it could promote urinary tract infection. Test-Taking Strategy: Focus on the issue and note the key words has not fully understood. These words indicate a false response question and that you need to select the incorrect client statement. General principles related to the prevention of urinary tract infections will direct you to option 1. Review the procedure for Kegel exercises if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 288. 1375. A client has been given a prescription for gemfibrozil (Lopid). The nurse plans to instruct the client to limit which of the following foods while taking this medication? 1. Fish 2. Beef 3. Spicy foods 4. Citrus products
PN~Comp~Review-CD-1301-140038 Answer: 2 Rationale: Gemfibrozil is a lipid-lowering agent. It is given as part of a therapeutic regimen that also includes dietary counseling, specifically the limitation of saturated fats and other fats in the diet. Test-Taking Strategy: Use the process of elimination, noting the key word limit. Recalling that gemfibrozil is a lipid-lowering agent will direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, pp. 656-657. 1376. A nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which of the following is the most appropriate action? 1. Check for blood return 2. Remove the IV 3. Apply a warm compress 4. Measure the area of infiltration Answer: 2 Rationale: Blanching, coolness, and edema at the IV site are all classic signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the most appropriate action is to remove the IV to prevent any further damage. The nurse should not depend solely on blood return for assurance that the cannula is in the vein because blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if the infiltrated solution is not damaging to the surrounding tissues. Measuring the area of infiltration should only be done after the IV has been removed so that further tissue damage is assessed. Test-Taking Strategy: Note the key words most appropriate. While all of the options may be appropriate, it is necessary to prioritize. The signs presented in the question identify infiltration. Infiltration indicates that the IV needs to be removed. Review the signs of infiltration and the appropriate interventions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, pp. 446-448. 1377. A nurse would monitor for which of the following laboratory results as indicating an adverse reaction in the client with endometrial cancer who is receiving chemotherapy? 1. White blood cell count 7000/mm3 2. Blood urea nitrogen 20 mg/dl 3. Hemoglobin 12.5 g/dl 4. Platelet count 20,000/mm3
PN~Comp~Review-CD-1301-140039 Answer: 4 Rationale: A normal platelet count ranges from 150,000/mm3 to 400,000/mm3. A platelet count of 20,000/mm3 places the client at severe risk for bleeding. All of the other values are within normal limits. Test-Taking Strategy: Use the process of elimination and knowledge of normal blood studies. Option 4 is the only value that is not normal. Review the risks associated with chemotherapy and these normal laboratory values if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 382. 1378. A nurse determines that a client with a history of which of the following is most at risk of endometrial cancer? 1. Estrogen replacement therapy 2. Steroid replacement therapy 3. Occupational exposure to carcinogens 4. Surgical interventions Answer: 1 Rationale: Endometrial cancer is related to the hormone estrogen because estrogen is the primary stimulant of endometrial proliferation. Surgical interventions, environmental exposure to carcinogens, and steroid replacement therapy are not considered to be risk factors for endometrial cancer. Test-Taking Strategy: Specific knowledge of the risk factors for endometrial cancer is needed to answer this question. Note the correlation also between the word “endometrial” in the question and the word “estrogen” in the correct option. Review these risk factors if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1071. 1379. A client with endometrial cancer is receiving doxorubicin (Adriamycin), an antineoplastic agent. The nurse would specifically collect data about which of the following? 1. Hematological laboratory values 2. Level of orientation 3. Pupillary response to light 4. Neuromuscular reflexes Answer: 1 Rationale: Because of bone marrow suppression during therapy with antineoplastic agents, hematological laboratory values should be monitored closely. The incorrect options all reflect neurological symptoms, which are not the issue with this medication.
PN~Comp~Review-CD-1301-140040 Test-Taking Strategy: Use the process of elimination. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 2, 3, and 4 because they reflect neurological data. Review the effects of doxorubicin if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 294. 1380. A nurse is caring for a client with cancer receiving chemotherapy who has developed stomatitis. The nurse plans to give mouth care by using oral care agents and devices: 1. That are the preference of the nurse 2. Based on the grade of stomatitis 3. That the client requests 4. That are readily available Answer: 2 Rationale: Interventions used to treat stomatitis are based on the varying degrees of the disorder. The incorrect options do not focus on the individual needs of the client with this complication of cancer chemotherapy. Test-Taking Strategy: Use the process of elimination and focus on the client’s problem. This will direct you to option 2. Review care to the client with stomatitis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 671. 1381. A client with cancer has undergone a total abdominal hysterectomy and has a Foley catheter in place during the immediate postoperative period. The nurse would expect to note which of the following types of urinary drainage immediately following this surgery? 1. Blood-tinged 2. Colorless 3. Purulent 4. Bright red Answer: 1 Rationale: Because of the handling of the bladder during surgery, the urine is likely to be bloodtinged. Option 2 would indicate overhydration. Option 3 indicates infection. Option 4 would indicate active bleeding. Test-Taking Strategy: Use the process of elimination and note the key words immediately following. Use general knowledge of postsurgical urinary drainage and the effects of surgical manipulation to direct you to option 1. Review the expected findings following this surgery if you had difficulty with this question. Level of Cognitive Ability: Analysis
PN~Comp~Review-CD-1301-140041 Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1070. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, pp. 1674, 1840. 1382. A nurse is caring for a client immediately following a total abdominal hysterectomy. The nurse anticipates that which of the following will be the priority in the first 24 hours following surgery? 1. Pain 2. Lack of information about recovery 3. Changes in body image 4. Inability to cope with stressors Answer: 1 Rationale: The client who has had surgery is most likely to be faced with greater or lesser amounts of pain in the first 24 hours after surgery, depending on the effectiveness of pain control measures. The other priorities are of lesser importance during this timeframe, and could increase in importance later in recovery. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to answer the question. Option 1 is the only option that addresses a physiological need. Remember that physiological needs are the priority. Review care to the client following a total abdominal hysterectomy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Clients Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1069-1070. 1383. A nurse is caring for a client with a skin infection who is receiving amoxicillin (Amoxil) 500 mg every 8 hours. Which of the following would indicate to the nurse that the client is experiencing a frequent side effect related to the medication? 1. Severe abdominal cramps 2. Vaginal drainage 3. Fever 4. Severe watery diarrhea Answer: 2 Rationale: Amoxicillin (Amoxil) is a type of penicillin. Frequent side effects include gastrointestinal disturbances, headache, and oral or vaginal candidiasis. Less common but more harmful adverse reactions that can occur include superinfection, such as potentially fatal antibiotic-associated colitis, which results from altered bacterial balance. Symptoms would include abdominal cramps, severe watery diarrhea, and fever. Test-Taking Strategy: Focus on the key words frequent side effect. This will assist in eliminating options 1 and 4. From the remaining options, recall that antibiotics can alter the normal vaginal
PN~Comp~Review-CD-1301-140042 flora to assist in directing you to option 2. If you had difficulty with this question, review the frequent side effects associated with the use of this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 60. 1384. A nurse is caring for a client with glaucoma who is receiving acetazolamide (Diamox) daily. Which of the following would indicate to the nurse that the client is experiencing an adverse reaction related to the medication? 1. Diarrhea 2. Lacrimation 3. Low back pain and dysuria 4. Irritability Answer: 3 Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity can occur and are manifested by dark-colored urine and stools, pain in the lower back, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression may also occur. Test-Taking Strategy: Focus on the key words adverse reaction in the stem of the question. Remembering that acetazolamide is nephrotoxic and hepatotoxic will assist in directing you to the correct option. Review the adverse effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Eye Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 10. 1385. A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when: 1. Suctioning is required frequently 2. Excessive secretions are suctioned from the tracheostomy 3. The client’s skin and mucous membranes are light pink in color 4. Aspiration of gastric contents occurs Answer: 4 Rationale: Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 3 are not signs of this complication. Test-Taking Strategy: Use knowledge of anatomy and medical terminology to assist you in answering this question. A fistula is an artificial opening. The term “tracheoesophageal” indicates trachea to esophagus. This will direct you to option 4. Review the signs of
PN~Comp~Review-CD-1301-140043 tracheoesophageal fistula if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1779. 1386. A nurse is assigned to care for a client with a Sengstaken-Blakemore tube. The nurse would suspect that the client has which diagnosis? 1. Gastritis 2. Esophageal varices 3. Bowel obstruction 4. Small bowel tumor Answer: 2 Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. Test-Taking Strategy: Use the process of elimination. Recalling that this tube is used for the client with ruptured esophageal varices will direct you to option 2. Review the purpose and use of this tube if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1345. 1387. A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. Following deflation of the balloon, the nurse would monitor the client most closely for which of the following? 1. Swelling of the abdomen 2. Bloody diarrhea 3. Hematemesis 4. An elevated temperature and an increase in blood pressure Answer: 3 Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis and ruptured esophageal varices. It has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, noted by vomiting of blood (hematemesis). Test-Taking Strategy: Use the process of elimination. Recalling that the esophageal balloon exerts pressure on the ruptured esophageal varices to stop the bleeding will direct you to option
PN~Comp~Review-CD-1301-140044 3. Review care to the client with a Sengstaken-Blakemore tube if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1345. 1388. A nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the laboratory results of the client and notes that the calcium level is extremely low. The nurse would expect to note which of the following on data collection of the client? 1. Positive Trousseau’s sign 2. Negative Chvostek’s sign 3. Unresponsive pupils 4. Hyperactive bowel sounds Answer: 1 Rationale: Hypoparathyroidism is related to a lack of parathyroid hormone secretion or to a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit positive Chvostek’s and Trousseau’s signs, which indicate potential tetany. Options 2, 3, and 4 are not related to the presence of hypocalcemia. Test-Taking Strategy: Use the process of elimination. Recalling that a positive Chvostek’s and Trousseau’s sign would be noted in this disorder will direct you to option 1. Review the findings in hypoparathyroidism and hypocalcemia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 470. 1389. A nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which of the following specific signs of this complication would be included on the list? 1. Decreased urine output 2. Profuse sweating 3. Increased thirst 4. Shakiness Answer: 3 Rationale: The classic signs of hyperglycemia include polydipsia, polyuria, and polyphagia. Profuse sweating and shakiness would be noted in a hypoglycemic condition. Test-Taking Strategy: Use the process of elimination. Remembering the “three P’s”—polyuria, polydipsia, and polyphagia—will assist in directing you to the correct option. Review the signs of hyperglycemia if you had difficulty with this question. Level of Cognitive Ability: Application
PN~Comp~Review-CD-1301-140045 Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1292. 1390. A nurse is caring for a 14-year-old child who was hospitalized and placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child’s needs? 1. Allow the child to have their hair dyed if the parent agrees 2. Allow the child to play loud music in the hospital room 3. Let the child wear own clothing when friends visit 4. Allow the child to keep the shades closed and the room darkened at all times Answer: 3 Rationale: Adolescents need to identify with their peers and have a strong need to belong to a group. They like to dress like the group and wear similar hairstyles, which are different from their parents. Because Crutchfield traction uses skeletal pins, hair dye is not appropriate. The child should be allowed to wear their own clothes to feel a sense of belonging to the group. Loud music may disturb others in the hospital. The child’s request for a darkened room is indicative of a possible problem with depression that may need further evaluation and intervention. Test-Taking Strategy: Use the process of elimination and focus on the issues—Crutchfield traction and a 14-year-old-child. Knowledge regarding Crutchfield traction and its limitations as well as growth and development concepts in the adolescent will direct you to option 3. Review growth and development and care to the child in Crutchfield traction if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 894. 1391. A nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. The priority data would include which of the following? 1. The client’s fear related to the use of crutches 2. The client’s understanding of the need for increased mobility 3. The client’s vital signs, muscle strength, and previous activity level 4. The client’s feelings about the restricted mobility Answer: 3 Rationale: Vitals signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine if the client has enough strength for crutch walking and if muscle strengthening exercises are necessary. Knowledge of the previous activity level will provide information related to the tolerance of activity. Options 1, 2, and 4 are also important but physiological needs take precedence over psychosocial needs.
PN~Comp~Review-CD-1301-140046 Test-Taking Strategy: Note the key word priority in the stem of the question. Use Maslow’s Hierarchy of Needs theory to prioritize. Remember that physiological needs take precedence over psychosocial needs. This should easily direct you to option 3. Review nursing interventions related to teaching a client about crutch walking if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 948-949. 1392. A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, the client is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern that he/she will not be able to continue the tube feedings at home. Which of the following nursing responses would be appropriate at this time? 1. “Do you want to stay in the nursing home a few more days?” 2. “Have you discussed your feelings with your doctor?” 3. “Tell me more about your concerns with your diet after going home.” 4. “You need to talk to your doctor about these findings.” Answer: 3 Rationale: A client often has fears about leaving the secure, cared-for environment of the health care facility. This client has a fear about not being able to care for self at home, and not being able to handle the tube feedings at home. An open communication statement such as “tell me more about” often leads to valuable information about the client and the client’s concerns. Options 1, 2, and 4 are nontherapeutic statements. Test-Taking Strategy: Use therapeutic communication techniques. Focus on the client’s feelings. Options 2 and 4 place the client’s feelings on hold. Option 1 is a close-ended statement. Option 3 focuses on the client’s feelings. Remember to address the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1393. A client who sustained an inhalation injury from a fire arrives in the emergency department. On data collection of the client, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing: 1. Anxiety 2. Fear 3. Hypoxia 4. Pain Answer: 3
PN~Comp~Review-CD-1301-140047 Rationale: After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after an inhalation injury and may occur after an electrical injury. Test-Taking Strategy: Use the process of elimination and knowledge regarding this type of burn injury to assist in answering the question. Use the ABCs—airway, breathing, and circulation— to assist in directing you to option 3. If you had difficulty with this question, review assessment of the client with a burn injury. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 516. 1394. A client is brought to the emergency department immediately following a smoke inhalation injury. The initial nursing action would be to prepare the client to receive: 1. Pain medication 2. Oxygen via nasal cannula 3. 100% humidified oxygen by face mask 4. Endotracheal intubation Answer: 3 Rationale: If the client sustains a smoke inhalation injury, the client is immediately treated with 100% humidified oxygen delivered by face mask. Endotracheal intubation is needed if the client exhibits respiratory stridor, which indicates airway obstruction. Test-Taking Strategy: Note the key word initial in the stem of the question. There are no data in the question that indicate the client would require endotracheal intubation. Use the ABCs— airway, breathing, and circulation—to assist in directing you to option 3. Review care to the client who sustained a burn injury if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 516. 1395. An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. On data collection of the client, which of the following would indicate that the client sustained a respiratory injury as a result of the burn? 1. Clear breath sounds 2. Use of accessory muscles for breathing 3. Fear and anxiety 4. Complaints of pain Answer: 2 Rationale: Clinical indicators in a burn client that would indicate respiratory injury include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs.
PN~Comp~Review-CD-1301-140048 Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing. Although anxiety may be a sign of hypoxemia, anxiety along with bradycardia, dysrhythmias, and lethargy would most likely indicate a concern related to a respiratory injury. Abnormal breath sounds and abnormal arterial blood gas values would also be noted. Test-Taking Strategy: Use the process of elimination. Note the issue—a respiratory injury. Focusing on the finding related to a respiratory problem will direct you to option 2. If you had difficulty with this question, review the findings in the client with a burn injury that may indicate a respiratory condition. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 521. 1396. A nurse is preparing a plan of care for a client in skeletal leg traction with an overbed frame. Which of the following nursing interventions would be included in the plan of care to best assist the client with positioning in bed? 1. Encourage the client to pull self up by pushing with the unaffected leg on the bed mattress 2. Use the assistance of four nurses to reposition the client 3. Place a draw sheet under the client for pulling the client up in bed 4. Place a trapeze on the bed to provide a means for the client to lift the hips off the bed Answer: 4 Rationale: The nurse can best assist the client in skeletal traction with repositioning by providing a trapeze on the bed for the client’s use. Encouraging the client to pull self up by pushing with the unaffected leg on the bed mattress may cause skin breakdown on the unaffected heel area. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote the means of repositioning by the client. Test-Taking Strategy: Focus on the key words to best assist the client with positioning. Eliminate options 2 and 3 first because they are similar. Next eliminate option 1 because this action may cause an alteration in skin integrity. If you had difficulty with this question, review care to the client in skeletal traction. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1480. 1397. A nurse is caring for a client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client’s alignment in bed and notes that proper alignment is maintained. Which of the following actions should the nurse take next? 1. Medicate the client 2. Provide pin care 3. Notify the registered nurse
PN~Comp~Review-CD-1301-140049 4. Remove 2 pounds of weight from the traction Answer: 3 Rationale: A client who complains of severe pain may need realignment or may have traction weights ordered that are too heavy. The nurse realigns the client and if ineffective, notifies the registered nurse who will then contact the physician. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction without a specific order to do so. Providing pin care is unrelated to the problem as described. Test-Taking Strategy: Note the key words severe left leg pain in the question. This should indicate to you that a problem exists. Recalling the causes of severe pain in a client in skeletal traction and noting that the question addresses that the nurse has already assured that the client is in proper alignment should assist in directing you to option 3. If you had difficulty with this question, review the complications associated with skeletal traction. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1480. 1398. A nurse is caring for a client who has a cast applied to the left lower leg. On data collection of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which of the following nursing interventions is appropriate? 1. Massage the skin at the edges of the cast 2. Contact the physician 3. Place a small face cloth in the cast around the edges of the cast 4. Petal the cast edges with adhesive tape Answer: 4 Rationale: If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. Massaging the skin will not eliminate the problem. Placing a small face cloth in the cast around the edges of the cast is not appropriate. It is not necessary to contact the physician. Test-Taking Strategy: Focus on the issue of the question and use the process of elimination. Eliminate option 3 first because this action is inappropriate. Next eliminate option 2 because this action is unnecessary. Option 1 will not alleviate the problem, which leaves option 4 as the correct option. If you had difficulty with this question, review care to the client with an extremity cast. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1481. 1399. A nurse is reinforcing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents
PN~Comp~Review-CD-1301-140050 understand these measures if the parents state which of the following? 1. “We will be sure to give our child a Fleet enema every day to prevent constipation.” 2. “We will make sure that our child participates in physical activity every day.” 3. “We will provide comfort measures to reduce any crying periods by our child.” 4. “We will encourage our child to cough every few hours on a daily basis.” Answer: 3 Rationale: A warm bath, avoidance of upright positioning, and comfort measures to reduce crying are all simple measures to reduce a hernia. Coughing and crying increase the strain on the hernia. Likewise, enemas of any type would increase the strain on the hernia. Test-Taking Strategy: Use the process of elimination and focus on the issue. The issue of the question is an appropriate action that will reduce a hernia. Options 1, 2, and 4 all increase pressure and strain on the hernia site. Review nursing measures for a hernia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 478. 1400. A nurse is assisting in developing a plan of care for a newborn infant with spina bifida (meningomyelocele type). The nurse includes data collection measures in the plan to monitor for increased intracranial pressure (ICP). Which of the following will best detect the presence of an increase in ICP? 1. Monitoring blood pressure for signs of hypotension 2. Monitoring for signs of dehydration 3. Monitoring urine for specific gravity 4. Monitoring the anterior fontanelle for bulging Answer: 4 Rationale: A bulging or taut anterior fontanelle would indicate the presence of increased ICP. Blood pressure is difficult to assess during the newborn period and is not the best indicator of increased ICP. Urine concentration is also not well developed in the newborn stage of development. Monitoring for signs of dehydration will not provide data related to increased ICP. Test-Taking Strategy: Focus on the issue of the question—monitoring for increased ICP. Use the process of elimination and knowledge regarding the findings in the newborn infant that would indicate the presence of increased ICP. Review these data collection techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 432.
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