Silvestri301-400
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PN Comprehensive Review CD Questions 301-400 {COMP: No Equations/Formulas; No questions} 301. A nursing student is assisting in caring for a client with a lung tumor who will be having a pneumonectomy. The nursing instructor reviews the postoperative plan of care developed by the student and suggests deleting which of the following from the plan? 1. Monitoring the closed chest tube drainage system 2. Encouraging coughing and deep breathing exercises 3. Checking the surgical dressing for drainage 4. Avoiding complete lateral positioning Answer: 1 Rationale: Closed chest drainage is not usually used following pneumonectomy. The serous fluid that accumulates in the empty thoracic cavity eventually consolidates. The consolidation prevents shifts of the mediastinum, heart, and remaining lung. Complete lateral positioning is avoided because the mediastinum is no longer held in place on both sides by lung tissue and extreme turning may cause mediastinal shift and compression of the remaining lung. Options 2 and 3 are general postoperative measures. Test-Taking Strategy: Use the process of elimination and note the key words suggests deleting. These words indicate a false response question and that you need to select the incorrect intervention. Eliminate options 2 and 3 first because they are general postoperative measures. From the remaining options, focus on the surgical procedure and the effects of the surgical procedure to direct you to the correct option. If you had difficulty with this question, review postoperative care of this surgical procedure. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Oncology Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 558. 302. A nurse is monitoring a client with a diagnosis of cancer for signs and symptoms related to vena cava syndrome. The nurse understands that which of the following is an early sign of this oncological emergency? 1. Periorbital edema 2. Confusion 3. Mental status changes 4. Disorientation Answer: 1 Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes are late signs. Test-Taking Strategy: Use the process of elimination and note the key word early. Note
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the similarity between options 2, 3, and 4 and eliminate these options. If you are unfamiliar with vena cava syndrome, review this oncological emergency. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 291. 303. A client arrives in the emergency room in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection would focus on: 1. The object of the crisis 2. The presence of support systems 3. The physical condition of the client 4. The client’s coping mechanisms Answer: 3 Rationale: The initial nursing assessment of a client in a crisis state is to determine the physical condition of the client, the potential for self-harm, and the potential for harm to others. Once this has been determined and appropriate interventions have been initiated, the nurse would then proceed to care for the client. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Physiological needs take priority over other needs. Option 3 is the only option that addresses a physiological need. Review care to the client in crisis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological 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. 198. 304. A nurse is collecting data from a client in crisis and is determining the potential for self-harm. Which of the following data would indicate that the client is a very high risk for suicide? 1. The client is disorganized 2. The client is impulsive 3. The client has a history of suicide attempts 4. The client has an immediate plan for a suicide attempt Answer: 4 Rationale: The client presents a lethality potential if the client appears disorganized and impulsive. Clients at higher risk include those with a history of a dual diagnosis of mental illness and substance abuse and those with a personal or family history of suicide attempts, depression, alcoholism, or psychotic episodes. Having a suicide plan, however, particularly if the method is immediate and available, makes the client very high risk. Test-Taking Strategy: Use the process of elimination. Noting the key words a very high risk should easily direct you to option 4. Also, note the key words immediate plan in the
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correct option. Review the risk factors associated with suicide 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. 287. 305. A nurse has been closely observing a client that has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which of the following nursing interventions is least helpful for this client at this time? 1. Acknowledge the client’s behavior 2. Maintain a safe distance from the client 3. Assist the client to an area that is quiet 4. Initiate confinement measures Answer: 4 Rationale: During the escalation period, the client’s behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. It is not appropriate during this period to initiate confinement measures. Initiating confinement measures is most appropriate during the crisis period. Test-Taking Strategy: Note the key words least helpful. These words indicate a false response question and that you need to select the least helpful intervention. Noting the word “confinement” in option 4 will direct you to this option. Review these interventions 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. 116. 306. A nursing assistant is assigned to work with a nurse to care for a client who was at risk for suicide. Which of these statements made by the nursing assistant indicates to the nurse that the nursing assistant understands suicide? 1. “When a person talks about making suicide threats, the only thing the person wants is attention from family and friends.” 2. “Discussing suicide with a client is not harmful.” 3. “Depressed clients are the only persons who commit suicide.” 4. “Those clients who talk about suicide never do it.” Answer: 2 Rationale: An open discussion of suicide will not encourage a client to make a decision to commit suicide, and will, in fact, often help to prevent it. Such a discussion offers the health care personnel the opportunity to assess the reality of suicide for the client and take necessary precautions to keep the client safe. Options 1, 3, and 4 are incorrect.
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Test-Taking Strategy: Use the process of elimination and note the key word understands in the question. Note the absolute words “only” in options 1 and 3 and “never” in option 4; eliminate these options. If you had difficulty with this question, review the concepts related to the suicidal client. 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. 289. 307. A nurse is assigned to care for a suicidal client. The appropriate nursing intervention in dealing with this client is to: 1. Demonstrate confidence in the client’s ability to deal with stressors 2. Provide hope and reassurance that the problems will resolve themselves 3. Display an attitude of detachment, confrontation, and efficiency 4. Provide authority, action, and participation Answer: 4 Rationale: A crisis is an acute time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous problemsolving methods. One who intervenes in this situation (the nurse) “takes over” for the client who is not in control and devises a plan (action) to secure and maintain the client’s safety. Once this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies. Test-Taking Strategy: Use the process of elimination. The client who experiences a “suicidal crisis” is in acute disequilibrium. Remember, in a “crisis” an authority figure must emerge to take action. Review crisis intervention and the nurse’s responsibilities 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. 289. 308. A depressed client is found unconscious on the floor in the day room of a psychiatric nursing unit. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. The immediate action of the nurse is to: 1. Call emergency medical personnel 2. Induce vomiting and notify the physician for further orders 3. Call Poison Control 4. Try to figure out the number of pills taken Answer: 1 Rationale: Tricyclic antidepressants can be fatal when taken as an overdose regardless of the amount ingested. Serious, life-threatening symptoms can develop after an overdose.
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Immediate emergency medical attention and cardiac monitoring is needed in the event of an overdose of tricyclics. Test-Taking Strategy: Use the process of elimination and note the key words immediate action. Options 3 and 4 would delay measures in providing immediate treatment. Eliminate option 2 because vomiting would not be induced in a client who is unconscious. Review immediate measures in a situation such as an overdose of tricyclics 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: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed.). St. Louis: Mosby, p. 478. 309. A nurse employed in a psychiatric unit receives a client assignment for the day. Which of the following clients assigned to the nurse is at the highest risk for committing suicide? 1. A 24-year-old client who just had an argument with another client 2. A 71-year-old client with mild depression and severe cognitive deficits 3. A 75-year-old male with severe depression and cancer 4. A 30-year-old newly divorced client who has custody of the children Answer: 3 Rationale: The individual at highest risk for suicide is the individual with a terminal illness. Other high-risk groups include adolescents; drug abusers; those individuals with social problems, recent losses, or few or no social support groups; and individuals with a history of suicide attempts and a suicide plan. Test-Taking Strategy: Use the process of elimination. Noting the word “severe” in option 3 will direct you to this option. Review the risk factors and groups at risk for suicide 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. 286. 310. A suicidal client is admitted to the hospital. The nurse reviews the nursing care plan and notes documentation of a nursing diagnosis of dysfunctional grieving related to the loss of a spouse. The client progresses well and is approaching discharge. Which of the following is an appropriate outcome for this client? 1. The client verbalizes stages of grief and plans to attend a community grief group 2. The client verbalizes connections between significant losses and low self-esteem 3. The client verbalizes decreased desire for self-harm and discusses two alternatives to suicide 4. The client reports three additional coping strategies Answer: 1
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Rationale: The question is focused on the nursing diagnosis of dysfunctional grieving. The only option that deals with grief is option 1. Options 2, 3, and 4 are unrelated to this nursing diagnosis. Test-Taking Strategy: When presented with a question that identifies a nursing diagnosis, use the information in the question to assist in directing you to the correct option. Option 1 is the only option that is focused on the nursing diagnosis of dysfunctional grieving. Additionally, note the word “grieving” in the question and the word “grief” in the correct option. Review the defining characteristics for dysfunctional grieving if you had difficulty with this question. Level of Cognitive Ability: Analysis 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. 166. 311. A client comes to the emergency room following an assault and is extremely agitated, trembling, and hyperventilating. The appropriate initial nursing action would be: 1. Encourage the client to discuss the assault 2. Place the client in a quiet room alone to decrease stimulation 3. Remain with the client until the anxiety decreases 4. Begin to teach relaxation techniques Answer: 3 Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is critical for the nurse to remain with the client. Processing the anxiety at this point will further increase the client’s level of anxiety. The client in a severe state of anxiety would not be able to learn relaxation techniques. Test-Taking Strategy: Knowledge of nursing interventions for clients who display symptoms of severe anxiety is necessary to assist you in answering this question. Remember to use therapeutic techniques. The best technique in this situation is to remain with the client. If you are unfamiliar with the symptoms of the different levels of anxiety and the interventions that are indicated, review this information. 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. 312. A woman comes into the emergency room following an assault. Her symptoms include hyperventilation, pacing, rapid speech, and headache. The nurse correctly determines that the client is experiencing which level of anxiety? 1. Panic 2. Severe 3. Moderate
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4. Psychotic Answer: 2 Rationale: Clients who have severe anxiety have significant somatic complaints, ineffective functioning, loud or rapid speech, and purposeless activity. The symptoms in the question do not relate to options 1, 3, or 4. Test-Taking Strategy: Note the client symptoms carefully when trying to correctly answer a question similar to this one. Review the signs and symptoms associated with each level of anxiety 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. 266, 263. 313. A nurse is caring for an older, depressed client whose son was killed in an armed robbery after murdering two people. The client says, “I don’t know what I did wrong. His Dad died a hero in Vietnam when he was only 2 years old, but he’s had everything. When he threw the cat up against the wall ‘to see if it landed on its feet’ and stole money from me and denied it, his sister ‘covered’ for him.” The nurse plans to make which therapeutic response to the client? 1. “It seems as if you or your daughter feel regret.” 2. “Oh well; we can only love our children, do our very best, and hope they reflect our upbringing.” 3. “Do I hear you saying that you feel that your son’s behavior was caused by the indulgence he received from his sister?” 4. “Don’t blame yourself. You seem to have been very caring. Some people just turn out evil despite all we do for them.” Answer: 1 Rationale: The most therapeutic response by the nurse is one that seeks to promote the client to reframe a situation. In option 2, the nurse uses trite, clichéd social, nontherapeutic communication. In option 3, the nurse uses an inappropriate and inaccurate dynamic interpretation, which is insensitive. In option 4, the nurse uses false reassurance, which is nontherapeutic. Test-Taking Strategy: This question tests your ability to identify the most therapeutic communication technique for the nurse to employ for clients who blame themselves for the behavior of others. Use the process of elimination and knowledge regarding the therapeutic communication techniques to assist in directing you to option 1. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological 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.
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314. A nurse is preparing a hospitalized client for discharge. In evaluating the coping strategies learned during hospitalization, the nurse would recognize which statement by the client as an indication that further teaching is needed? 1. “I have learned ways to deal with the stresses in my life.” 2. “I know that I won’t become depressed again.” 3. “I know that I can’t be all things to all people.” 4. “I need to take my medications just as prescribed.” Answer: 2 Rationale: Depression may be a recurring illness for some people. The client needs to understand the symptoms and recognize when or if treatment needs to begin again. Options 1, 3, and 4 identify that the client has learned some coping skills, such as setting limits and taking medications. Test-Taking Strategy: Note the key words further teaching is needed. These words indicate a false response question and that you need to select the client statement that indicates ineffective coping strategies. Options 1, 3, and 4 are positive and realistic. A client statement such as option 2 is the only unrealistic statement, and thus indicates further teaching is needed. Review the indicators of effective use of coping strategies if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 217-218. 315. A nurse is monitoring a client that is in seclusion. The nurse determines that the client is safe to come out of seclusion when the client states: 1. “I am no longer a threat to myself or others.” 2. “I need to go to the bathroom.” 3. “I want to be alone for a while in my own room.” 4. “I can’t breathe in here. The walls are closing in on me.” Answer: 1 Rationale: Option 1 is clearly the best choice of the four options. The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with a urinal or bedpan, if necessary. It does not indicate that the client has calmed down enough to leave the seclusion room. Option 3 could be an attempt to manipulate the nurse. It gives no indication that the client will demonstrate self-control when alone in their room. Option 4 indicates the need for supportive communication or possibly a PRN medication. It does not necessitate discontinuing seclusion. Test-Taking Strategy: Focus on the issue. The issue of the question specifically relates to safety. You should easily be directed to option 1. Review seclusion procedures if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation
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Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 264. 316. A nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which of the following? 1. Follow-up appointments 2. Contracts and immediately available crisis resources 3. Encouraging the family to always be with the client 4. Providing the hospital phone number Answer: 2 Rationale: Crisis times may occur between appointments. Contracts facilitate clients feeling responsible for keeping a promise. This gives the client control. Option 3 is unrealistic. Providing phone numbers will not assure available and immediate crisis intervention. Test-Taking Strategy: The issue of the question relates to the availability of immediate resources for the client if needed. Eliminate option 3 first because this is unrealistic. Options 1 and 4 will not necessarily provide immediate resources. Also, note the word “immediate” in the correct option. This word will assist you in answering correctly. Review discharge planning for a client who attempted suicide 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. 289. 317. A client with active tuberculosis (TB) demonstrates less than expected interest in learning about the prescribed medication therapy. The nurse suggests to the health care team that this client may ultimately need: 1. More medication instructions 2. Involvement of the family in teaching 3. Reinforcement by the physician 4. Directly observed therapy Answer: 4 Rationale: TB is a highly communicable disease, which is reportable to the local public health departments. Each of these agencies has regulations that may be enforced to ensure compliance with TB therapy. The client may be required to have directly observed therapy to reduce the risk to the general public. This involves having a responsible person actually observe the client taking the medication each day. Test-Taking Strategy: Note the key word ultimately in the stem of the question. This implies an action that would be taken as a last resort. Knowing that TB is a highly communicable, reportable disease, you would eliminate options 1, 2, and then 3 in turn as a final action. This leaves directly observed therapy, which is closely overseen and enforced through the Public Health Department. Review measures to ensure compliance
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with medication therapy in the client with TB if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 375. 318. A 2-year-old child is a suspected victim of child abuse. The nurse is interviewing the child’s parent. Which statement, if made by the parent, would indicate a characteristic associated with child abuse? 1. “Once my child is potty trained, I can still expect them to have some ‘accidents’.” 2. “When I tell my child to do something once, I don’t expect to have to tell them again.” 3. “My child is expected to try to do things on their own such as dress and feed.” 4. “A two-year-old’s vocabulary is usually limited to about 200 words.” Answer: 2 Rationale: One characteristic of abusive parents is that they have expectations that are too high. As a result, the child cannot live up to the expectation of the adult parent. Unrealistic expectations result in the disappointment and frustration of the parent. The parent may even believe that the action of the child is intentional or done out of spite. The parent may react in an excessive manner, causing severe injury to the child. Test-Taking Strategy: Use the process of elimination. Options 1, 3, and 4 are true statements in that they are appropriate for the 2-year-old child. Option 2 indicates an unrealistic expectation. Recalling normal growth and development activities for a 2-yearold child will assist you to correctly answer the question. If you had difficulty with this question, review growth and development and the characteristics associated with child abuse. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance 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. 271. 319. A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, “I’m finally cured.” The nurse interprets this behavior as a cue to modify the treatment plan by: 1. Allowing the client off unit privileges PRN 2. Suggesting a reduction of medication 3. Allowing increased “in room” activities 4. Increasing the level of suicide precautions Answer: 4 Rationale: A client who is moderately depressed and has only been hospitalized for 2 days is very unlikely to have such a dramatic cure. When a mood suddenly lifts, it is very likely that the client may have made the decision to harm self. Suicide precautions are
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necessary to keep the client safe. Test-Taking Strategy: Use the process of elimination. Options 1 and 2 support the client’s notion that a cure has occurred. Option 3 allows the client to increase isolation, and that would present a threat to the treatment plan. Safety is of the utmost importance; therefore option 4 is the correct choice. Review care to the client with depression if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment 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. 222. 320. A nurse employed in a mental health unit who cares for suicidal clients is reviewing the work schedule. The nurse expects to note in the schedule that additional precautions related to safety for the clients will be provided at which of the following times? 1. Day shift 2. Weekdays 3. 7 AM to 10 AM 4. Weekends Answer: 4 Rationale: There is less availability of nursing staff on the weekends, and the nurse should be alert to this high-risk time. Additionally, often during shift change there is less availability of staff. The nurse should increase precautions of identified suicidal clients at these times. The night shift is also more likely to have a suicide attempt, rather than the day shift. Test-Taking Strategy: Use the process of elimination. Options 1, 2, and 3 are similar and can be eliminated. The nurse could anticipate that times with less supervision of the client could be times of increased risk. Review the guidelines related to caring for a client at risk for suicide if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 287-288. 321. An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which of the following would be least effective in preparing the client to return to a safe, effective care environment? 1. Identify the family’s strengths and weaknesses 2. Suggest that the mother’s boyfriend move out of the home 3. Provide and offer the family options and resources 4. Encourage sharing of feelings Answer: 2 Rationale: Option 2 is clearly the least effective option because there is no information in
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the question that leads one to believe that the boyfriend’s involvement has anything to do with the suicide attempt. Options 1, 3, and 4 are helpful ways to enhance the family processes. Test-Taking Strategy: Note the key words least effective. These words indicate a false response question and that you need to select the least helpful measure. There is no information in the question that leads you to believe there is a problem with the boyfriend that led the adolescent’s attempt to commit suicide. It is important that a nurse remain nonjudgmental when dealing with clients. Additionally, options 1, 3, and 4 identify positive measures that will assure a safe environment for the client. Review care to the client at risk for suicide if you had difficulty with this question. Level of Cognitive Ability: Analysis 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. 286. 322. A client tells a nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment? 1. Administer the prescribed antianxiety medication immediately 2. Move the client to a quiet room and talk about their feelings 3. Isolate the client in a seclusion room 4. Continue to monitor the client Answer: 2 Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client decreases environmental stimuli and talking gives the nurse an opportunity to identify the cause of these feelings and appropriate interventions. Seclusion is not appropriate. Medication is used only when other noninvasive approaches have been unsuccessful. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 first. From the remaining options, select option 2 over option 3 because it addresses the client’s feelings. Remember, client’s feelings are most important. Review interventions for a client who feels out of control 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, p. 70. 323. A nurse employed in an emergency room is assisting in caring for an adult client who is a victim of family violence. The nurse includes which priority instruction to the victim in the discharge plan? 1. Instructions explaining the importance of leaving the violent situation 2. Information regarding the location of shelters
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3. Information regarding self-defense classes 4. Instructions regarding calling the police Answer: 2 Rationale: Tertiary prevention of family violence includes assisting the victim once the abuse has already occurred. The nurse should provide the client with information identifying sources of assistance, such as a specific plan for removing self from the abuser, phone numbers of hot lines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Test-Taking Strategy: Use the process of elimination and note the key word priority. Focus on the issue of the question, which relates to providing the client with a safe environment. Use Maslow’s Hierarchy of Needs theory to assist in directing you to option 2. If you had difficulty with this question, review the nursing measures for caring for a victim of family violence. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed.). St. Louis: Mosby, p. 527. 324. A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels “as though the rape just happened yesterday” even though it has been a few months since the incident. The appropriate nursing response is which of the following? 1. “What do you think that you can do to alleviate some of your fears about being raped again?” 2. “Tell me more about the incidence that causes you to feel like the rape just occurred.” 3. “It will take some time to get over these feelings about your rape.” 4. “You need to try to be realistic. The rape did not just occur.” Answer: 2 Rationale: Option 2 allows for the client to express her ideas and feelings more fully, and portrays a nonhurried, nonjudgmental, supportive attitude. Clients need to be reassured that their feelings are normal, and that they may freely express their concerns in a safe care environment. Option 1 places the problem-solving totally on the client. Option 3 places the client’s feelings on hold. Option 4 immediately blocks communication. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. The client is seeking help. Remember to always 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: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88.
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325. A client is admitted to the psychiatric unit following a serious suicidal attempt by a drug overdose. The priority nursing intervention is to: 1. Remain with the client at all times 2. Place the client in a seclusion room where all potentially dangerous articles are removed 3. Remove the client’s clothing and place the client in a hospital gown 4. Request that a peer remain with the client at all times Answer: 1 Rationale: Drug overdose is a serious suicide attempt. The plan of care must reflect the action that will promote the client’s safety. Constant observation by a staff member who is never less than an arm’s length away is the best action. Options 2, 3, and 4 are inappropriate. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because it is not a peer’s responsibility to safeguard a client. Eliminate option 3 next because removing one’s clothing does not maximize all possible safety strategies. From the remaining options, select option 1 because it provides a constant supervision in this critical situation. Review care to the client at risk for suicide 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, p. 288. 326. A nurse is working with a victim of rape in a clinic setting and assists to develop a plan of care for the client. Which short-term initial goal is inappropriate? 1. The client will resolve feelings of fear and anxiety related to the rape trauma 2. Physical wounds will heal 3. The client will verbalize feelings about the event 4. The client will participate in the treatment plan Answer: 1 Rationale: Short-term goals will include the beginning stages of dealing with the rape trauma. Clients will be expected initially to keep appointments, participate in care, begin to explore feelings, and begin to heal physical wounds that were inflicted at the time of the rape. Test-Taking Strategy: Note the key words short-term initial goal and inappropriate. Use the process of elimination, considering each option and the reality of the option statement being achieved short term. Note the word “resolve” in option 1. This word should provide you with the clue that this option is a long-term goal. Review realistic goals for a client who was a victim of rape if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health
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Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 274-275. 327. A client who is experiencing suicidal thoughts states to the nurse, “It just doesn’t seem to be worth it anymore. Why not just end it all?” The appropriate initial nursing response is: 1. “I’m sure your family loves you.” 2. “I know you don’t feel good about yourself.” 3. “Did you sleep last night?” 4. “What do you mean by that?” Answer: 4 Rationale: Option 4 allows the client to tell you more about his/her current state of mind. Option 1 is false reassurance and may close communication. While option 2 is offering empathy for the client, it does not provide further assessment. Option 3 changes the subject and may close communication. Test-Taking Strategy: Use the steps of the nursing process and therapeutic communication techniques to select the correct option. Options 1 and 2 can be easily eliminated because they do not reflect data collection. Both options 3 and 4 relate to further data collection, but option 4 is directly related to the issue of the question. 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. 328. A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse reviews the plan of care for the client and notes that a nursing diagnosis of ineffective coping is documented in the plan. Which of the following is the least realistic goal for this client? 1. The client will identify a realistic perception of stressors 2. The client will develop adaptive coping patterns 3. The client will express and share feelings regarding the present crisis 4. The client will stop blaming himself for the lack of insurance Answer: 4 Rationale: Options 1, 2, and 3 identify a positive movement toward increased selfesteem and problem-solving. Option 4 places undue pressure on the client by implying that the client was negligent and contributed to the loss. Test-Taking Strategy: Use the process of elimination. Note the key words least realistic. The words “realistic,” “adaptive,” and “express and share feelings” in options 1, 2, and 3, respectively, identify positive goals. This should assist in directing you to option 4. Additionally, there is nothing in the question that indicates that the client lacked insurance, as option 4 reflects. Review goals for the client with a nursing diagnosis of ineffective coping if you had difficulty with this question. Level of Cognitive Ability: Analysis
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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. 181. 329. A nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which of the following is the priority nursing action? 1. Adhering to the mandatory abuse reporting laws 2. Obtaining treatment for the abusing family member 3. Notifying the case worker of the family situation 4. Removing the client from any immediate danger Answer: 4 Rationale: Whenever the abused client remains in the abusive environment, priority must be placed on ascertaining whether the person is in any immediate danger. If so, emergency action must be taken to remove them from the abusing situation. Options 1, 2, and 3 may be appropriate interventions but are not the priority. Test-Taking Strategy: Note the key word priority. Use Maslow’s Hierarchy of Needs theory, remembering that if a physiological need is not present than safety is the priority. This guide should direct you to option 4, the only option that directly addresses client safety. Review care to the client who is a victim of physical abuse if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Stuart, G., & Laraia, M. (2005) Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 809. 330. A nurse in the emergency department is assisting in caring for a young female victim of sexual assault. The client’s physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. These behaviors are interpreted by the nurse as: 1. Evidence that the client is a high suicide risk 2. Indicative of the need for hospital admission 3. Signs of depression 4. Normal reactions to a devastating event Answer: 4 Rationale: The symptoms noted in the question indicate a normal reaction to a very intensely difficult crisis event. Although the client’s initial reactions may be predictive of later problems, they do not indicate an abnormal initial response. Test-Taking Strategy: Remember, during the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. Use knowledge regarding client responses to devastating events and the process of elimination to answer the question. If you had difficulty with this question, review normal and abnormal client responses to dealing with devastating crisis events.
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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. 273. 331. A nurse caring for a client scheduled for a transsphenoidal hypophysectomy assists to develop a plan of care for the client. The nurse suggests inclusion of which specific information in the preoperative teaching plan? 1. Hair will need to be shaved 2. Deep breathing and coughing will be needed after surgery 3. Tooth brushing will not be permitted for at least 2 weeks following surgery 4. Spinal anesthesia will be used Answer: 3 Rationale: Based on the location of the surgical procedure, spinal anesthesia would not be used. Additionally, the hair would not be shaved. Although coughing and deep breathing is important, specific to this procedure is the avoidance of tooth brushing to prevent disruption of the surgical site. Test-Taking Strategy: Note the key word specific. Consider the anatomical location and the surgical procedure itself to eliminate options 1 and 4. Although you may be tempted to select option 2, read carefully. Because of the anatomical location of the surgery, option 3 is most important. Review this surgical procedure 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/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 861. 332. Following a hypophysectomy, the client complains of being very thirsty and having to urinate frequently. The initial nursing action is to: 1. Document the complaints 2. Increase fluid intake 3. Check the urine’s specific gravity 4. Check for the presence of glucose in the urine Answer: 3 Rationale: Following a hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone (ADH) deficiency. This deficiency is related to surgical manipulation. The nurse should check the urine’s specific gravity and report the results if it is less than 1.005. Test-Taking Strategy: Note the key word initial. Knowledge that diabetes insipidus is a complication of this type of surgery will assist in eliminating option 4. From the remaining options, recall the pathophysiology related to diabetes insipidus to direct you to option 3. Review this pathophysiology if you had difficulty with this question.
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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 861-862. 333. A nurse is reviewing the physician’s orders for a client with hypothyroidism. Which of the following medications, if prescribed for the client, would the nurse question and verify? 1. Docusate sodium (Colace) 2. Morphine sulfate 3. Levothyroxine (Synthroid) 4. Atenolol (Tenormin) Answer: 2 Rationale: The client with hypothyroidism experiences fatigue, lethargy, and increased somnolence. The decreased metabolism and oxygen consumption are manifested by a slow heart rate, decreased cardiac output, and decreased blood pressure. Levothyroxine, a thyroid hormone, is a component of therapy. Stool softeners such as docusate sodium are prescribed to promote defecation. Morphine sulfate would further depress bodily functions. Atenolol is used with caution in clients with hyperthyroidism. Test-Taking Strategy: Use the process of elimination. Keeping in mind that a decreased metabolic rate occurs in the client with hypothyroidism will direct you to option 2 as the medication that would be avoided in this condition. Review the pathophysiology associated with hypothyroidism if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1322. 334. A client is brought to the emergency room in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse who is assisting to care for the client obtains which of the following immediately in preparation for the treatment of this syndrome? 1. NPH insulin 2. A nasal cannula 3. Intravenous (IV) infusion of sodium bicarbonate 4. IV infusion of normal saline Answer: 4 Rationale: The primary goal of treatment is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. IV fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium
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levels. A nasal cannula for oxygen administration is not necessarily required to treat HHNS. Test-Taking Strategy: Use the process of elimination. If you can recall the treatment for DKA, you will easily be able to answer this question. Treatment for HHNS is similar to the treatment for DKA. Review the treatment for HHNS 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/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 905. 335. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency room. Which of the following findings would the nurse expect to note as confirming this diagnosis? 1. Elevated blood glucose and low plasma bicarbonate levels 2. Decreased urine output 3. Increased respirations and an increase in arterial pH 4. Coma Answer: 1 Rationale: In DKA, the arterial pH is less than 7.35, the plasma bicarbonate level is less than 15 mEq/L, the blood glucose level is greater than 250 mg/dl, and ketones are present in the blood and urine. The client would be experiencing polyuria, and Kussmaul’s respirations would be present. Coma may occur if DKA is not treated, but coma would not confirm the diagnosis. Test-Taking Strategy: Note the key word confirm in the stem of the question. Eliminate option 4 because coma can exist is many conditions. Eliminate option 3 because in acidosis the pH would be low. Remember that polyuria exists in DKA. This leaves option 1 as the correct choice. Review the clinical manifestations of this disorder 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 904-905. 336. A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial serum glucose level was 950 mg/dl. Intravenous (IV) insulin was started along with rehydration with IV normal saline. The serum glucose level is now 240 mg/dl. The nurse who is assisting in caring for the client obtains which of the following items, anticipating a physician’s order? 1. IV infusion containing 5% dextrose 2. NPH insulin and a syringe for subcutaneous injection 3. An ampule of 50% dextrose
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4. Phenytoin (Dilantin) for the prevention of seizures Answer: 1 Rationale: During management of DKA, when the blood glucose level falls to 300 mg/dl the infusion rate is reduced and 5% dextrose is added to maintain a blood glucose level of about 250 mg/dl, or until the client recovers from ketosis. NPH insulin is not used to treat DKA. Dextrose 50% is used to treat hypoglycemia. Phenytoin is not a normal treatment measure in DKA. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first, knowing that regular insulin is used in the management of DKA. Eliminate option 3 next, knowing that this is the treatment for hypoglycemia. Note the key words the serum glucose level is now 240 mg/dl. This should indicate that the IV solution of 5% dextrose is the next step in management of care. Review care to the client with DKA if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 905. 337. A client with diabetes mellitus is being discharged following treatment for hyperglycemic hyperosmolar nonketotic syndrome (HHNS) precipitated by acute illness. The client states to the nurse, “I will call the doctor next time I can’t eat for more than a day or so.” The nurse plans care understanding that which of the following most accurately reflects this client’s level of knowledge? 1. The client needs immediate education before discharge 2. The client’s statement is accurate but knowledge should be evaluated further 3. The client’s statement is inaccurate and the client should be scheduled for outpatient diabetic counseling 4. The client requires follow-up teaching regarding the administration of insulin Answer: 1 Rationale: If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the physician should be notified. The client’s statement in this question indicates a need for immediate education to prevent HHNS, a life-threatening emergency situation. Test-Taking Strategy: Knowledge regarding the causes of HHNS will assist in answering the question. Focusing on the client’s statement and noting the words “I can’t eat for more than a day or so” will direct you to the correct option. Review diabetic management during times of illness if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 908. 338. A physician has prescribed propylthiouracil (Propylthiouracil) for a client with
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hyperthyroidism, and the nurse assists in developing a plan of care for the client. A priority nursing measure to be included in the plan regarding this medication is to monitor the client for: 1. Signs and symptoms of hypothyroidism 2. Signs and symptoms of hyperglycemia 3. Relief of pain 4. Signs of renal toxicity Answer: 1 Rationale: Excessive dosing with propylthiouracil may convert the client from a hyperthyroid state to a hypothyroid state. If this occurs, the dosage should be reduced. Temporary administration of thyroid hormone may be required. Propylthiouracil is not used for pain and does not cause hyperglycemia or renal toxicity. Test-Taking Strategy: Focus on the data in the question. Noting that propylthiouracil is used to treat hyperthyroidism should direct you to option 1. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 904-905. 339. A nurse is monitoring a client with diabetes insipidus. Desmopressin (DDAVP) has been prescribed for the client. Which of the following outcomes reflects a therapeutic effect of this medication? 1. Increased serum osmolality 2. Increased blood pressure 3. Decreased urine output 4. Decreased urine osmolality Answer: 3 Rationale: Desmopressin is a synthetic form of antidiuretic hormone. It causes increased reabsorption of water with a resultant decrease in urine output. Therapeutic response to desmopressin would demonstrate a decrease in serum osmolality as more fluid is retained, and an increase in urine osmolality as less fluid is excreted. Increased blood pressure is a side effect rather than a therapeutic effect of desmopressin. Test-Taking Strategy: Use the process of elimination and note the key words therapeutic effect. Knowledge of the action of desmopressin and the pathophysiology related to diabetes insipidus will direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 301.
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340. A nurse is assisting in preparing a care plan for a client with diabetes mellitus who has hyperglycemia. The nurse suggests addressing which priority problem in the plan of care? 1. Deficient fluid volume 2. Deficient knowledge 3. Imbalanced nutrition 4. Compromised family coping Answer: 1 Rationale: Increased blood glucose will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 2, 3, and 4 may be concerns at some point, but are not the priority with hyperglycemia. Test-Taking Strategy: Focus on the client’s diagnosis. Option 1 indicates a physiological response to the hyperglycemia that should be a priority. Options 2, 3, and 4 may or may not need to be addressed after providing for the physiological need associated with hyperglycemia. Review the effects of hyperglycemia in the diabetic client if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 487. 341. A nurse is assigned to care for a client at home who has a diagnosis of type 1 diabetes mellitus. When the nurse arrives to care for the client, the client tells the nurse that she has been vomiting and has diarrhea. Which additional statement by the client indicates a need for reinforcing teaching? 1. “I need to stop my insulin.” 2. “I need to increase my fluid intake.” 3. “I need to call my physician.” 4. “I need to monitor my blood glucose every 4 to 6 hours.” Answer: 1 Rationale: When a diabetic client is unable to eat normally due to illness, the client should still take the prescribed insulin or oral medication. Additional fluids should be consumed and a call placed to the health care provider. The client should monitor the blood glucose levels every 4 to 6 hours. Test-Taking Strategy: Use the process of elimination and note the key words need for reinforcing teaching. Remembering that clients need to take their insulin will direct you to option 1. Review these principles 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/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical
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management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1286. 342. A nurse is assigned to assist in caring for a client admitted to the emergency room with diabetic ketoacidosis (DKA). In the acute phase, the priority nursing action is to prepare to: 1. Administer intravenous (IV) regular insulin 2. Administer IV 5% dextrose 3. Correct the acidosis 4. Apply an ECG monitor Answer: 1 Rationale: Lack (absolute or relative) of insulin is the primary cause leading to DKA. Treatment consists of IV fluids (normal saline initially), regular insulin administration, and potassium replacement, followed by correcting the acidosis. An ECG monitor may be applied but is not the priority in this situation. Test-Taking Strategy: Note the key word priority. Remember, in DKA the initial treatment is IV fluid replacement and the administration of regular insulin. Normal saline is administered initially; therefore option 2 is incorrect. Options 3 and 4 may be a component of the treatment plan, but are not the priority. Review care to the client with DKA 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/Endocrine References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 488. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 904. 343. A client with type 2 diabetes mellitus has a blood glucose level over 600 mg/dl and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the physician’s documentation and would expect to note which of the following diagnoses? 1. Diabetic ketoacidosis (DKA) 2. Hypoglycemia 3. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) 4. Pheochromocytoma Answer: 3 Rationale: HHNS is seen primarily in type 2 diabetics who experience a relative deficiency of insulin. The onset of symptoms may be gradual. The symptoms may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness. DKA normally occurs in type 1 diabetes mellitus. The clinical manifestations noted in the question are not signs of hypoglycemia. Pheochromocytoma is not related to these clinical manifestations. Test-Taking Strategy: Use the process of elimination. The key words are type 2 diabetes mellitus and blood glucose level over 600 mg/dl. These key words will assist in eliminating options 2 and 4. Recalling that HHNS most commonly occurs in type 2 diabetes mellitus will direct you to option 3. Review the complications associated with
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type 2 diabetes mellitus 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 References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 488. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 906. 344. A family of a bedridden client with type 2 diabetes mellitus calls the clinic nurse to report the following symptoms: blood glucose level 400 mg/dl (by fingerstick), polydipsia, and increased lethargy. In determining the client’s problem, the most important question to ask the family is which of the following? 1. “Has there been any change in eating patterns?” 2. “Are there any ketones in the urine?” 3. “Has there been any fever?” 4. “Have you increased the amount of fluids provided?” Answer: 2 Rationale: In type 2 diabetes mellitus, hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is a concern. The clinical manifestations are similar to diabetic ketoacidosis (DKA) except that HHNS is differentiated from DKA by the absence of excessive ketone bodies. Options 1, 3, and 4 may be questions that will be asked but are not the most important in this situation. Test-Taking Strategy: Note the key words most important and the signs and symptoms presented in the question. Options 1 and 3 can be eliminated first because they are unrelated to these signs and symptoms. From the remaining options, option 2 is most specific in assisting to determine the client’s problem. Review the complications associated with type 2 diabetes mellitus and the differences between DKA and HHNS 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 References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 488. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 905. 345. A nurse is preparing to administer an injection of regular insulin. The vial of regular insulin has been refrigerated. Upon inspection of the vial, the nurse finds that the medication is frozen. The nurse should: 1. Wait for the insulin to thaw at room temperature 2. Check the temperature settings of the refrigerator 3. Discard the insulin and obtain another vial 4. Rotate the vial between the hands until the medication becomes liquid
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Answer: 3 Rationale: Insulin preparations are stable at room temperature for up to 1 month without significant loss of activity. Insulin should not be frozen. If the insulin is frozen, the insulin should be discarded and the nurse should obtain another vial. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 because they are similar. From the remaining options, option 3 is most directly related to client safety. Therefore select this option. Review insulin storage principles 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/Endocrine Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 604. 346. A nurse has collected data on a client with diabetes mellitus. Findings include a fasting blood glucose level of 100 mg/dl, temperature 101° F, pulse 78 beats per minute, respirations 22 breaths per minute, and blood pressure 118/78 mm Hg. Which finding would be of most concern to the nurse? 1. Pulse and respirations 2. Blood pressure 3. Blood glucose 4. Temperature Answer: 4 Rationale: Elevated temperature may be indicative of infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) or diabetic ketoacidosis (DKA). Options 1, 2, and 3 are findings that are within a normal range. Test-Taking Strategy: Basic knowledge of the normal values of vital signs will easily direct you to the correct option. The client’s temperature is the only abnormal value. Remember that an elevated temperature can indicate an infectious process that may lead to diabetic complications. Review the complications associated with diabetes mellitus 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: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1272. 347. A nurse is collecting data from a client newly diagnosed with diabetes mellitus regarding the client’s learning readiness. Which client behavior indicates to the nurse that the client is not ready to learn? 1. The client complains of fatigue whenever the nurse plans a teaching session 2. The client asks if the spouse can attend the classes also 3. The client asks for written materials about diabetes before class
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4. The client asks appropriate questions about what will be taught Answer: 1 Rationale: Physical symptoms can interfere with an individual’s ability to learn and can also indicate to the teacher that the learner lacks motivation to learn if the symptoms repeatedly recur when teaching is initiated. Options 2, 3, and 4 identify the client as actively seeking information. Test-Taking Strategy: Note the key words not ready to learn in the stem of the question and use the process of elimination. Options 2, 3, and 4 identify the client as actively seeking information. Option 1 suggests avoidance on the part of the client. Review teaching learning principles if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 451-454. 348. A client with diabetes mellitus visits the health care clinic. The client had previously been well controlled with glyburide (DiaBeta), but recently the fasting blood glucose level has been 180 to 200 mg/dl. Which of the following medications, if added to the client’s regimen, may be contributing to the hyperglycemia? 1. Prednisone (Deltasone) 2. Atenolol (Tenormin) 3. Phenelzine sulfate (Nardil) 4. Allopurinol (Zyloprim) Answer: 1 Rationale: Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Options 2, a beta-blocker, and 3, a monoamine oxidase inhibitor, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral medications, which can lead to hypoglycemia. Test-Taking Strategy: The issue of the question relates to hyperglycemia. This question requires that you know the medication classifications of the medications in the options and correlate these with their potential hypoglycemic or hyperglycemic effect. Remember, prednisone may decrease the effect of oral hypoglycemics. Review these medications if you are unfamiliar with them. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 883. 349. A nurse collects urine specimens for catecholamine testing from a client with suspected pheochromocytoma. The results of the catecholamine test are reported as 20 mcg/100 mL of urine. The nurse analyzes these results as:
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1. Normal 2. Lower than normal, ruling out pheochromocytoma 3. Higher than normal, indicating pheochromocytoma 4. Insignificant and unrelated to pheochromocytoma Answer: 3 Rationale: Assays of catecholamines are performed on single-voided urine specimens, 2hour to 4-hour specimens, and 24-hour urine specimens. The normal range of urinary catecholamines is up to 14 mcg/100 mL of urine, with higher levels occurring in pheochromocytoma. Test-Taking Strategy: Knowing that pheochromocytoma is a catecholamine-producing tumor, you would expect that the results of such a test would indicate higher than normal amounts of catecholamine. Additionally, the question addresses that the client is suspected of having pheochromocytoma, so if you need to select an option and you are not quite sure, select the option that has similarity to the issue of the question. In this case, suspected pheochromocytoma is similar to indicating pheochromocytoma addressed in option 3. Review this diagnostic test if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 928-929. 350. A physician orders a 24-hour urine collection for vanillylmandelic acid (VMA). The nurse instructs the client about the procedure for the collection of the urine. Which statement by the client would indicate a need for further instruction? 1. “I will start the collection in 2 days. I cannot eat or drink any tea, chocolate, vanilla, or fruit until the test is completed.” 2. “When I start the collection, I will urinate and discard that specimen.” 3. “I will pour the urine in the collection bottle each time I urinate and refrigerate the urine.” 4. “I can take medications if I need to before the collection.” Answer: 4 Rationale: Since a 24-hour urine collection is a timed quantitative determination, it is essential that the client start the test with an empty bladder. Therefore the client is instructed to void and discard the first urine and note the time and then start the test. The 24-hour urine specimen collection bottle must be kept on ice or refrigerated. In a VMA collection, the client is instructed to avoid tea, chocolate, vanilla, and all fruits for 2 days before urine collection begins. Also, clients are reminded not to take medications for 2 to 3 days before the test. Test-Taking Strategy: Note the key words need for further instruction. These words indicate a false response question and that you need to select the incorrect client statement. Knowledge regarding the procedure for 24-hour urine collections will assist you in answering this question. Remember that medications can affect the results of a test. Review the procedure for collecting 24-hour urine specimens if you had difficulty with this question.
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Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1131. 351. A perinatal client has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures? 1. “I should avoid the use of condoms.” 2. “I can douche anytime I want.” 3. “I can wear my tight fitting jeans.” 4. “I should choose underwear with a cotton panel liner.” Answer: 4 Rationale: Condoms should be used to minimize the spread of sexually transmitted infectious diseases. Wearing tight clothes irritates the genital area and does not allow for air circulation. Douching is to be avoided. Wearing items with a cotton panel liner allows for air movement in and around the genital area. Test-Taking Strategy: Use the process of elimination, noting the key words indicates an understanding. Options 1, 2, and 3 are all incorrect statements regarding self-care. Review the measures that will prevent genital tract infections 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: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 422. 352. During initial data collection of a maternity client, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects the presence of human immunodeficiency virus (HIV). Which of the following laboratory studies would further support the presence of HIV? 1. T lymphocyte levels 2. Angiotensin levels 3. Glomerular filtration rate 4. Platelet count Answer: 1 Rationale: HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for T lymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney. Glomerular filtration rate indicates kidney function. Platelet count is important and may be an indicator of HIV, but this laboratory test has already been identified in the components of the question. Test-Taking Strategy: Use the process of elimination. Option 4 has already been identified in the components of the question and can be eliminated. Options 2 and 3 are
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similar in that they are related to kidney function. Review this information if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 339. 353. When caring for the maternal client with human immunodeficiency virus (HIV), which goal would be appropriate? 1. The client will not have sexual relations during the remainder of the pregnancy 2. The client will not develop an opportunistic infection during the remainder of the pregnancy 3. The client is advised of an HIV support group 4. The client is assisted with the grief process Answer: 2 Rationale: HIV is caused by a retrovirus that infects T lymphocytes. This disables the body’s ability to fight infection. Nursing goals are directed at the prevention of infections. Sexual relations are not contraindicated with the proper use of protective devices. Options 3 and 4 are the focus of interventions, not goals. Test-Taking Strategy: Use the process of elimination and note that the question asks for a goal. Options 3 and 4 are interventions and can be eliminated. Option 1 is inappropriate. Knowledge regarding the infectious nature of HIV will direct you to option 2. Review this information if you had difficulty with the question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 340. 354. A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client’s health record, the nurse notes that the laboratory values indicate a low hemoglobin and hematocrit level. Which of the following problems do the data best support? 1. Anxiety 2. Low self-esteem 3. Cerebrovascular accident 4. High risk for infection Answer: 4 Rationale: Women with anemia have a higher incidence of puerperal complications such as infection than do pregnant women with normal hematological values. There are no data in the question to support options 1, 2, or 3. Test-Taking Strategy: Use the process of elimination. Options 1 and 2 could occur, but the data needed to support these options are not provided in the question. Eliminate
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option 3 because it is a medical diagnosis. Review the risks associated with infection in the pregnant client if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 108-109. Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 384. 355. A nurse is planning interventions for counseling a pregnant client newly diagnosed with sickle cell anemia. The nurse understands that the most important psychosocial intervention at this time would be which of the following? 1. Providing all information regarding the disease immediately 2. Allowing the client to be alone if she is crying 3. Providing emotional support 4. Avoiding the topic of the disease Answer: 3 Rationale: Probably the most important of all nursing functions is providing emotional support to the client and family. Option 1 overwhelms the client with information while the client is trying to cope with the news of the disease. Option 2 is only appropriate if the client requests to be alone. If unrequested, the nurse is abandoning the client in a time of need. Option 4 is nontherapeutic. Supportive therapy allows the client to express feelings, explore alternatives, and make decisions in a safe, caring environment. Test-Taking Strategy: Use therapeutic communication techniques. Remember to always address client feelings first. This will easily direct you to the correct option. Review psychosocial needs of the client with sickle cell anemia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 108. 356. A nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be most appropriate? 1. The client will verbalize a reduction of pain 2. The client will no longer have a positive Homans’ sign 3. The client will report that an infection is likely to occur 4. The client will be able to identify measures to prevent infection Answer: 4 Rationale: The uterus is theoretically sterile during pregnancy until the membrane ruptures. It is capable of being invaded by pathogens after that rupture. Puerperal infection is a major cause of maternal morbidity and mortality. Option 3 is inaccurate.
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Options 1 and 2 are not directly related to infection. Test-Taking Strategy: Use the process of elimination, focusing on the issue—infection. Eliminate options 1 and 2 because they are not directly related to infection. Eliminate option 3 because it is inaccurate. Review postpartum infection if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1048. 357. A nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which of the following statements would the nurse make to the client? 1. “Hands should be washed thoroughly before holding the infant.” 2. “The infant will not be allowed in the room at all.” 3. “There is no danger of the newborn contracting the disease.” 4. “Visitors are not allowed to hold the baby.” Answer: 1 Rationale: Transmission of infectious diseases can occur through contaminated items such as hands and bed linens in clients with endometritis. An important method of preventing infection is to break the chain of infection. Hand washing is one of the most effective methods of preventing the transmission of infectious diseases. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Avoid options that contain absolute terminology such as in options 2, 3, and 4. These options use the words “all” and “no.” Also, remember that hand washing is one of the most effective methods of preventing the transmission of infectious diseases. Review content related to the transmission of infection 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: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 160. 358. A nursing student prepares a teaching plan for a pregnant client newly diagnosed with diabetes mellitus. The nursing instructor suggests changing the plan if the student includes which information? 1. Effects of diabetes on the pregnancy and the fetus 2. Nutritional requirements for pregnancy and for the control of diabetes 3. Avoidance of exercise because of the negative effects on insulin production 4. Awareness of any infections and instructions to report signs of infection immediately to the health care provider Answer: 3
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Rationale: Options 1, 2, and 4 are all important points to include in the teaching plan for the new diabetic. Exercise is necessary for the pregnant diabetic. Concepts related to the timing of exercise, control of food intake, and insulin injection around the time of exercise should be included in the plan. Test-Taking Strategy: Use the process of elimination. Note the key words suggests changing the plan in the question. These words indicate a false response question and that you need to select the incorrect intervention. Remember, exercise is necessary for the pregnant diabetic. If you had difficulty with this question, review the effects of diet and exercise on diabetes. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 228. 359. A postpartum client with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, “Do I have to worry about this diabetes anymore?” The nurse makes which response to the client? 1. “Your blood glucose level is within normal limits now; you will be all right.” 2. “You will only have to worry about the diabetes if you become pregnant again.” 3. “You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus.” 4. “Once you have gestational diabetes you have overt diabetes and must be treated with medication for the rest of your life.” Answer: 3 Rationale: The client is at risk for developing gestational diabetes with each pregnancy. She also has an increased risk of developing overt diabetes and needs to comply with follow-up appointments. She also needs to be taught techniques to lower her risk for developing diabetes, such as weight control. The diagnosis of gestational diabetes indicates that this client has an increased risk for developing overt diabetes; however, with proper care it may not develop. Test-Taking Strategy: Use the process of elimination. Identify the issue of the question, which is the long-term effects of gestational diabetes. Knowledge regarding these effects will direct you to the correct option. Review the long-term effects of gestational diabetes if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 229. 360. A new prenatal client is 6 months pregnant. On the first prenatal visit, the nurse notes that the client is gravida IV, para 0, aborta III. The client is 5 feet 6 inches tall, weighs 130 pounds, and is 25 years old. She states: “I get really tired after working all
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day and can’t keep up with my housework.” Which factor in the above data would lead the nurse to suspect gestational diabetes? 1. Fatigue 2. Obesity 3. Maternal age 4. Fetal demise Answer: 4 Rationale: A previous history of unexplained stillbirths or miscarriages puts the client at high risk for gestational diabetes. Fatigue is a normal occurrence during pregnancy. A client at 5 feet 6 inches tall, 130 pounds does not meet the criteria of 20% over ideal weight. Therefore the client is not obese. To be at high risk for gestational diabetes, the maternal age is usually greater than 30 years. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Note that options 2 and 3 do not apply to this client. Recalling that fatigue is a normal occurrence during pregnancy will direct you to option 4. Review the risk factors related to gestational diabetes if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 101. Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 229. 361. A pregnant client is newly diagnosed as having gestational diabetes. She cries during the interview and keeps repeating, “What have I done to cause this? If I could only live my life over.” Which presenting problem should initially direct nursing care at this time? 1. Situational low self-esteem related to a complication of pregnancy 2. Deficient knowledge related to diabetic self-care during pregnancy 3. Disturbed body image related to complications of pregnancy 4. Risk for injury to the fetus related to maternal distress Answer: 1 Rationale: The client is putting the blame for the diabetes upon herself, lowering her self-esteem. She is expressing fear and grief. Deficient knowledge is important for this client, but not immediately. The client will not be able to comprehend information at this time. There are no data to support options 3 and 4. Test-Taking Strategy: Focus on the data provided in the question and use the process of elimination. Focus on the key words “What have I done to cause this?” to direct you to option 1. Review the defining characteristics for situational low self-esteem if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum References: Gulanick, M., Myers, J., Klopp, A., Gradishar, D., Galanes, S., & Puzas, M.
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(2003). Nursing care plans: Nursing diagnosis and intervention (5th ed.). St. Louis: Mosby, p. 137. Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 106. 362. A primigravida is receiving magnesium sulfate for pregnancy-induced hypertension. The nurse is asked to monitor the client every 30 minutes. Which of the following information would be of most concern to the nurse? 1. Urinary output of 20 mL since the last check 2. Deep tendon reflexes of 2+ 3. Respirations of 10 breaths per minute 4. Fetal heart tone of 116 beats per minute Answer: 3 Rationale: Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the continuation of the medication needs to be reassessed. Option 1 is adequate because there is 20 mL of urine produced in 30 minutes and the acceptable criterion is greater than 30 mL per hour. Deep tendon reflexes of 2+ are normal. The fetal heart tone is within normal limits for a resting fetus. Test-Taking Strategy: Note the key words most concern. Use the process of elimination, recalling the adverse effects of magnesium sulfate to select the correct option. Review the adverse effects of magnesium sulfate if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 222. 363. During a routine prenatal visit the client states, “I have not been able to get my wedding ring off for the last two days. I guess the heat is making my fingers swell.” The nurse needs to further check: 1. The client for blood pressure changes and protein in the urine 2. The client’s height of the fundus as compared to the date of her last visit 3. The blood glucose level 4. For any vaginal discharge Answer: 1 Rationale: Finger edema is a frequent forerunner of pregnancy-induced hypertension (PIH) and should be investigated further. Options 2, 3, and 4 are all indicators of other problems such as diabetes, infections, and molar pregnancy. Test-Taking Strategy: Use the process of elimination. Focus on the data provided in the question and recall the complications and the indicators associated with the complications of pregnancy, specifically PIH. Review these complications if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection
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Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 94. 364. A nurse reinforces instructions to a client with mild preeclampsia on home care. The nurse evaluates that the teaching has been effective when the client states: 1. “As long as the health care nurse is visiting me daily I do not have to keep my next physician’s appointment.” 2. “I need to take my blood pressure each morning and alternate arms each time.” 3. “I need to check my weight every day at different times during the day.” 4. “I need to check my urine with a dipstick every day for protein and call the physician if it is 2+ or more.” Answer: 4 Rationale: Option 4 is a correct statement. It is still important to keep physician appointments to assess for any other physical changes in the mother or baby. Blood pressures need to be taken in the same arm, in a sitting position every day in order to obtain a consistent and accurate reading. The weight needs to be checked at the same time each day, wearing the same clothes, after voiding, and before breakfast in order to obtain reliable weights. Test-Taking Strategy: Use the process of elimination, reading each option carefully. Use knowledge regarding preeclampsia and general principles related to home care and weight and blood pressure measurement to answer the question. Review care to the client with preeclampsia 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: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 847. 365. A nurse in an ambulatory clinic is preparing to administer a Mantoux skin test to a client who may have been exposed to an individual with tuberculosis (TB). The client reports having had the bacille Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. The nurse interprets that: 1. The client’s Mantoux test will be negative, and will require sputum culture to diagnose 2. The client’s Mantoux test will be positive, and will require chest x-ray for evaluation 3. The client has no risk of acquiring TB, and needs no further workup 4. The client is at more risk of acquiring TB, and needs immediate medication therapy Answer: 2 Rationale: The bacille Calmette-Guérin vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the client will always test positive on Mantoux skin testing after receiving the vaccine. This client needs to be evaluated for TB with a chest x-ray. Test-Taking Strategy: Knowledge of this specific vaccine is necessary to answer this question correctly. Remember that the client will always test positive on Mantoux skin testing after receiving the vaccine. Review this vaccine if you had difficulty with this
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question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation 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. 1846. 366. A client has just had surgery to deliver a nonviable fetus due to abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, “God, just let me die now!” Which problem should direct care for this client? 1. Hopelessness related to loss of the baby and personal health 2. Deficient knowledge related to the disease process 3. Situational low self-esteem related to being ill 4. Grieving related to loss of the baby Answer: 1 Rationale: By seeing no way out of the situation except for death, the client meets the criteria for hopelessness. A person who lacks hope feels that life is too much to handle. Option 2 is a possible problem later, but there are not enough data to support it at this point. The data given do not support a situational low self-esteem. Option 4 is a possible problem at a later time; however, at this time hopelessness should take precedence. Test-Taking Strategy: Focus on the data in the question and the key words “God, just let me die now!” These key words and the process of elimination will direct you to option 1. Review the defining characteristics for hopelessness if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 877. 367. A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Part of the plan of care for this client should be to monitor for: 1. Any bleeding, such as in the gums, petechiae, and purpura 2. Enlargement of the breasts 3. Periods of fetal movement followed by quiet periods 4. Complaints of feeling hot when the room is cool Answer: 1 Rationale: Bleeding is an early sign of disseminated intravascular coagulation (DIC), a complication of preeclampsia, and should be reported. Options 2, 3, and 4 are all normal occurrences in the last trimester of pregnancy. Test-Taking Strategy: Use the process of elimination, noting that options 2, 3, and 4 are normal occurrences in the last trimester of pregnancy. Recall that bleeding does not
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normally occur with pregnancy. Review the signs of DIC if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 287. 368. When collecting data from a client at risk for disseminated intravascular coagulation (DIC), which of the following factors would the nurse consider being the most significant? 1. A gravida VI that delivered 10 hours ago and has lost 450 mL of blood 2. A gravida II that has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago 3. A primigravida with mild preeclampsia 4. A primigravida that delivered a 10-pound baby 3 hours ago Answer: 2 Rationale: Dead fetus syndrome is considered a risk factor for DIC. Hemorrhage is a risk factor with DIC; however, a loss of 450 mL is not considered hemorrhage. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large baby is not considered a risk factor for DIC. Test-Taking Strategy: Use the process of elimination and knowledge of the risk factors associated with DIC. Remember, dead fetus syndrome is considered a risk factor for DIC. Review these risk factors if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1044. 369. For the previous 4 hours, a client in labor has been experiencing contractions every 2 minutes, lasting 60 to 70 seconds, and strong to palpation. She is 2-cm dilated and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia? 1. Hypotonic 2. Precipitate 3. Hypertonic 4. Protracted active phase Answer: 3 Rationale: The client is 2-cm dilated and in the latent phase of labor. The most common type of dysfunctional labor at this point is hypertonic. A normal pattern during the latent phase of labor is contractions every 5 to 10 minutes, lasting 30 to 45 seconds, and mild in intensity. Precipitate labor is that which lasts in its entirety for 3 hours or less. The client has already been in labor for at least 4 hours. Hypotonic labor contractions are short,
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irregular, and weak, and usually occur during the active phase of labor. Test-Taking Strategy: Use the process of elimination. Note that the client is 2-cm dilated and focus on the client’s contraction pattern to determine the type of dystocia. Review the characteristics of hypertonic dystocia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 240. 370. A nurse is collecting data from a client and is reviewing the client’s health record to determine the risk for preterm labor. Which of the following findings would place the client at this risk? 1. A 26-year-old primigravida 2. A single-fetus pregnancy 3. A hemoglobin level of 13.5 g/dl 4. A diagnosed urinary tract infection Answer: 4 Rationale: One risk factor for preterm labor is the presence of a genitourinary infection. Although the connection is not clearly understood, one hypothesis involves the release of prostaglandins by the pathogens, which may contribute to the initiation of contractions. Other risk factors for preterm labor include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; age less than 15 years; or first pregnancy over the age of 35. Test-Taking Strategy: Use the process of elimination. Options 1, 2, and 3 are all average findings. By the process of elimination, option 4 is the only deviation from normal. Review the risk factors associated with preterm labor if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 235. 371. A nurse is assisting in caring for a client in labor. The nurse recognizes that the risks for uterine rupture during labor and delivery include: 1. Hypotonic contractions 2. Shoulder dystocia 3. Primigravida 4. Weak bearing-down efforts Answer: 2 Rationale: Shoulder dystocia at delivery causes increased pressure in the thin lower uterine segment and subsequently the risk for spontaneous rupture. Statistically, rupture is more common in multigravidas, especially when combined with the use of oxytocin.
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Hypotonic contractions and weak bearing-down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall. Test-Taking Strategy: Use the process of elimination. Look for the option that identifies a situation that would provide an additional source of pressure to the uterus, and would be most likely to add to the risk of rupturing the uterus. Option 2 is the only option that would provide an additional source of pressure to the uterus. Review the causes of uterine rupture if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 193. 372. A nurse is assigned to assist in caring for a client in labor. The nurse would determine that which of the following would least likely indicate dystocia? 1. High level of maternal fear or anxiety 2. Failure of fetus to descend 3. Progressive changes in the cervix 4. Signs of fetal distress Answer: 3 Rationale: Progressive changes in the cervix are a reassuring pattern in labor. Abnormal labor patterns are assessed according to the nature of the cervical dilation and fetal descent. Options 1, 2, and 4 could indicate signs of dystocia. Test-Taking Strategy: Note the key words least likely. Use the process of elimination, selecting the option that is a normal finding in labor. Review these normal findings if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 239-240. 373. A mother experiencing dystocia looks alarmed and asks: “What’s going on? Why are you all poking and prodding? Is my baby OK?” Based on the client’s statement, the nurse understands that the client is experiencing which of the following problems? 1. Anxiety and fear 2. Powerlessness 3. Impaired parenting 4. Disturbed sensory perception Answer: 1 Rationale: The client is expressing anxiety and fear related to the situation. Powerlessness would be identified if the client verbalized a lack of control over the situation. Disturbed sensory perception may be displayed by confusion. Impaired parenting is unrelated to the situation.
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Test-Taking Strategy: Focus on the client’s question: “Is my baby OK?” Use the process of elimination, relating the information in the question to the correct option. This will direct you to option 1. Review the defining characteristics for anxiety and fear if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1003. 374. A nurse is assigned to care for a client experiencing dystocia. In planning care, the nurse would consider the highest priority to be frequent: 1. Explanations to family members about what is happening in this situation 2. Comfort measures, change of position, and touch 3. Reinforcement of breathing techniques learned in childbirth preparatory classes 4. Monitoring for changes in the physical and emotional condition of the mother and fetus Answer: 4 Rationale: All the options are correct and would be implemented during the care of the client. However, the highest priority would be to monitor for changes in physiological integrity in both the mother and the fetus. Test-Taking Strategy: Note the key words highest priority. Use Maslow’s Hierarchy of Needs theory, recalling that physiological needs are the priority. Also, note that option 4 is the only option that addresses both the mother and the fetus. Review care to a client experiencing dystocia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 240. 375. A nurse is caring for a nullipara woman in labor. The nurse understands that the potential for precipitate labor and delivery should be a concern, and understands that the physician needs to be contacted if which one of the following becomes apparent? 1. Decreased periods of uterine relaxation between contractions 2. Dilation of the cervix of greater than 1 cm and less than 5 cm per hour during the active phase 3. Descent of less than 1 to 2 cm per hour 4. Latent phase of less than 6 hours Answer: 1 Rationale: Signs of a possible need for emergency intervention are inadequate uterine relaxation between contractions. Inadequate relaxation interferes with the transfer of oxygen and nutrients to the fetus through the mother’s placenta. All other options are within normal limits for a nulliparous woman. By definition, a precipitate labor lasts less
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than 3 hours. Test-Taking Strategy: Use the process of elimination and knowledge about the normal parameters of labor to answer this question. Noting the key words physician needs to be contacted will direct you to option 1. If you had difficulty with this question, review content related to precipitate labor and delivery and the indications that warrant the need to contact the physician. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 247. Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1003. 376. After a precipitate delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse would do which of the following first to help the woman process what has happened? 1. Encourage the mother to breast-feed soon after birth 2. Consider the cultural characteristics of the woman 3. Write a complete account of the parent’s reaction on the birth record 4. Support the mother no matter what her reaction to the newborn is Answer: 4 Rationale: There may be many reactions to the birth of a baby. The mother may be exhausted, in pain, or stunned by the rapid nature of the delivery, or she may be following her cultural norms. The mother may want to process what has happened and will need time to assimilate all that happened. The new mother requires support, and the nurse needs to provide a nurturing and accepting attitude. Test-Taking Strategy: Note the key word first. Use the process of elimination, remembering to always address the client’s feelings first. This will direct you to option 4. Review the psychosocial reaction of the mother following a precipitate delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1105. 377. A nurse reviews the arterial blood gas values and notes a pH of 7.50 and a PCO2 of 30 mm Hg. The nurse interprets these values as indicating: 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Answer: 2
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Rationale: In respiratory alkalosis, the pH will be higher than normal and the PCO2 will be low. The normal pH is 7.35 to 7.45. The normal PCO2 is 35 to 45 mm Hg. The only option that reflects these conditions is option 2. Test-Taking Strategy: Use the process of elimination. Remember that when an alkalotic condition exists, the pH will be high. Next, recall that in a respiratory alkalotic condition the PCO2 will move in the opposite direction as the pH. The only option that represents these conditions is option 2. Review the process of blood gas analysis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 245. 378. The nurse is collecting data on a client with chronic airflow limitation (CAL), and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of CAL? 1. Chronic obstructive bronchitis 2. Emphysema 3. Bronchial asthma 4. Both bronchial asthma and bronchitis Answer: 2 Rationale: The client with emphysema has hyperinflation of the alveoli, and has flattening of the diaphragm. These factors lead to increased anteroposterior diameter, which is referred to as “barrel chest.” The client also has dyspnea with prolonged expiration, and has hyperresonant lungs to percussion. Test-Taking Strategy: To answer this question correctly, it is necessary to understand that the “barrel chest” is a result of long-term hyperinflation of the lungs and air trapping. By knowing that emphysema is the only type of CAL in which this occurs, you are able to eliminate each of the other incorrect options. Review the characteristics of emphysema 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/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1819. 379. A client is at risk of developing a pulmonary embolism. The nurse monitors for which of the following, which is the most commonly reported initial symptom? 1. Dyspnea noted when deep breaths are taken 2. Hot, flushed feeling 3. Chest pain that occurs suddenly 4. Sudden chills and fever Answer: 3
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Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include cough, tachycardia, fever, diaphoresis, anxiety, and possibly syncope. Test-Taking Strategy: Use the process of elimination and note the key word initial. Because pulmonary embolism does not result from either an infectious process or an allergic reaction, options 2 and 4 are eliminated first. To select between options 1 and 3, look at them closely. Option 1 states dyspnea occurs when deep breaths are taken. Although dyspnea commonly occurs with pulmonary embolism, dyspnea is not associated only with deep breathing. Therefore option 3 is correct, and option 1 is eliminated. Review the signs of pulmonary embolism 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/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 391. 380. A nurse is assisting in caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse monitors the portable wound suction for which of the following types of drainage expected in the immediate postoperative period? 1. Serosanguinous 2. Grossly bloody 3. Serous 4. Serous with sputum Answer: 1 Rationale: Immediately following radical neck dissection, the client will have a wound drain in the neck attached to portable suction, which drains serosanguinous drainage. In the first 24 hours after surgery, the drainage may total 80 to 120 mL. The drainage should not be grossly bloody, and would not be serous or serous with sputum at this time. Test-Taking Strategy: Note the key words immediate postoperative period in the stem of the question. Because the wound suction tube is not placed in the airway, option 4 is eliminated. Because serous drainage has no blood, this is not likely in the immediate postoperative period, and is also eliminated. Knowing that grossly bloody drainage indicates bleeding or hemorrhage, you would choose option 1 (serosanguinous drainage) as the correct option. Review normal expected findings following radical neck dissection 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/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1795.
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381. A client is admitted to the nursing unit experiencing confusion and tremors. An initial arterial blood gas report indicates that the PaCO2 level is 72 mm Hg while the PaO2 level is 64 mm Hg. The nurse interprets that the client is most likely experiencing: 1. Carbon monoxide poisoning 2. Carbon dioxide narcosis 3. Respiratory alkalosis 4. Metabolic acidosis Answer: 2 Rationale: Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors, which may progress to convulsions and possibly coma. Test-Taking Strategy: To answer this question, you need to be able to interpret arterial blood gases. Also, noting that the client has a highly elevated carbon dioxide level will assist in directing you to option 2. Review the manifestations associated with carbon dioxide narcosis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1833. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 482-483. 382. A client is admitted to the hospital with a diagnosis of carbon dioxide narcosis. In addition to respiratory failure, the nurse plans to monitor the client for which of the following complications of this disorder? 1. Paralytic ileus 2. Hypernatremia 3. Increased intracranial pressure 4. Hyperglycemia Answer: 3 Rationale: Carbon dioxide acts as a vasodilator to cerebral blood vessels. With sufficient increase in carbon dioxide levels, the client may suffer increased intracranial pressure, which is initially reflected as papilledema and dilated conjunctival blood vessels. Options 1, 2, and 4 are not complications. Test-Taking Strategy: Focus on the client’s diagnosis. Knowing that carbon dioxide vasodilates the cerebral blood vessels guides you to choose option 3 as the correct option, because the cerebral circulation is one of the components that contributes to increased intracranial pressure. Review the complications associated with carbon dioxide narcosis 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing
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(3rd ed.). Philadelphia: W.B. Saunders, p. 482. 383. A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which of the following signs and symptoms? 1. Weight gain 2. Dyspnea 3. Hypothermia 4. Headache Answer: 2 Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection, and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be enlargement of the client’s lymph nodes, liver, and spleen as well. Test-Taking Strategy: Use the process of elimination. Knowing that histoplasmosis is an infectious process helps you to eliminate option 3. Because the client has AIDS as well as another infection, weight gain is an unlikely symptom, and can be eliminated next. From the remaining options, recalling that histoplasmosis begins as a respiratory infection helps you to choose dyspnea over headache. Review the signs of histoplasmosis 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/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 685. 384. A nurse is caring for a client with exacerbation of sarcoidosis. The nurse plans to provide instructions to the client about the adverse effects of medication therapy, which would include: 1. Weight loss 2. Hyperglycemia 3. Hyperkalemia 4. Pruritis Answer: 2 Rationale: The usual treatment for exacerbation of sarcoidosis includes systemic corticosteroids. Side effects of this therapy include weight gain, changes in mood, and hyperglycemia. Corticosteroids can cause hypokalemia. Pruritis is an unrelated finding. Test-Taking Strategy: To answer this question successfully, it is necessary to know that sarcoidosis is a restrictive lung disease, with exacerbations that are treated with corticosteroids. Knowing that corticosteroids cause hyperglycemia, you can eliminate each of the incorrect options. Review the medication therapy used in the treatment of sarcoidosis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity
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Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 507. 385. A client tells a nurse that the physician has confirmed a diagnosis of uncomplicated or simple silicosis. The client asks the nurse exactly what this means. In formulating a response, the nurse incorporates the knowledge that: 1. There is evidence of silica in the bloodstream, but no clinical symptoms 2. The client has normal pulmonary function studies but has shortness of breath 3. The client has mild ventilation restriction and has fibrosis on chest x-ray 4. There is massive pulmonary fibrosis on chest x-ray but there are no extrapulmonary symptoms Answer: 3 Rationale: The client with simple silicosis may be asymptomatic or have mild ventilatory restriction, and has evidence of fibrosis on chest x-ray. Pulmonary function studies reveal some decreases in vital capacity and total lung volume. There is no evidence of massive fibrosis at this stage. This disease is restricted to the respiratory system only. Test-Taking Strategy: Use the process of elimination. Option 4 has the least amount of “fit” with a disorder that is described as simple or uncomplicated, and therefore is eliminated as a possible option first. Because silicosis is a pulmonary disease, option 1 is also eliminated. Option 2 does not make sense; it would be difficult for one to have shortness of breath but yet have normal pulmonary function studies. Review the pathophysiology associated with simple silicosis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 546. 386. A client has been taking pyrazinamide (Pyrazinamide) for 1 month. The client asks the nurse if the therapy is due to be terminated soon. The nurse determines that the medication probably will be continued based on a positive finding on which of the following reports? 1. Blood culture 2. Sputum culture 3. Urine culture 4. Wound culture Answer: 2 Rationale: Pyrazinamide is an antitubercular medication that is given in conjunction with other antitubercular medications. Its use might not be discontinued if sputum cultures continue to be positive. Options 1, 3, and 4 are not tests that would determine discontinuation of the medication. Test-Taking Strategy: Use the process of elimination and knowledge of the purpose and action of this medication. Recalling that this medication is an antitubercular medication
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helps you to eliminate each of the incorrect options. If this question was difficult, review this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 735. 387. A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The most appropriate nursing action would be to: 1. Document the findings 2. Notify the registered nurse 3. Medicate the client for pain 4. Reposition the client Answer: 2 Rationale: The nurse would notify the registered nurse who would then contact the physician. The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client’s central venous pressure (CVP) rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter. Test-Taking Strategy: Use the process of elimination. Noting the key words severe pain and dyspnea will assist in directing you to option 2. Review the complications associated with flail chest 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/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 487-488. 388. A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which of the following results, which are consistent with this disorder? 1. PaO2 58 mm Hg, PaCO2 32 mm Hg 2. PaO2 60 mm Hg, PaCO2 45 mm Hg 3. PaO2 49 mm Hg, PaCO2 52 mm Hg 4. PaO2 73 mm Hg, PaCO2 62 mm Hg Answer: 3 Rationale: Respiratory failure is described as a PaO2 of 50 mm Hg or less and a PaCO2 of 50 mm Hg or greater in a client with no history of respiratory disease. In a client with a history of respiratory disorder with hypercapnea, elevations of 5 mm Hg or more from the client’s baseline are considered diagnostic. Test-Taking Strategy: Use the process of elimination. Knowing that the carbon dioxide level in respiratory failure is above 50 mm Hg helps you to eliminate options 1 and 2
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first. You would choose option 3 over option 4 because the arterial oxygen level in respiratory failure is less than 50 mm Hg. Review the blood gas findings in a client with respiratory failure 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 490. 389. A nurse is encouraging an older female client’s participation in recreational therapy. What nursing intervention would the nurse consider performing first? 1. Change the client’s soiled disposable brief 2. Have the client’s nails manicured 3. Have the client’s hair washed and cut 4. Ask the client to wear supportive shoes Answer: 1 Rationale: Basic physiological needs are a priority in administering nursing care. Although options 2, 3, and 4 address the client’s needs, the priority would be to keep the client clean and dry and to avoid embarrassment. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Option 1 addresses a basic physiological need. Review the physiological needs of the older client if you had difficulty with this question. Level of Cognitive Ability: Application Clients Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 264266. 390. A client diagnosed with pleurisy is being started on medication therapy with indomethacin (Indocin). The nurse tells the client that this medication is a: 1. Topical anesthetic that alleviates surface pain 2. Mild narcotic analgesic to allow the client to deep breathe 3. Corticosteroid to decrease the inflammatory response at the site 4. Nonsteroidal anti-inflammatory medication to enhance coughing and deep breathing Answer: 4 Rationale: Indomethacin is a nonsteroidal anti-inflammatory medication that has an analgesic effect, and allows the client to cough and deep breathe more effectively. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination. Knowing that the medication needed to treat this condition would be an anti-inflammatory helps you to eliminate options 1 and 2. In order to select between options 3 and 4, you should recall that indomethacin is a nonsteroidal anti-inflammatory agent. This medication is also used to treat inflammation of the epicardium in the pericardial sac, which is called pericarditis. If you are unfamiliar with this medication, review its uses and actions.
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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, pp. 565-566. 391. A nurse is assisting in caring for a postoperative pneumonectomy client. The nurse monitors the client for which adverse finding indicating acute pulmonary edema? 1. Respiratory rate of 20 breaths per minute 2. Pain with deep breathing 3. Frothy sputum 4. Increased chest tube drainage Answer: 3 Rationale: The client developing pulmonary edema after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. A respiratory rate of 20 breaths per minute is within normal limits. Pain with deep breathing is expected, and managed with analgesics. The client with pneumonectomy does not usually have a chest tube. Test-Taking Strategy: Use the process of elimination. Increased chest drainage indicates hemorrhage, not pulmonary edema, and is eliminated first. Additionally, the client with pneumonectomy usually does not have a chest tube. A respiratory rate of 20 breaths per minute is normal and pain with deep breathing is expected in the immediate postoperative period, so these options may be eliminated next. The presence of frothy sputum indicates pulmonary edema, and is the correct option. Review the signs of pulmonary edema 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/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 321. 392. A nurse is assisting in admitting a client to the emergency room with suspected carbon monoxide poisoning. The nurse understands that which of the following manifestations is least reliable for determining the oxygenation status of this client? 1. Complaints of a headache 2. Muscular weakness 3. Palpitations 4. Skin color Answer: 4 Rationale: Skin color is the least reliable sign for determining the oxygenation status of the client with carbon monoxide poisoning. Skin color may vary and range from pink to cherry red, or pale to cyanotic. Other signs that result from the lack of oxygen include dizziness, headache, muscular weakness, palpitations, and mental confusion, which can progress rapidly to coma.
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Test-Taking Strategy: Note the key words least reliable. Without specific knowledge of this condition, this question may be difficult to answer. Because palpitations could accompany tachycardia (which is expected with hypoxia), you may conclude that this sign is reliable. Because headache is a central nervous (CNS) symptom and the CNS relies heavily on a ready oxygen supply, this option may be eliminated also, because this should be a reliable sign. Muscular weakness is an example of the effects of hypoxia at the tissue level, and therefore should be considered reliable also. By the process of elimination, skin color is the unreliable sign, because it may vary considerably. Review the clinical manifestations associated with carbon monoxide poisoning 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 200. 393. A client with carbon dioxide narcosis has a potassium level of 6.2 mEq/L. The nurse interprets that this result is: 1. Unexpected, and indicates a concurrent history of renal insufficiency 2. Unexpected, and indicates a deficit of hydrogen ions in the bloodstream 3. Expected, and indicates the result of massive hemolysis 4. Expected, and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out Answer: 4 Rationale: With the severe respiratory acidosis that occurs in carbon dioxide narcosis, compensatory mechanisms fail. As hydrogen ion concentrations continue to rise, they are driven into the cell, forcing intracellular potassium out. This is an expected finding in this situation. Test-Taking Strategy: To answer this question, an understanding of the effects of acidosis on the body is required. With buildup of carbon dioxide, the body attempts to eliminate hydrogen ions from the circulation, because they are another source of body acid. The blood buffer system tries to buffer them as the first line of defense. With a rapid buildup of carbon dioxide, this is insufficient, and the body needs to find another way to lose hydrogen ions. Because the renal system does not “kick in” for almost 24 hours, the hydrogen ions are driven into the cells, and potassium comes out (hydrogen and potassium are both cations). With these concepts in mind, hyperkalemia is an expected finding, which eliminates options 1 and 2. Because this disorder has nothing to do with hemolysis, the only correct choice is option 4. Review the effects of carbon dioxide narcosis on the body if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 669,
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1833. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 384. 394. A nurse is assisting in evaluating the respiratory status of the client with carbon dioxide narcosis, who is being mechanically ventilated. Upon evaluation of a set of arterial blood gases, the nurse notes that the client’s carbon dioxide level has dropped significantly. The nurse then monitors the client for which adverse effect of this rapid change? 1. Tachypnea 2. Hyponatremia 3. Seizure activity 4. Confusion Answer: 3 Rationale: With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete bicarbonate ions at the same pace. The client can experience rebound metabolic alkalosis, with resulting seizure activity. The nurse evaluates the client’s status carefully during this period. Test-Taking Strategy: To answer this question accurately, an understanding of how the body maintains acid/base balance is needed. With a drop in carbon dioxide levels, the body also needs to drop bicarbonate levels correspondingly. Otherwise, the body is in a state of metabolic alkalosis. However, it is difficult for the body to do this, because bicarbonate must be eliminated by the kidneys, which do not “kick in” to restore acid/ base balance for approximately 24 hours. Because of this, rapid declines in carbon dioxide levels often do result in metabolic alkalosis, putting the client at risk for seizure activity. This is a difficult question to answer unless you understand these concepts. Review the effects of carbon dioxide narcosis on the body 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 References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 18321833. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 384-385. Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 460. 395. A client has been admitted to the nursing unit with pulmonary sarcoidosis. The nurse monitors the client for which of the following signs indicating a complication of the disorder? 1. Bilateral lung crackles 2. Flat neck veins 3. Peripheral edema
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4. Shrunken liver Answer: 3 Rationale: Pulmonary sarcoidosis can lead to cor pulmonale (or right-sided heart failure), which is characterized by distended neck veins, elevated central venous pressure, engorged liver, and peripheral edema. Bilateral crackles would indicate left-sided heart failure, not right-sided heart failure. Test-Taking Strategy: To answer this question accurately, it is necessary to know that sarcoidosis is a restrictive lung disease. A complication of restrictive lung disease is cor pulmonale, because the right side of the heart has to work hard on a continuous basis to overcome pulmonary resistance. Knowing this, you would eliminate options 2 and 4, because they are the opposite of the symptoms expected with right-sided heart failure. You would choose option 3 over option 1 by knowing how to discriminate between leftand right-sided heart failure. Review the complications of pulmonary sarcoidosis and the signs of right- and left-sided heart failure 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 507. 396. A nurse is collecting data on a client with silicosis. The nurse asks the client if he wears which of the following items during periods of exposure to silica particles? 1. Mask 2. Gown 3. Gloves 4. Eye protection Answer: 1 Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. Options 2, 3, and 4 are not necessary to prevent exposure to these particles. Test-Taking Strategy: To answer this question, it is necessary to know that exposure to silica dust causes the illness. The dust is inhaled into the respiratory tract. Knowing this, each of the incorrect options can be eliminated. Review the cause of this respiratory disorder if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 547. 397. A client has been taking benzonatate (Tessalon Perles) as prescribed. The nurse determines that the medication is having the intended effect if the client experiences: 1. Decreased anxiety level
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2. Increased comfort level 3. Reduction in nausea and vomiting 4. Decreased frequency and intensity of cough Answer: 4 Rationale: Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex. Options 1, 2, and 3 are not associated with the effects of this medication. Test-Taking Strategy: This question tests your knowledge of the purpose and effects of this medication. Recalling that benzonatate is a locally acting antitussive will direct you to option 4. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 114. 398. A nurse reviews the nursing care plan of a client and notes documentation of a nursing diagnosis of impaired gas exchange related to decreased ventilation and mucous plugs. The nurse understands that which of the following items documented in the client’s health care record most accurately indicates achievement of the expected outcome for this nursing diagnosis? 1. Client demonstrated effective coughing techniques 2. Arterial blood gases indicate a pH of 7.4, PaO2 of 80 mm Hg, and PaCO2 of 40 mm Hg 3. Venous oxygen saturation of 95% 4. Respiratory rate of 20 breaths per minute Answer: 2 Rationale: Demonstration of adequate gas exchange can only be accurately evaluated when both PaO2 and PaCO2 levels are known. The other options do not indicate adequate gas exchange. Remember that the oxygen saturation index is a measure of the percent of oxygen attached to the available hemoglobin. Test-Taking Strategy: Focus on the issue of the question. Note the key words most accurately. Demonstration of adequate gas exchange can only be accurately evaluated when both PaO2 and PaCO2 levels are known. Review the expected outcomes for impaired gas exchange if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation 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, pp. 1880, 1824. 399. A nurse is caring for a client with pheochromocytoma. As part of the nursing care plan, the nurse monitors for hypertensive crisis. In the event that hypertensive crisis
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occurs, the nurse would anticipate that the most likely medication to be prescribed would be: 1. Propranolol (Inderal) 2. Phentolamine mesylate (Regitine) 3. Phenoxybenxamine hydrochloride (Dibenzyline) 4. Prazosin hydrochloride (Minipress) Answer: 2 Rationale: The most likely medication to be ordered in hypertensive crisis is phentolamine (Regitine). This medication is a short-acting alpha-adrenergic blocker and would be given by intravenous bolus or infusion for a hypertensive crisis. Phenoxybenxamine hydrochloride is an oral medication and produces long-acting alphaadrenergic blockade. It is used in the management of pheochromocytoma and is most suitable for preoperative management of hypertension and prevention of hypertensive crisis. Prazosin hydrochloride, an alpha-blocker, is used less frequently for the preoperative pheochromocytoma client because of its shorter duration of action. The physician would not prescribe beta-receptor blocking agents in clients with suspected or confirmed pheochromocytoma until after alpha-adrenergic blockade has been initiated, because these medications may cause the blood pressure to rise. After alpha-adrenergic blockade, low doses of propranolol (Inderal) may be used to treat tachycardia and dysrhythmias. Test-Taking Strategy: Knowledge of the actions and uses of these medications is required to assist you in answering this question. If you knew that phentolamine mesylate is a short-acting medication, then you would select this option. The question asks about hypertensive crisis, and such a situation requires immediate intervention. Review these medications if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological integrity Integrated Process: Nursing Process/Planning Content Area: Adult/Health Endocrine Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 852. 400. Prednisone (Deltasone) 10 mg orally daily has been prescribed for the client. The nurse provides instructions to the client regarding the medication. Which statement by the client indicates that further teaching is necessary? 1. “I need to take the medication every day at the same time.” 2. “I can take acetylsalicylic acid (aspirin) or my antihistamine if I need it.” 3. “If I gain more than 5 pounds a week, I will call my doctor.” 4. “I need to avoid coffee, tea, cola, and chocolate in my diet.” Answer: 2 Rationale: Aspirin and other over-the-counter medications should not be used unless the client consults with the physician. The client is instructed to take the medication every day at the same time. A slight weight gain with improved appetite is expected, but after the dosage is stabilized, an increase in weight of 5 pounds or more weekly should be reported to the physician. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development.
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Test-Taking Strategy: Note the key words further teaching is necessary. These words indicate a false response question and that you need to select the incorrect client statement. Remember, a very important point to remember is that clients should not take other medications, especially over-the-counter medications, without first consulting with their physician. Review 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: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 714.
PN Comprehensive Review CD Questions 301-400 {COMP: No Equations/Formulas; No
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the similarity between options 2, 3, and 4 and eliminate these options. If you are unfamiliar with vena cava syndrome, review this oncological emergency. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 291. 303. A client arrives in the emergency room in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection would focus on: 1. The object of the crisis 2. The presence of support systems 3. The physical condition of the client 4. The client’s coping mechanisms Answer: 3 Rationale: The initial nursing assessment of a client in a crisis state is to determine the physical condition of the client, the potential for self-harm, and the potential for harm to others. Once this has been determined and appropriate interventions have been initiated, the nurse would then proceed to care for the client. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Physiological needs take priority over other needs. Option 3 is the only option that addresses a physiological need. Review care to the client in crisis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological 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. 198. 304. A nurse is collecting data from a client in crisis and is determining the potential for self-harm. Which of the following data would indicate that the client is a very high risk for suicide? 1. The client is disorganized 2. The client is impulsive 3. The client has a history of suicide attempts 4. The client has an immediate plan for a suicide attempt Answer: 4 Rationale: The client presents a lethality potential if the client appears disorganized and impulsive. Clients at higher risk include those with a history of a dual diagnosis of mental illness and substance abuse and those with a personal or family history of suicide attempts, depression, alcoholism, or psychotic episodes. Having a suicide plan, however, particularly if the method is immediate and available, makes the client very high risk. Test-Taking Strategy: Use the process of elimination. Noting the key words a very high risk should easily direct you to option 4. Also, note the key words immediate plan in the
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correct option. Review the risk factors associated with suicide 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. 287. 305. A nurse has been closely observing a client that has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which of the following nursing interventions is least helpful for this client at this time? 1. Acknowledge the client’s behavior 2. Maintain a safe distance from the client 3. Assist the client to an area that is quiet 4. Initiate confinement measures Answer: 4 Rationale: During the escalation period, the client’s behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. It is not appropriate during this period to initiate confinement measures. Initiating confinement measures is most appropriate during the crisis period. Test-Taking Strategy: Note the key words least helpful. These words indicate a false response question and that you need to select the least helpful intervention. Noting the word “confinement” in option 4 will direct you to this option. Review these interventions 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. 116. 306. A nursing assistant is assigned to work with a nurse to care for a client who was at risk for suicide. Which of these statements made by the nursing assistant indicates to the nurse that the nursing assistant understands suicide? 1. “When a person talks about making suicide threats, the only thing the person wants is attention from family and friends.” 2. “Discussing suicide with a client is not harmful.” 3. “Depressed clients are the only persons who commit suicide.” 4. “Those clients who talk about suicide never do it.” Answer: 2 Rationale: An open discussion of suicide will not encourage a client to make a decision to commit suicide, and will, in fact, often help to prevent it. Such a discussion offers the health care personnel the opportunity to assess the reality of suicide for the client and take necessary precautions to keep the client safe. Options 1, 3, and 4 are incorrect.
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Test-Taking Strategy: Use the process of elimination and note the key word understands in the question. Note the absolute words “only” in options 1 and 3 and “never” in option 4; eliminate these options. If you had difficulty with this question, review the concepts related to the suicidal client. 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. 289. 307. A nurse is assigned to care for a suicidal client. The appropriate nursing intervention in dealing with this client is to: 1. Demonstrate confidence in the client’s ability to deal with stressors 2. Provide hope and reassurance that the problems will resolve themselves 3. Display an attitude of detachment, confrontation, and efficiency 4. Provide authority, action, and participation Answer: 4 Rationale: A crisis is an acute time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous problemsolving methods. One who intervenes in this situation (the nurse) “takes over” for the client who is not in control and devises a plan (action) to secure and maintain the client’s safety. Once this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies. Test-Taking Strategy: Use the process of elimination. The client who experiences a “suicidal crisis” is in acute disequilibrium. Remember, in a “crisis” an authority figure must emerge to take action. Review crisis intervention and the nurse’s responsibilities 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. 289. 308. A depressed client is found unconscious on the floor in the day room of a psychiatric nursing unit. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. The immediate action of the nurse is to: 1. Call emergency medical personnel 2. Induce vomiting and notify the physician for further orders 3. Call Poison Control 4. Try to figure out the number of pills taken Answer: 1 Rationale: Tricyclic antidepressants can be fatal when taken as an overdose regardless of the amount ingested. Serious, life-threatening symptoms can develop after an overdose.
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Immediate emergency medical attention and cardiac monitoring is needed in the event of an overdose of tricyclics. Test-Taking Strategy: Use the process of elimination and note the key words immediate action. Options 3 and 4 would delay measures in providing immediate treatment. Eliminate option 2 because vomiting would not be induced in a client who is unconscious. Review immediate measures in a situation such as an overdose of tricyclics 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: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed.). St. Louis: Mosby, p. 478. 309. A nurse employed in a psychiatric unit receives a client assignment for the day. Which of the following clients assigned to the nurse is at the highest risk for committing suicide? 1. A 24-year-old client who just had an argument with another client 2. A 71-year-old client with mild depression and severe cognitive deficits 3. A 75-year-old male with severe depression and cancer 4. A 30-year-old newly divorced client who has custody of the children Answer: 3 Rationale: The individual at highest risk for suicide is the individual with a terminal illness. Other high-risk groups include adolescents; drug abusers; those individuals with social problems, recent losses, or few or no social support groups; and individuals with a history of suicide attempts and a suicide plan. Test-Taking Strategy: Use the process of elimination. Noting the word “severe” in option 3 will direct you to this option. Review the risk factors and groups at risk for suicide 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. 286. 310. A suicidal client is admitted to the hospital. The nurse reviews the nursing care plan and notes documentation of a nursing diagnosis of dysfunctional grieving related to the loss of a spouse. The client progresses well and is approaching discharge. Which of the following is an appropriate outcome for this client? 1. The client verbalizes stages of grief and plans to attend a community grief group 2. The client verbalizes connections between significant losses and low self-esteem 3. The client verbalizes decreased desire for self-harm and discusses two alternatives to suicide 4. The client reports three additional coping strategies Answer: 1
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Rationale: The question is focused on the nursing diagnosis of dysfunctional grieving. The only option that deals with grief is option 1. Options 2, 3, and 4 are unrelated to this nursing diagnosis. Test-Taking Strategy: When presented with a question that identifies a nursing diagnosis, use the information in the question to assist in directing you to the correct option. Option 1 is the only option that is focused on the nursing diagnosis of dysfunctional grieving. Additionally, note the word “grieving” in the question and the word “grief” in the correct option. Review the defining characteristics for dysfunctional grieving if you had difficulty with this question. Level of Cognitive Ability: Analysis 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. 166. 311. A client comes to the emergency room following an assault and is extremely agitated, trembling, and hyperventilating. The appropriate initial nursing action would be: 1. Encourage the client to discuss the assault 2. Place the client in a quiet room alone to decrease stimulation 3. Remain with the client until the anxiety decreases 4. Begin to teach relaxation techniques Answer: 3 Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is critical for the nurse to remain with the client. Processing the anxiety at this point will further increase the client’s level of anxiety. The client in a severe state of anxiety would not be able to learn relaxation techniques. Test-Taking Strategy: Knowledge of nursing interventions for clients who display symptoms of severe anxiety is necessary to assist you in answering this question. Remember to use therapeutic techniques. The best technique in this situation is to remain with the client. If you are unfamiliar with the symptoms of the different levels of anxiety and the interventions that are indicated, review this information. 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. 312. A woman comes into the emergency room following an assault. Her symptoms include hyperventilation, pacing, rapid speech, and headache. The nurse correctly determines that the client is experiencing which level of anxiety? 1. Panic 2. Severe 3. Moderate
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4. Psychotic Answer: 2 Rationale: Clients who have severe anxiety have significant somatic complaints, ineffective functioning, loud or rapid speech, and purposeless activity. The symptoms in the question do not relate to options 1, 3, or 4. Test-Taking Strategy: Note the client symptoms carefully when trying to correctly answer a question similar to this one. Review the signs and symptoms associated with each level of anxiety 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. 266, 263. 313. A nurse is caring for an older, depressed client whose son was killed in an armed robbery after murdering two people. The client says, “I don’t know what I did wrong. His Dad died a hero in Vietnam when he was only 2 years old, but he’s had everything. When he threw the cat up against the wall ‘to see if it landed on its feet’ and stole money from me and denied it, his sister ‘covered’ for him.” The nurse plans to make which therapeutic response to the client? 1. “It seems as if you or your daughter feel regret.” 2. “Oh well; we can only love our children, do our very best, and hope they reflect our upbringing.” 3. “Do I hear you saying that you feel that your son’s behavior was caused by the indulgence he received from his sister?” 4. “Don’t blame yourself. You seem to have been very caring. Some people just turn out evil despite all we do for them.” Answer: 1 Rationale: The most therapeutic response by the nurse is one that seeks to promote the client to reframe a situation. In option 2, the nurse uses trite, clichéd social, nontherapeutic communication. In option 3, the nurse uses an inappropriate and inaccurate dynamic interpretation, which is insensitive. In option 4, the nurse uses false reassurance, which is nontherapeutic. Test-Taking Strategy: This question tests your ability to identify the most therapeutic communication technique for the nurse to employ for clients who blame themselves for the behavior of others. Use the process of elimination and knowledge regarding the therapeutic communication techniques to assist in directing you to option 1. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological 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.
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314. A nurse is preparing a hospitalized client for discharge. In evaluating the coping strategies learned during hospitalization, the nurse would recognize which statement by the client as an indication that further teaching is needed? 1. “I have learned ways to deal with the stresses in my life.” 2. “I know that I won’t become depressed again.” 3. “I know that I can’t be all things to all people.” 4. “I need to take my medications just as prescribed.” Answer: 2 Rationale: Depression may be a recurring illness for some people. The client needs to understand the symptoms and recognize when or if treatment needs to begin again. Options 1, 3, and 4 identify that the client has learned some coping skills, such as setting limits and taking medications. Test-Taking Strategy: Note the key words further teaching is needed. These words indicate a false response question and that you need to select the client statement that indicates ineffective coping strategies. Options 1, 3, and 4 are positive and realistic. A client statement such as option 2 is the only unrealistic statement, and thus indicates further teaching is needed. Review the indicators of effective use of coping strategies if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 217-218. 315. A nurse is monitoring a client that is in seclusion. The nurse determines that the client is safe to come out of seclusion when the client states: 1. “I am no longer a threat to myself or others.” 2. “I need to go to the bathroom.” 3. “I want to be alone for a while in my own room.” 4. “I can’t breathe in here. The walls are closing in on me.” Answer: 1 Rationale: Option 1 is clearly the best choice of the four options. The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with a urinal or bedpan, if necessary. It does not indicate that the client has calmed down enough to leave the seclusion room. Option 3 could be an attempt to manipulate the nurse. It gives no indication that the client will demonstrate self-control when alone in their room. Option 4 indicates the need for supportive communication or possibly a PRN medication. It does not necessitate discontinuing seclusion. Test-Taking Strategy: Focus on the issue. The issue of the question specifically relates to safety. You should easily be directed to option 1. Review seclusion procedures if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation
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Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 264. 316. A nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which of the following? 1. Follow-up appointments 2. Contracts and immediately available crisis resources 3. Encouraging the family to always be with the client 4. Providing the hospital phone number Answer: 2 Rationale: Crisis times may occur between appointments. Contracts facilitate clients feeling responsible for keeping a promise. This gives the client control. Option 3 is unrealistic. Providing phone numbers will not assure available and immediate crisis intervention. Test-Taking Strategy: The issue of the question relates to the availability of immediate resources for the client if needed. Eliminate option 3 first because this is unrealistic. Options 1 and 4 will not necessarily provide immediate resources. Also, note the word “immediate” in the correct option. This word will assist you in answering correctly. Review discharge planning for a client who attempted suicide 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. 289. 317. A client with active tuberculosis (TB) demonstrates less than expected interest in learning about the prescribed medication therapy. The nurse suggests to the health care team that this client may ultimately need: 1. More medication instructions 2. Involvement of the family in teaching 3. Reinforcement by the physician 4. Directly observed therapy Answer: 4 Rationale: TB is a highly communicable disease, which is reportable to the local public health departments. Each of these agencies has regulations that may be enforced to ensure compliance with TB therapy. The client may be required to have directly observed therapy to reduce the risk to the general public. This involves having a responsible person actually observe the client taking the medication each day. Test-Taking Strategy: Note the key word ultimately in the stem of the question. This implies an action that would be taken as a last resort. Knowing that TB is a highly communicable, reportable disease, you would eliminate options 1, 2, and then 3 in turn as a final action. This leaves directly observed therapy, which is closely overseen and enforced through the Public Health Department. Review measures to ensure compliance
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with medication therapy in the client with TB if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 375. 318. A 2-year-old child is a suspected victim of child abuse. The nurse is interviewing the child’s parent. Which statement, if made by the parent, would indicate a characteristic associated with child abuse? 1. “Once my child is potty trained, I can still expect them to have some ‘accidents’.” 2. “When I tell my child to do something once, I don’t expect to have to tell them again.” 3. “My child is expected to try to do things on their own such as dress and feed.” 4. “A two-year-old’s vocabulary is usually limited to about 200 words.” Answer: 2 Rationale: One characteristic of abusive parents is that they have expectations that are too high. As a result, the child cannot live up to the expectation of the adult parent. Unrealistic expectations result in the disappointment and frustration of the parent. The parent may even believe that the action of the child is intentional or done out of spite. The parent may react in an excessive manner, causing severe injury to the child. Test-Taking Strategy: Use the process of elimination. Options 1, 3, and 4 are true statements in that they are appropriate for the 2-year-old child. Option 2 indicates an unrealistic expectation. Recalling normal growth and development activities for a 2-yearold child will assist you to correctly answer the question. If you had difficulty with this question, review growth and development and the characteristics associated with child abuse. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance 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. 271. 319. A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, “I’m finally cured.” The nurse interprets this behavior as a cue to modify the treatment plan by: 1. Allowing the client off unit privileges PRN 2. Suggesting a reduction of medication 3. Allowing increased “in room” activities 4. Increasing the level of suicide precautions Answer: 4 Rationale: A client who is moderately depressed and has only been hospitalized for 2 days is very unlikely to have such a dramatic cure. When a mood suddenly lifts, it is very likely that the client may have made the decision to harm self. Suicide precautions are
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necessary to keep the client safe. Test-Taking Strategy: Use the process of elimination. Options 1 and 2 support the client’s notion that a cure has occurred. Option 3 allows the client to increase isolation, and that would present a threat to the treatment plan. Safety is of the utmost importance; therefore option 4 is the correct choice. Review care to the client with depression if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment 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. 222. 320. A nurse employed in a mental health unit who cares for suicidal clients is reviewing the work schedule. The nurse expects to note in the schedule that additional precautions related to safety for the clients will be provided at which of the following times? 1. Day shift 2. Weekdays 3. 7 AM to 10 AM 4. Weekends Answer: 4 Rationale: There is less availability of nursing staff on the weekends, and the nurse should be alert to this high-risk time. Additionally, often during shift change there is less availability of staff. The nurse should increase precautions of identified suicidal clients at these times. The night shift is also more likely to have a suicide attempt, rather than the day shift. Test-Taking Strategy: Use the process of elimination. Options 1, 2, and 3 are similar and can be eliminated. The nurse could anticipate that times with less supervision of the client could be times of increased risk. Review the guidelines related to caring for a client at risk for suicide if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 287-288. 321. An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which of the following would be least effective in preparing the client to return to a safe, effective care environment? 1. Identify the family’s strengths and weaknesses 2. Suggest that the mother’s boyfriend move out of the home 3. Provide and offer the family options and resources 4. Encourage sharing of feelings Answer: 2 Rationale: Option 2 is clearly the least effective option because there is no information in
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the question that leads one to believe that the boyfriend’s involvement has anything to do with the suicide attempt. Options 1, 3, and 4 are helpful ways to enhance the family processes. Test-Taking Strategy: Note the key words least effective. These words indicate a false response question and that you need to select the least helpful measure. There is no information in the question that leads you to believe there is a problem with the boyfriend that led the adolescent’s attempt to commit suicide. It is important that a nurse remain nonjudgmental when dealing with clients. Additionally, options 1, 3, and 4 identify positive measures that will assure a safe environment for the client. Review care to the client at risk for suicide if you had difficulty with this question. Level of Cognitive Ability: Analysis 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. 286. 322. A client tells a nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment? 1. Administer the prescribed antianxiety medication immediately 2. Move the client to a quiet room and talk about their feelings 3. Isolate the client in a seclusion room 4. Continue to monitor the client Answer: 2 Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client decreases environmental stimuli and talking gives the nurse an opportunity to identify the cause of these feelings and appropriate interventions. Seclusion is not appropriate. Medication is used only when other noninvasive approaches have been unsuccessful. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 first. From the remaining options, select option 2 over option 3 because it addresses the client’s feelings. Remember, client’s feelings are most important. Review interventions for a client who feels out of control 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, p. 70. 323. A nurse employed in an emergency room is assisting in caring for an adult client who is a victim of family violence. The nurse includes which priority instruction to the victim in the discharge plan? 1. Instructions explaining the importance of leaving the violent situation 2. Information regarding the location of shelters
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3. Information regarding self-defense classes 4. Instructions regarding calling the police Answer: 2 Rationale: Tertiary prevention of family violence includes assisting the victim once the abuse has already occurred. The nurse should provide the client with information identifying sources of assistance, such as a specific plan for removing self from the abuser, phone numbers of hot lines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Test-Taking Strategy: Use the process of elimination and note the key word priority. Focus on the issue of the question, which relates to providing the client with a safe environment. Use Maslow’s Hierarchy of Needs theory to assist in directing you to option 2. If you had difficulty with this question, review the nursing measures for caring for a victim of family violence. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed.). St. Louis: Mosby, p. 527. 324. A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels “as though the rape just happened yesterday” even though it has been a few months since the incident. The appropriate nursing response is which of the following? 1. “What do you think that you can do to alleviate some of your fears about being raped again?” 2. “Tell me more about the incidence that causes you to feel like the rape just occurred.” 3. “It will take some time to get over these feelings about your rape.” 4. “You need to try to be realistic. The rape did not just occur.” Answer: 2 Rationale: Option 2 allows for the client to express her ideas and feelings more fully, and portrays a nonhurried, nonjudgmental, supportive attitude. Clients need to be reassured that their feelings are normal, and that they may freely express their concerns in a safe care environment. Option 1 places the problem-solving totally on the client. Option 3 places the client’s feelings on hold. Option 4 immediately blocks communication. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. The client is seeking help. Remember to always 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: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88.
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325. A client is admitted to the psychiatric unit following a serious suicidal attempt by a drug overdose. The priority nursing intervention is to: 1. Remain with the client at all times 2. Place the client in a seclusion room where all potentially dangerous articles are removed 3. Remove the client’s clothing and place the client in a hospital gown 4. Request that a peer remain with the client at all times Answer: 1 Rationale: Drug overdose is a serious suicide attempt. The plan of care must reflect the action that will promote the client’s safety. Constant observation by a staff member who is never less than an arm’s length away is the best action. Options 2, 3, and 4 are inappropriate. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because it is not a peer’s responsibility to safeguard a client. Eliminate option 3 next because removing one’s clothing does not maximize all possible safety strategies. From the remaining options, select option 1 because it provides a constant supervision in this critical situation. Review care to the client at risk for suicide 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, p. 288. 326. A nurse is working with a victim of rape in a clinic setting and assists to develop a plan of care for the client. Which short-term initial goal is inappropriate? 1. The client will resolve feelings of fear and anxiety related to the rape trauma 2. Physical wounds will heal 3. The client will verbalize feelings about the event 4. The client will participate in the treatment plan Answer: 1 Rationale: Short-term goals will include the beginning stages of dealing with the rape trauma. Clients will be expected initially to keep appointments, participate in care, begin to explore feelings, and begin to heal physical wounds that were inflicted at the time of the rape. Test-Taking Strategy: Note the key words short-term initial goal and inappropriate. Use the process of elimination, considering each option and the reality of the option statement being achieved short term. Note the word “resolve” in option 1. This word should provide you with the clue that this option is a long-term goal. Review realistic goals for a client who was a victim of rape if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health
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Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 274-275. 327. A client who is experiencing suicidal thoughts states to the nurse, “It just doesn’t seem to be worth it anymore. Why not just end it all?” The appropriate initial nursing response is: 1. “I’m sure your family loves you.” 2. “I know you don’t feel good about yourself.” 3. “Did you sleep last night?” 4. “What do you mean by that?” Answer: 4 Rationale: Option 4 allows the client to tell you more about his/her current state of mind. Option 1 is false reassurance and may close communication. While option 2 is offering empathy for the client, it does not provide further assessment. Option 3 changes the subject and may close communication. Test-Taking Strategy: Use the steps of the nursing process and therapeutic communication techniques to select the correct option. Options 1 and 2 can be easily eliminated because they do not reflect data collection. Both options 3 and 4 relate to further data collection, but option 4 is directly related to the issue of the question. 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. 328. A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse reviews the plan of care for the client and notes that a nursing diagnosis of ineffective coping is documented in the plan. Which of the following is the least realistic goal for this client? 1. The client will identify a realistic perception of stressors 2. The client will develop adaptive coping patterns 3. The client will express and share feelings regarding the present crisis 4. The client will stop blaming himself for the lack of insurance Answer: 4 Rationale: Options 1, 2, and 3 identify a positive movement toward increased selfesteem and problem-solving. Option 4 places undue pressure on the client by implying that the client was negligent and contributed to the loss. Test-Taking Strategy: Use the process of elimination. Note the key words least realistic. The words “realistic,” “adaptive,” and “express and share feelings” in options 1, 2, and 3, respectively, identify positive goals. This should assist in directing you to option 4. Additionally, there is nothing in the question that indicates that the client lacked insurance, as option 4 reflects. Review goals for the client with a nursing diagnosis of ineffective coping if you had difficulty with this question. Level of Cognitive Ability: Analysis
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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. 181. 329. A nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which of the following is the priority nursing action? 1. Adhering to the mandatory abuse reporting laws 2. Obtaining treatment for the abusing family member 3. Notifying the case worker of the family situation 4. Removing the client from any immediate danger Answer: 4 Rationale: Whenever the abused client remains in the abusive environment, priority must be placed on ascertaining whether the person is in any immediate danger. If so, emergency action must be taken to remove them from the abusing situation. Options 1, 2, and 3 may be appropriate interventions but are not the priority. Test-Taking Strategy: Note the key word priority. Use Maslow’s Hierarchy of Needs theory, remembering that if a physiological need is not present than safety is the priority. This guide should direct you to option 4, the only option that directly addresses client safety. Review care to the client who is a victim of physical abuse if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Stuart, G., & Laraia, M. (2005) Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 809. 330. A nurse in the emergency department is assisting in caring for a young female victim of sexual assault. The client’s physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. These behaviors are interpreted by the nurse as: 1. Evidence that the client is a high suicide risk 2. Indicative of the need for hospital admission 3. Signs of depression 4. Normal reactions to a devastating event Answer: 4 Rationale: The symptoms noted in the question indicate a normal reaction to a very intensely difficult crisis event. Although the client’s initial reactions may be predictive of later problems, they do not indicate an abnormal initial response. Test-Taking Strategy: Remember, during the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. Use knowledge regarding client responses to devastating events and the process of elimination to answer the question. If you had difficulty with this question, review normal and abnormal client responses to dealing with devastating crisis events.
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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. 273. 331. A nurse caring for a client scheduled for a transsphenoidal hypophysectomy assists to develop a plan of care for the client. The nurse suggests inclusion of which specific information in the preoperative teaching plan? 1. Hair will need to be shaved 2. Deep breathing and coughing will be needed after surgery 3. Tooth brushing will not be permitted for at least 2 weeks following surgery 4. Spinal anesthesia will be used Answer: 3 Rationale: Based on the location of the surgical procedure, spinal anesthesia would not be used. Additionally, the hair would not be shaved. Although coughing and deep breathing is important, specific to this procedure is the avoidance of tooth brushing to prevent disruption of the surgical site. Test-Taking Strategy: Note the key word specific. Consider the anatomical location and the surgical procedure itself to eliminate options 1 and 4. Although you may be tempted to select option 2, read carefully. Because of the anatomical location of the surgery, option 3 is most important. Review this surgical procedure 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/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 861. 332. Following a hypophysectomy, the client complains of being very thirsty and having to urinate frequently. The initial nursing action is to: 1. Document the complaints 2. Increase fluid intake 3. Check the urine’s specific gravity 4. Check for the presence of glucose in the urine Answer: 3 Rationale: Following a hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone (ADH) deficiency. This deficiency is related to surgical manipulation. The nurse should check the urine’s specific gravity and report the results if it is less than 1.005. Test-Taking Strategy: Note the key word initial. Knowledge that diabetes insipidus is a complication of this type of surgery will assist in eliminating option 4. From the remaining options, recall the pathophysiology related to diabetes insipidus to direct you to option 3. Review this pathophysiology if you had difficulty with this question.
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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 861-862. 333. A nurse is reviewing the physician’s orders for a client with hypothyroidism. Which of the following medications, if prescribed for the client, would the nurse question and verify? 1. Docusate sodium (Colace) 2. Morphine sulfate 3. Levothyroxine (Synthroid) 4. Atenolol (Tenormin) Answer: 2 Rationale: The client with hypothyroidism experiences fatigue, lethargy, and increased somnolence. The decreased metabolism and oxygen consumption are manifested by a slow heart rate, decreased cardiac output, and decreased blood pressure. Levothyroxine, a thyroid hormone, is a component of therapy. Stool softeners such as docusate sodium are prescribed to promote defecation. Morphine sulfate would further depress bodily functions. Atenolol is used with caution in clients with hyperthyroidism. Test-Taking Strategy: Use the process of elimination. Keeping in mind that a decreased metabolic rate occurs in the client with hypothyroidism will direct you to option 2 as the medication that would be avoided in this condition. Review the pathophysiology associated with hypothyroidism if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1322. 334. A client is brought to the emergency room in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse who is assisting to care for the client obtains which of the following immediately in preparation for the treatment of this syndrome? 1. NPH insulin 2. A nasal cannula 3. Intravenous (IV) infusion of sodium bicarbonate 4. IV infusion of normal saline Answer: 4 Rationale: The primary goal of treatment is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. IV fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium
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levels. A nasal cannula for oxygen administration is not necessarily required to treat HHNS. Test-Taking Strategy: Use the process of elimination. If you can recall the treatment for DKA, you will easily be able to answer this question. Treatment for HHNS is similar to the treatment for DKA. Review the treatment for HHNS 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/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 905. 335. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency room. Which of the following findings would the nurse expect to note as confirming this diagnosis? 1. Elevated blood glucose and low plasma bicarbonate levels 2. Decreased urine output 3. Increased respirations and an increase in arterial pH 4. Coma Answer: 1 Rationale: In DKA, the arterial pH is less than 7.35, the plasma bicarbonate level is less than 15 mEq/L, the blood glucose level is greater than 250 mg/dl, and ketones are present in the blood and urine. The client would be experiencing polyuria, and Kussmaul’s respirations would be present. Coma may occur if DKA is not treated, but coma would not confirm the diagnosis. Test-Taking Strategy: Note the key word confirm in the stem of the question. Eliminate option 4 because coma can exist is many conditions. Eliminate option 3 because in acidosis the pH would be low. Remember that polyuria exists in DKA. This leaves option 1 as the correct choice. Review the clinical manifestations of this disorder 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 904-905. 336. A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial serum glucose level was 950 mg/dl. Intravenous (IV) insulin was started along with rehydration with IV normal saline. The serum glucose level is now 240 mg/dl. The nurse who is assisting in caring for the client obtains which of the following items, anticipating a physician’s order? 1. IV infusion containing 5% dextrose 2. NPH insulin and a syringe for subcutaneous injection 3. An ampule of 50% dextrose
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4. Phenytoin (Dilantin) for the prevention of seizures Answer: 1 Rationale: During management of DKA, when the blood glucose level falls to 300 mg/dl the infusion rate is reduced and 5% dextrose is added to maintain a blood glucose level of about 250 mg/dl, or until the client recovers from ketosis. NPH insulin is not used to treat DKA. Dextrose 50% is used to treat hypoglycemia. Phenytoin is not a normal treatment measure in DKA. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first, knowing that regular insulin is used in the management of DKA. Eliminate option 3 next, knowing that this is the treatment for hypoglycemia. Note the key words the serum glucose level is now 240 mg/dl. This should indicate that the IV solution of 5% dextrose is the next step in management of care. Review care to the client with DKA if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 905. 337. A client with diabetes mellitus is being discharged following treatment for hyperglycemic hyperosmolar nonketotic syndrome (HHNS) precipitated by acute illness. The client states to the nurse, “I will call the doctor next time I can’t eat for more than a day or so.” The nurse plans care understanding that which of the following most accurately reflects this client’s level of knowledge? 1. The client needs immediate education before discharge 2. The client’s statement is accurate but knowledge should be evaluated further 3. The client’s statement is inaccurate and the client should be scheduled for outpatient diabetic counseling 4. The client requires follow-up teaching regarding the administration of insulin Answer: 1 Rationale: If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the physician should be notified. The client’s statement in this question indicates a need for immediate education to prevent HHNS, a life-threatening emergency situation. Test-Taking Strategy: Knowledge regarding the causes of HHNS will assist in answering the question. Focusing on the client’s statement and noting the words “I can’t eat for more than a day or so” will direct you to the correct option. Review diabetic management during times of illness if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 908. 338. A physician has prescribed propylthiouracil (Propylthiouracil) for a client with
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hyperthyroidism, and the nurse assists in developing a plan of care for the client. A priority nursing measure to be included in the plan regarding this medication is to monitor the client for: 1. Signs and symptoms of hypothyroidism 2. Signs and symptoms of hyperglycemia 3. Relief of pain 4. Signs of renal toxicity Answer: 1 Rationale: Excessive dosing with propylthiouracil may convert the client from a hyperthyroid state to a hypothyroid state. If this occurs, the dosage should be reduced. Temporary administration of thyroid hormone may be required. Propylthiouracil is not used for pain and does not cause hyperglycemia or renal toxicity. Test-Taking Strategy: Focus on the data in the question. Noting that propylthiouracil is used to treat hyperthyroidism should direct you to option 1. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 904-905. 339. A nurse is monitoring a client with diabetes insipidus. Desmopressin (DDAVP) has been prescribed for the client. Which of the following outcomes reflects a therapeutic effect of this medication? 1. Increased serum osmolality 2. Increased blood pressure 3. Decreased urine output 4. Decreased urine osmolality Answer: 3 Rationale: Desmopressin is a synthetic form of antidiuretic hormone. It causes increased reabsorption of water with a resultant decrease in urine output. Therapeutic response to desmopressin would demonstrate a decrease in serum osmolality as more fluid is retained, and an increase in urine osmolality as less fluid is excreted. Increased blood pressure is a side effect rather than a therapeutic effect of desmopressin. Test-Taking Strategy: Use the process of elimination and note the key words therapeutic effect. Knowledge of the action of desmopressin and the pathophysiology related to diabetes insipidus will direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 301.
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340. A nurse is assisting in preparing a care plan for a client with diabetes mellitus who has hyperglycemia. The nurse suggests addressing which priority problem in the plan of care? 1. Deficient fluid volume 2. Deficient knowledge 3. Imbalanced nutrition 4. Compromised family coping Answer: 1 Rationale: Increased blood glucose will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 2, 3, and 4 may be concerns at some point, but are not the priority with hyperglycemia. Test-Taking Strategy: Focus on the client’s diagnosis. Option 1 indicates a physiological response to the hyperglycemia that should be a priority. Options 2, 3, and 4 may or may not need to be addressed after providing for the physiological need associated with hyperglycemia. Review the effects of hyperglycemia in the diabetic client if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 487. 341. A nurse is assigned to care for a client at home who has a diagnosis of type 1 diabetes mellitus. When the nurse arrives to care for the client, the client tells the nurse that she has been vomiting and has diarrhea. Which additional statement by the client indicates a need for reinforcing teaching? 1. “I need to stop my insulin.” 2. “I need to increase my fluid intake.” 3. “I need to call my physician.” 4. “I need to monitor my blood glucose every 4 to 6 hours.” Answer: 1 Rationale: When a diabetic client is unable to eat normally due to illness, the client should still take the prescribed insulin or oral medication. Additional fluids should be consumed and a call placed to the health care provider. The client should monitor the blood glucose levels every 4 to 6 hours. Test-Taking Strategy: Use the process of elimination and note the key words need for reinforcing teaching. Remembering that clients need to take their insulin will direct you to option 1. Review these principles 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/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical
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management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1286. 342. A nurse is assigned to assist in caring for a client admitted to the emergency room with diabetic ketoacidosis (DKA). In the acute phase, the priority nursing action is to prepare to: 1. Administer intravenous (IV) regular insulin 2. Administer IV 5% dextrose 3. Correct the acidosis 4. Apply an ECG monitor Answer: 1 Rationale: Lack (absolute or relative) of insulin is the primary cause leading to DKA. Treatment consists of IV fluids (normal saline initially), regular insulin administration, and potassium replacement, followed by correcting the acidosis. An ECG monitor may be applied but is not the priority in this situation. Test-Taking Strategy: Note the key word priority. Remember, in DKA the initial treatment is IV fluid replacement and the administration of regular insulin. Normal saline is administered initially; therefore option 2 is incorrect. Options 3 and 4 may be a component of the treatment plan, but are not the priority. Review care to the client with DKA 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/Endocrine References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 488. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 904. 343. A client with type 2 diabetes mellitus has a blood glucose level over 600 mg/dl and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the physician’s documentation and would expect to note which of the following diagnoses? 1. Diabetic ketoacidosis (DKA) 2. Hypoglycemia 3. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) 4. Pheochromocytoma Answer: 3 Rationale: HHNS is seen primarily in type 2 diabetics who experience a relative deficiency of insulin. The onset of symptoms may be gradual. The symptoms may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness. DKA normally occurs in type 1 diabetes mellitus. The clinical manifestations noted in the question are not signs of hypoglycemia. Pheochromocytoma is not related to these clinical manifestations. Test-Taking Strategy: Use the process of elimination. The key words are type 2 diabetes mellitus and blood glucose level over 600 mg/dl. These key words will assist in eliminating options 2 and 4. Recalling that HHNS most commonly occurs in type 2 diabetes mellitus will direct you to option 3. Review the complications associated with
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type 2 diabetes mellitus 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 References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 488. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 906. 344. A family of a bedridden client with type 2 diabetes mellitus calls the clinic nurse to report the following symptoms: blood glucose level 400 mg/dl (by fingerstick), polydipsia, and increased lethargy. In determining the client’s problem, the most important question to ask the family is which of the following? 1. “Has there been any change in eating patterns?” 2. “Are there any ketones in the urine?” 3. “Has there been any fever?” 4. “Have you increased the amount of fluids provided?” Answer: 2 Rationale: In type 2 diabetes mellitus, hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is a concern. The clinical manifestations are similar to diabetic ketoacidosis (DKA) except that HHNS is differentiated from DKA by the absence of excessive ketone bodies. Options 1, 3, and 4 may be questions that will be asked but are not the most important in this situation. Test-Taking Strategy: Note the key words most important and the signs and symptoms presented in the question. Options 1 and 3 can be eliminated first because they are unrelated to these signs and symptoms. From the remaining options, option 2 is most specific in assisting to determine the client’s problem. Review the complications associated with type 2 diabetes mellitus and the differences between DKA and HHNS 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 References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 488. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 905. 345. A nurse is preparing to administer an injection of regular insulin. The vial of regular insulin has been refrigerated. Upon inspection of the vial, the nurse finds that the medication is frozen. The nurse should: 1. Wait for the insulin to thaw at room temperature 2. Check the temperature settings of the refrigerator 3. Discard the insulin and obtain another vial 4. Rotate the vial between the hands until the medication becomes liquid
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Answer: 3 Rationale: Insulin preparations are stable at room temperature for up to 1 month without significant loss of activity. Insulin should not be frozen. If the insulin is frozen, the insulin should be discarded and the nurse should obtain another vial. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 because they are similar. From the remaining options, option 3 is most directly related to client safety. Therefore select this option. Review insulin storage principles 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/Endocrine Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 604. 346. A nurse has collected data on a client with diabetes mellitus. Findings include a fasting blood glucose level of 100 mg/dl, temperature 101° F, pulse 78 beats per minute, respirations 22 breaths per minute, and blood pressure 118/78 mm Hg. Which finding would be of most concern to the nurse? 1. Pulse and respirations 2. Blood pressure 3. Blood glucose 4. Temperature Answer: 4 Rationale: Elevated temperature may be indicative of infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) or diabetic ketoacidosis (DKA). Options 1, 2, and 3 are findings that are within a normal range. Test-Taking Strategy: Basic knowledge of the normal values of vital signs will easily direct you to the correct option. The client’s temperature is the only abnormal value. Remember that an elevated temperature can indicate an infectious process that may lead to diabetic complications. Review the complications associated with diabetes mellitus 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: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1272. 347. A nurse is collecting data from a client newly diagnosed with diabetes mellitus regarding the client’s learning readiness. Which client behavior indicates to the nurse that the client is not ready to learn? 1. The client complains of fatigue whenever the nurse plans a teaching session 2. The client asks if the spouse can attend the classes also 3. The client asks for written materials about diabetes before class
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4. The client asks appropriate questions about what will be taught Answer: 1 Rationale: Physical symptoms can interfere with an individual’s ability to learn and can also indicate to the teacher that the learner lacks motivation to learn if the symptoms repeatedly recur when teaching is initiated. Options 2, 3, and 4 identify the client as actively seeking information. Test-Taking Strategy: Note the key words not ready to learn in the stem of the question and use the process of elimination. Options 2, 3, and 4 identify the client as actively seeking information. Option 1 suggests avoidance on the part of the client. Review teaching learning principles if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 451-454. 348. A client with diabetes mellitus visits the health care clinic. The client had previously been well controlled with glyburide (DiaBeta), but recently the fasting blood glucose level has been 180 to 200 mg/dl. Which of the following medications, if added to the client’s regimen, may be contributing to the hyperglycemia? 1. Prednisone (Deltasone) 2. Atenolol (Tenormin) 3. Phenelzine sulfate (Nardil) 4. Allopurinol (Zyloprim) Answer: 1 Rationale: Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Options 2, a beta-blocker, and 3, a monoamine oxidase inhibitor, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral medications, which can lead to hypoglycemia. Test-Taking Strategy: The issue of the question relates to hyperglycemia. This question requires that you know the medication classifications of the medications in the options and correlate these with their potential hypoglycemic or hyperglycemic effect. Remember, prednisone may decrease the effect of oral hypoglycemics. Review these medications if you are unfamiliar with them. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 883. 349. A nurse collects urine specimens for catecholamine testing from a client with suspected pheochromocytoma. The results of the catecholamine test are reported as 20 mcg/100 mL of urine. The nurse analyzes these results as:
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1. Normal 2. Lower than normal, ruling out pheochromocytoma 3. Higher than normal, indicating pheochromocytoma 4. Insignificant and unrelated to pheochromocytoma Answer: 3 Rationale: Assays of catecholamines are performed on single-voided urine specimens, 2hour to 4-hour specimens, and 24-hour urine specimens. The normal range of urinary catecholamines is up to 14 mcg/100 mL of urine, with higher levels occurring in pheochromocytoma. Test-Taking Strategy: Knowing that pheochromocytoma is a catecholamine-producing tumor, you would expect that the results of such a test would indicate higher than normal amounts of catecholamine. Additionally, the question addresses that the client is suspected of having pheochromocytoma, so if you need to select an option and you are not quite sure, select the option that has similarity to the issue of the question. In this case, suspected pheochromocytoma is similar to indicating pheochromocytoma addressed in option 3. Review this diagnostic test if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 928-929. 350. A physician orders a 24-hour urine collection for vanillylmandelic acid (VMA). The nurse instructs the client about the procedure for the collection of the urine. Which statement by the client would indicate a need for further instruction? 1. “I will start the collection in 2 days. I cannot eat or drink any tea, chocolate, vanilla, or fruit until the test is completed.” 2. “When I start the collection, I will urinate and discard that specimen.” 3. “I will pour the urine in the collection bottle each time I urinate and refrigerate the urine.” 4. “I can take medications if I need to before the collection.” Answer: 4 Rationale: Since a 24-hour urine collection is a timed quantitative determination, it is essential that the client start the test with an empty bladder. Therefore the client is instructed to void and discard the first urine and note the time and then start the test. The 24-hour urine specimen collection bottle must be kept on ice or refrigerated. In a VMA collection, the client is instructed to avoid tea, chocolate, vanilla, and all fruits for 2 days before urine collection begins. Also, clients are reminded not to take medications for 2 to 3 days before the test. Test-Taking Strategy: Note the key words need for further instruction. These words indicate a false response question and that you need to select the incorrect client statement. Knowledge regarding the procedure for 24-hour urine collections will assist you in answering this question. Remember that medications can affect the results of a test. Review the procedure for collecting 24-hour urine specimens if you had difficulty with this question.
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Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1131. 351. A perinatal client has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures? 1. “I should avoid the use of condoms.” 2. “I can douche anytime I want.” 3. “I can wear my tight fitting jeans.” 4. “I should choose underwear with a cotton panel liner.” Answer: 4 Rationale: Condoms should be used to minimize the spread of sexually transmitted infectious diseases. Wearing tight clothes irritates the genital area and does not allow for air circulation. Douching is to be avoided. Wearing items with a cotton panel liner allows for air movement in and around the genital area. Test-Taking Strategy: Use the process of elimination, noting the key words indicates an understanding. Options 1, 2, and 3 are all incorrect statements regarding self-care. Review the measures that will prevent genital tract infections 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: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 422. 352. During initial data collection of a maternity client, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects the presence of human immunodeficiency virus (HIV). Which of the following laboratory studies would further support the presence of HIV? 1. T lymphocyte levels 2. Angiotensin levels 3. Glomerular filtration rate 4. Platelet count Answer: 1 Rationale: HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for T lymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney. Glomerular filtration rate indicates kidney function. Platelet count is important and may be an indicator of HIV, but this laboratory test has already been identified in the components of the question. Test-Taking Strategy: Use the process of elimination. Option 4 has already been identified in the components of the question and can be eliminated. Options 2 and 3 are
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similar in that they are related to kidney function. Review this information if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 339. 353. When caring for the maternal client with human immunodeficiency virus (HIV), which goal would be appropriate? 1. The client will not have sexual relations during the remainder of the pregnancy 2. The client will not develop an opportunistic infection during the remainder of the pregnancy 3. The client is advised of an HIV support group 4. The client is assisted with the grief process Answer: 2 Rationale: HIV is caused by a retrovirus that infects T lymphocytes. This disables the body’s ability to fight infection. Nursing goals are directed at the prevention of infections. Sexual relations are not contraindicated with the proper use of protective devices. Options 3 and 4 are the focus of interventions, not goals. Test-Taking Strategy: Use the process of elimination and note that the question asks for a goal. Options 3 and 4 are interventions and can be eliminated. Option 1 is inappropriate. Knowledge regarding the infectious nature of HIV will direct you to option 2. Review this information if you had difficulty with the question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 340. 354. A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client’s health record, the nurse notes that the laboratory values indicate a low hemoglobin and hematocrit level. Which of the following problems do the data best support? 1. Anxiety 2. Low self-esteem 3. Cerebrovascular accident 4. High risk for infection Answer: 4 Rationale: Women with anemia have a higher incidence of puerperal complications such as infection than do pregnant women with normal hematological values. There are no data in the question to support options 1, 2, or 3. Test-Taking Strategy: Use the process of elimination. Options 1 and 2 could occur, but the data needed to support these options are not provided in the question. Eliminate
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option 3 because it is a medical diagnosis. Review the risks associated with infection in the pregnant client if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 108-109. Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 384. 355. A nurse is planning interventions for counseling a pregnant client newly diagnosed with sickle cell anemia. The nurse understands that the most important psychosocial intervention at this time would be which of the following? 1. Providing all information regarding the disease immediately 2. Allowing the client to be alone if she is crying 3. Providing emotional support 4. Avoiding the topic of the disease Answer: 3 Rationale: Probably the most important of all nursing functions is providing emotional support to the client and family. Option 1 overwhelms the client with information while the client is trying to cope with the news of the disease. Option 2 is only appropriate if the client requests to be alone. If unrequested, the nurse is abandoning the client in a time of need. Option 4 is nontherapeutic. Supportive therapy allows the client to express feelings, explore alternatives, and make decisions in a safe, caring environment. Test-Taking Strategy: Use therapeutic communication techniques. Remember to always address client feelings first. This will easily direct you to the correct option. Review psychosocial needs of the client with sickle cell anemia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 108. 356. A nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be most appropriate? 1. The client will verbalize a reduction of pain 2. The client will no longer have a positive Homans’ sign 3. The client will report that an infection is likely to occur 4. The client will be able to identify measures to prevent infection Answer: 4 Rationale: The uterus is theoretically sterile during pregnancy until the membrane ruptures. It is capable of being invaded by pathogens after that rupture. Puerperal infection is a major cause of maternal morbidity and mortality. Option 3 is inaccurate.
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Options 1 and 2 are not directly related to infection. Test-Taking Strategy: Use the process of elimination, focusing on the issue—infection. Eliminate options 1 and 2 because they are not directly related to infection. Eliminate option 3 because it is inaccurate. Review postpartum infection if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1048. 357. A nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which of the following statements would the nurse make to the client? 1. “Hands should be washed thoroughly before holding the infant.” 2. “The infant will not be allowed in the room at all.” 3. “There is no danger of the newborn contracting the disease.” 4. “Visitors are not allowed to hold the baby.” Answer: 1 Rationale: Transmission of infectious diseases can occur through contaminated items such as hands and bed linens in clients with endometritis. An important method of preventing infection is to break the chain of infection. Hand washing is one of the most effective methods of preventing the transmission of infectious diseases. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Avoid options that contain absolute terminology such as in options 2, 3, and 4. These options use the words “all” and “no.” Also, remember that hand washing is one of the most effective methods of preventing the transmission of infectious diseases. Review content related to the transmission of infection 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: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 160. 358. A nursing student prepares a teaching plan for a pregnant client newly diagnosed with diabetes mellitus. The nursing instructor suggests changing the plan if the student includes which information? 1. Effects of diabetes on the pregnancy and the fetus 2. Nutritional requirements for pregnancy and for the control of diabetes 3. Avoidance of exercise because of the negative effects on insulin production 4. Awareness of any infections and instructions to report signs of infection immediately to the health care provider Answer: 3
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Rationale: Options 1, 2, and 4 are all important points to include in the teaching plan for the new diabetic. Exercise is necessary for the pregnant diabetic. Concepts related to the timing of exercise, control of food intake, and insulin injection around the time of exercise should be included in the plan. Test-Taking Strategy: Use the process of elimination. Note the key words suggests changing the plan in the question. These words indicate a false response question and that you need to select the incorrect intervention. Remember, exercise is necessary for the pregnant diabetic. If you had difficulty with this question, review the effects of diet and exercise on diabetes. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 228. 359. A postpartum client with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, “Do I have to worry about this diabetes anymore?” The nurse makes which response to the client? 1. “Your blood glucose level is within normal limits now; you will be all right.” 2. “You will only have to worry about the diabetes if you become pregnant again.” 3. “You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus.” 4. “Once you have gestational diabetes you have overt diabetes and must be treated with medication for the rest of your life.” Answer: 3 Rationale: The client is at risk for developing gestational diabetes with each pregnancy. She also has an increased risk of developing overt diabetes and needs to comply with follow-up appointments. She also needs to be taught techniques to lower her risk for developing diabetes, such as weight control. The diagnosis of gestational diabetes indicates that this client has an increased risk for developing overt diabetes; however, with proper care it may not develop. Test-Taking Strategy: Use the process of elimination. Identify the issue of the question, which is the long-term effects of gestational diabetes. Knowledge regarding these effects will direct you to the correct option. Review the long-term effects of gestational diabetes if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 229. 360. A new prenatal client is 6 months pregnant. On the first prenatal visit, the nurse notes that the client is gravida IV, para 0, aborta III. The client is 5 feet 6 inches tall, weighs 130 pounds, and is 25 years old. She states: “I get really tired after working all
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day and can’t keep up with my housework.” Which factor in the above data would lead the nurse to suspect gestational diabetes? 1. Fatigue 2. Obesity 3. Maternal age 4. Fetal demise Answer: 4 Rationale: A previous history of unexplained stillbirths or miscarriages puts the client at high risk for gestational diabetes. Fatigue is a normal occurrence during pregnancy. A client at 5 feet 6 inches tall, 130 pounds does not meet the criteria of 20% over ideal weight. Therefore the client is not obese. To be at high risk for gestational diabetes, the maternal age is usually greater than 30 years. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Note that options 2 and 3 do not apply to this client. Recalling that fatigue is a normal occurrence during pregnancy will direct you to option 4. Review the risk factors related to gestational diabetes if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 101. Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 229. 361. A pregnant client is newly diagnosed as having gestational diabetes. She cries during the interview and keeps repeating, “What have I done to cause this? If I could only live my life over.” Which presenting problem should initially direct nursing care at this time? 1. Situational low self-esteem related to a complication of pregnancy 2. Deficient knowledge related to diabetic self-care during pregnancy 3. Disturbed body image related to complications of pregnancy 4. Risk for injury to the fetus related to maternal distress Answer: 1 Rationale: The client is putting the blame for the diabetes upon herself, lowering her self-esteem. She is expressing fear and grief. Deficient knowledge is important for this client, but not immediately. The client will not be able to comprehend information at this time. There are no data to support options 3 and 4. Test-Taking Strategy: Focus on the data provided in the question and use the process of elimination. Focus on the key words “What have I done to cause this?” to direct you to option 1. Review the defining characteristics for situational low self-esteem if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum References: Gulanick, M., Myers, J., Klopp, A., Gradishar, D., Galanes, S., & Puzas, M.
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(2003). Nursing care plans: Nursing diagnosis and intervention (5th ed.). St. Louis: Mosby, p. 137. Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 106. 362. A primigravida is receiving magnesium sulfate for pregnancy-induced hypertension. The nurse is asked to monitor the client every 30 minutes. Which of the following information would be of most concern to the nurse? 1. Urinary output of 20 mL since the last check 2. Deep tendon reflexes of 2+ 3. Respirations of 10 breaths per minute 4. Fetal heart tone of 116 beats per minute Answer: 3 Rationale: Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the continuation of the medication needs to be reassessed. Option 1 is adequate because there is 20 mL of urine produced in 30 minutes and the acceptable criterion is greater than 30 mL per hour. Deep tendon reflexes of 2+ are normal. The fetal heart tone is within normal limits for a resting fetus. Test-Taking Strategy: Note the key words most concern. Use the process of elimination, recalling the adverse effects of magnesium sulfate to select the correct option. Review the adverse effects of magnesium sulfate if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 222. 363. During a routine prenatal visit the client states, “I have not been able to get my wedding ring off for the last two days. I guess the heat is making my fingers swell.” The nurse needs to further check: 1. The client for blood pressure changes and protein in the urine 2. The client’s height of the fundus as compared to the date of her last visit 3. The blood glucose level 4. For any vaginal discharge Answer: 1 Rationale: Finger edema is a frequent forerunner of pregnancy-induced hypertension (PIH) and should be investigated further. Options 2, 3, and 4 are all indicators of other problems such as diabetes, infections, and molar pregnancy. Test-Taking Strategy: Use the process of elimination. Focus on the data provided in the question and recall the complications and the indicators associated with the complications of pregnancy, specifically PIH. Review these complications if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection
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Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 94. 364. A nurse reinforces instructions to a client with mild preeclampsia on home care. The nurse evaluates that the teaching has been effective when the client states: 1. “As long as the health care nurse is visiting me daily I do not have to keep my next physician’s appointment.” 2. “I need to take my blood pressure each morning and alternate arms each time.” 3. “I need to check my weight every day at different times during the day.” 4. “I need to check my urine with a dipstick every day for protein and call the physician if it is 2+ or more.” Answer: 4 Rationale: Option 4 is a correct statement. It is still important to keep physician appointments to assess for any other physical changes in the mother or baby. Blood pressures need to be taken in the same arm, in a sitting position every day in order to obtain a consistent and accurate reading. The weight needs to be checked at the same time each day, wearing the same clothes, after voiding, and before breakfast in order to obtain reliable weights. Test-Taking Strategy: Use the process of elimination, reading each option carefully. Use knowledge regarding preeclampsia and general principles related to home care and weight and blood pressure measurement to answer the question. Review care to the client with preeclampsia 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: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 847. 365. A nurse in an ambulatory clinic is preparing to administer a Mantoux skin test to a client who may have been exposed to an individual with tuberculosis (TB). The client reports having had the bacille Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. The nurse interprets that: 1. The client’s Mantoux test will be negative, and will require sputum culture to diagnose 2. The client’s Mantoux test will be positive, and will require chest x-ray for evaluation 3. The client has no risk of acquiring TB, and needs no further workup 4. The client is at more risk of acquiring TB, and needs immediate medication therapy Answer: 2 Rationale: The bacille Calmette-Guérin vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the client will always test positive on Mantoux skin testing after receiving the vaccine. This client needs to be evaluated for TB with a chest x-ray. Test-Taking Strategy: Knowledge of this specific vaccine is necessary to answer this question correctly. Remember that the client will always test positive on Mantoux skin testing after receiving the vaccine. Review this vaccine if you had difficulty with this
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question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation 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. 1846. 366. A client has just had surgery to deliver a nonviable fetus due to abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, “God, just let me die now!” Which problem should direct care for this client? 1. Hopelessness related to loss of the baby and personal health 2. Deficient knowledge related to the disease process 3. Situational low self-esteem related to being ill 4. Grieving related to loss of the baby Answer: 1 Rationale: By seeing no way out of the situation except for death, the client meets the criteria for hopelessness. A person who lacks hope feels that life is too much to handle. Option 2 is a possible problem later, but there are not enough data to support it at this point. The data given do not support a situational low self-esteem. Option 4 is a possible problem at a later time; however, at this time hopelessness should take precedence. Test-Taking Strategy: Focus on the data in the question and the key words “God, just let me die now!” These key words and the process of elimination will direct you to option 1. Review the defining characteristics for hopelessness if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 877. 367. A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Part of the plan of care for this client should be to monitor for: 1. Any bleeding, such as in the gums, petechiae, and purpura 2. Enlargement of the breasts 3. Periods of fetal movement followed by quiet periods 4. Complaints of feeling hot when the room is cool Answer: 1 Rationale: Bleeding is an early sign of disseminated intravascular coagulation (DIC), a complication of preeclampsia, and should be reported. Options 2, 3, and 4 are all normal occurrences in the last trimester of pregnancy. Test-Taking Strategy: Use the process of elimination, noting that options 2, 3, and 4 are normal occurrences in the last trimester of pregnancy. Recall that bleeding does not
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normally occur with pregnancy. Review the signs of DIC if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 287. 368. When collecting data from a client at risk for disseminated intravascular coagulation (DIC), which of the following factors would the nurse consider being the most significant? 1. A gravida VI that delivered 10 hours ago and has lost 450 mL of blood 2. A gravida II that has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago 3. A primigravida with mild preeclampsia 4. A primigravida that delivered a 10-pound baby 3 hours ago Answer: 2 Rationale: Dead fetus syndrome is considered a risk factor for DIC. Hemorrhage is a risk factor with DIC; however, a loss of 450 mL is not considered hemorrhage. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large baby is not considered a risk factor for DIC. Test-Taking Strategy: Use the process of elimination and knowledge of the risk factors associated with DIC. Remember, dead fetus syndrome is considered a risk factor for DIC. Review these risk factors if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1044. 369. For the previous 4 hours, a client in labor has been experiencing contractions every 2 minutes, lasting 60 to 70 seconds, and strong to palpation. She is 2-cm dilated and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia? 1. Hypotonic 2. Precipitate 3. Hypertonic 4. Protracted active phase Answer: 3 Rationale: The client is 2-cm dilated and in the latent phase of labor. The most common type of dysfunctional labor at this point is hypertonic. A normal pattern during the latent phase of labor is contractions every 5 to 10 minutes, lasting 30 to 45 seconds, and mild in intensity. Precipitate labor is that which lasts in its entirety for 3 hours or less. The client has already been in labor for at least 4 hours. Hypotonic labor contractions are short,
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irregular, and weak, and usually occur during the active phase of labor. Test-Taking Strategy: Use the process of elimination. Note that the client is 2-cm dilated and focus on the client’s contraction pattern to determine the type of dystocia. Review the characteristics of hypertonic dystocia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 240. 370. A nurse is collecting data from a client and is reviewing the client’s health record to determine the risk for preterm labor. Which of the following findings would place the client at this risk? 1. A 26-year-old primigravida 2. A single-fetus pregnancy 3. A hemoglobin level of 13.5 g/dl 4. A diagnosed urinary tract infection Answer: 4 Rationale: One risk factor for preterm labor is the presence of a genitourinary infection. Although the connection is not clearly understood, one hypothesis involves the release of prostaglandins by the pathogens, which may contribute to the initiation of contractions. Other risk factors for preterm labor include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; age less than 15 years; or first pregnancy over the age of 35. Test-Taking Strategy: Use the process of elimination. Options 1, 2, and 3 are all average findings. By the process of elimination, option 4 is the only deviation from normal. Review the risk factors associated with preterm labor if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 235. 371. A nurse is assisting in caring for a client in labor. The nurse recognizes that the risks for uterine rupture during labor and delivery include: 1. Hypotonic contractions 2. Shoulder dystocia 3. Primigravida 4. Weak bearing-down efforts Answer: 2 Rationale: Shoulder dystocia at delivery causes increased pressure in the thin lower uterine segment and subsequently the risk for spontaneous rupture. Statistically, rupture is more common in multigravidas, especially when combined with the use of oxytocin.
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Hypotonic contractions and weak bearing-down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall. Test-Taking Strategy: Use the process of elimination. Look for the option that identifies a situation that would provide an additional source of pressure to the uterus, and would be most likely to add to the risk of rupturing the uterus. Option 2 is the only option that would provide an additional source of pressure to the uterus. Review the causes of uterine rupture if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 193. 372. A nurse is assigned to assist in caring for a client in labor. The nurse would determine that which of the following would least likely indicate dystocia? 1. High level of maternal fear or anxiety 2. Failure of fetus to descend 3. Progressive changes in the cervix 4. Signs of fetal distress Answer: 3 Rationale: Progressive changes in the cervix are a reassuring pattern in labor. Abnormal labor patterns are assessed according to the nature of the cervical dilation and fetal descent. Options 1, 2, and 4 could indicate signs of dystocia. Test-Taking Strategy: Note the key words least likely. Use the process of elimination, selecting the option that is a normal finding in labor. Review these normal findings if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 239-240. 373. A mother experiencing dystocia looks alarmed and asks: “What’s going on? Why are you all poking and prodding? Is my baby OK?” Based on the client’s statement, the nurse understands that the client is experiencing which of the following problems? 1. Anxiety and fear 2. Powerlessness 3. Impaired parenting 4. Disturbed sensory perception Answer: 1 Rationale: The client is expressing anxiety and fear related to the situation. Powerlessness would be identified if the client verbalized a lack of control over the situation. Disturbed sensory perception may be displayed by confusion. Impaired parenting is unrelated to the situation.
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Test-Taking Strategy: Focus on the client’s question: “Is my baby OK?” Use the process of elimination, relating the information in the question to the correct option. This will direct you to option 1. Review the defining characteristics for anxiety and fear if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1003. 374. A nurse is assigned to care for a client experiencing dystocia. In planning care, the nurse would consider the highest priority to be frequent: 1. Explanations to family members about what is happening in this situation 2. Comfort measures, change of position, and touch 3. Reinforcement of breathing techniques learned in childbirth preparatory classes 4. Monitoring for changes in the physical and emotional condition of the mother and fetus Answer: 4 Rationale: All the options are correct and would be implemented during the care of the client. However, the highest priority would be to monitor for changes in physiological integrity in both the mother and the fetus. Test-Taking Strategy: Note the key words highest priority. Use Maslow’s Hierarchy of Needs theory, recalling that physiological needs are the priority. Also, note that option 4 is the only option that addresses both the mother and the fetus. Review care to a client experiencing dystocia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 240. 375. A nurse is caring for a nullipara woman in labor. The nurse understands that the potential for precipitate labor and delivery should be a concern, and understands that the physician needs to be contacted if which one of the following becomes apparent? 1. Decreased periods of uterine relaxation between contractions 2. Dilation of the cervix of greater than 1 cm and less than 5 cm per hour during the active phase 3. Descent of less than 1 to 2 cm per hour 4. Latent phase of less than 6 hours Answer: 1 Rationale: Signs of a possible need for emergency intervention are inadequate uterine relaxation between contractions. Inadequate relaxation interferes with the transfer of oxygen and nutrients to the fetus through the mother’s placenta. All other options are within normal limits for a nulliparous woman. By definition, a precipitate labor lasts less
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than 3 hours. Test-Taking Strategy: Use the process of elimination and knowledge about the normal parameters of labor to answer this question. Noting the key words physician needs to be contacted will direct you to option 1. If you had difficulty with this question, review content related to precipitate labor and delivery and the indications that warrant the need to contact the physician. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 247. Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1003. 376. After a precipitate delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse would do which of the following first to help the woman process what has happened? 1. Encourage the mother to breast-feed soon after birth 2. Consider the cultural characteristics of the woman 3. Write a complete account of the parent’s reaction on the birth record 4. Support the mother no matter what her reaction to the newborn is Answer: 4 Rationale: There may be many reactions to the birth of a baby. The mother may be exhausted, in pain, or stunned by the rapid nature of the delivery, or she may be following her cultural norms. The mother may want to process what has happened and will need time to assimilate all that happened. The new mother requires support, and the nurse needs to provide a nurturing and accepting attitude. Test-Taking Strategy: Note the key word first. Use the process of elimination, remembering to always address the client’s feelings first. This will direct you to option 4. Review the psychosocial reaction of the mother following a precipitate delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1105. 377. A nurse reviews the arterial blood gas values and notes a pH of 7.50 and a PCO2 of 30 mm Hg. The nurse interprets these values as indicating: 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Answer: 2
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Rationale: In respiratory alkalosis, the pH will be higher than normal and the PCO2 will be low. The normal pH is 7.35 to 7.45. The normal PCO2 is 35 to 45 mm Hg. The only option that reflects these conditions is option 2. Test-Taking Strategy: Use the process of elimination. Remember that when an alkalotic condition exists, the pH will be high. Next, recall that in a respiratory alkalotic condition the PCO2 will move in the opposite direction as the pH. The only option that represents these conditions is option 2. Review the process of blood gas analysis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 245. 378. The nurse is collecting data on a client with chronic airflow limitation (CAL), and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of CAL? 1. Chronic obstructive bronchitis 2. Emphysema 3. Bronchial asthma 4. Both bronchial asthma and bronchitis Answer: 2 Rationale: The client with emphysema has hyperinflation of the alveoli, and has flattening of the diaphragm. These factors lead to increased anteroposterior diameter, which is referred to as “barrel chest.” The client also has dyspnea with prolonged expiration, and has hyperresonant lungs to percussion. Test-Taking Strategy: To answer this question correctly, it is necessary to understand that the “barrel chest” is a result of long-term hyperinflation of the lungs and air trapping. By knowing that emphysema is the only type of CAL in which this occurs, you are able to eliminate each of the other incorrect options. Review the characteristics of emphysema 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/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1819. 379. A client is at risk of developing a pulmonary embolism. The nurse monitors for which of the following, which is the most commonly reported initial symptom? 1. Dyspnea noted when deep breaths are taken 2. Hot, flushed feeling 3. Chest pain that occurs suddenly 4. Sudden chills and fever Answer: 3
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Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include cough, tachycardia, fever, diaphoresis, anxiety, and possibly syncope. Test-Taking Strategy: Use the process of elimination and note the key word initial. Because pulmonary embolism does not result from either an infectious process or an allergic reaction, options 2 and 4 are eliminated first. To select between options 1 and 3, look at them closely. Option 1 states dyspnea occurs when deep breaths are taken. Although dyspnea commonly occurs with pulmonary embolism, dyspnea is not associated only with deep breathing. Therefore option 3 is correct, and option 1 is eliminated. Review the signs of pulmonary embolism 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/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 391. 380. A nurse is assisting in caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse monitors the portable wound suction for which of the following types of drainage expected in the immediate postoperative period? 1. Serosanguinous 2. Grossly bloody 3. Serous 4. Serous with sputum Answer: 1 Rationale: Immediately following radical neck dissection, the client will have a wound drain in the neck attached to portable suction, which drains serosanguinous drainage. In the first 24 hours after surgery, the drainage may total 80 to 120 mL. The drainage should not be grossly bloody, and would not be serous or serous with sputum at this time. Test-Taking Strategy: Note the key words immediate postoperative period in the stem of the question. Because the wound suction tube is not placed in the airway, option 4 is eliminated. Because serous drainage has no blood, this is not likely in the immediate postoperative period, and is also eliminated. Knowing that grossly bloody drainage indicates bleeding or hemorrhage, you would choose option 1 (serosanguinous drainage) as the correct option. Review normal expected findings following radical neck dissection 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/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1795.
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381. A client is admitted to the nursing unit experiencing confusion and tremors. An initial arterial blood gas report indicates that the PaCO2 level is 72 mm Hg while the PaO2 level is 64 mm Hg. The nurse interprets that the client is most likely experiencing: 1. Carbon monoxide poisoning 2. Carbon dioxide narcosis 3. Respiratory alkalosis 4. Metabolic acidosis Answer: 2 Rationale: Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors, which may progress to convulsions and possibly coma. Test-Taking Strategy: To answer this question, you need to be able to interpret arterial blood gases. Also, noting that the client has a highly elevated carbon dioxide level will assist in directing you to option 2. Review the manifestations associated with carbon dioxide narcosis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1833. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 482-483. 382. A client is admitted to the hospital with a diagnosis of carbon dioxide narcosis. In addition to respiratory failure, the nurse plans to monitor the client for which of the following complications of this disorder? 1. Paralytic ileus 2. Hypernatremia 3. Increased intracranial pressure 4. Hyperglycemia Answer: 3 Rationale: Carbon dioxide acts as a vasodilator to cerebral blood vessels. With sufficient increase in carbon dioxide levels, the client may suffer increased intracranial pressure, which is initially reflected as papilledema and dilated conjunctival blood vessels. Options 1, 2, and 4 are not complications. Test-Taking Strategy: Focus on the client’s diagnosis. Knowing that carbon dioxide vasodilates the cerebral blood vessels guides you to choose option 3 as the correct option, because the cerebral circulation is one of the components that contributes to increased intracranial pressure. Review the complications associated with carbon dioxide narcosis 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing
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(3rd ed.). Philadelphia: W.B. Saunders, p. 482. 383. A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which of the following signs and symptoms? 1. Weight gain 2. Dyspnea 3. Hypothermia 4. Headache Answer: 2 Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection, and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be enlargement of the client’s lymph nodes, liver, and spleen as well. Test-Taking Strategy: Use the process of elimination. Knowing that histoplasmosis is an infectious process helps you to eliminate option 3. Because the client has AIDS as well as another infection, weight gain is an unlikely symptom, and can be eliminated next. From the remaining options, recalling that histoplasmosis begins as a respiratory infection helps you to choose dyspnea over headache. Review the signs of histoplasmosis 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/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 685. 384. A nurse is caring for a client with exacerbation of sarcoidosis. The nurse plans to provide instructions to the client about the adverse effects of medication therapy, which would include: 1. Weight loss 2. Hyperglycemia 3. Hyperkalemia 4. Pruritis Answer: 2 Rationale: The usual treatment for exacerbation of sarcoidosis includes systemic corticosteroids. Side effects of this therapy include weight gain, changes in mood, and hyperglycemia. Corticosteroids can cause hypokalemia. Pruritis is an unrelated finding. Test-Taking Strategy: To answer this question successfully, it is necessary to know that sarcoidosis is a restrictive lung disease, with exacerbations that are treated with corticosteroids. Knowing that corticosteroids cause hyperglycemia, you can eliminate each of the incorrect options. Review the medication therapy used in the treatment of sarcoidosis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity
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Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 507. 385. A client tells a nurse that the physician has confirmed a diagnosis of uncomplicated or simple silicosis. The client asks the nurse exactly what this means. In formulating a response, the nurse incorporates the knowledge that: 1. There is evidence of silica in the bloodstream, but no clinical symptoms 2. The client has normal pulmonary function studies but has shortness of breath 3. The client has mild ventilation restriction and has fibrosis on chest x-ray 4. There is massive pulmonary fibrosis on chest x-ray but there are no extrapulmonary symptoms Answer: 3 Rationale: The client with simple silicosis may be asymptomatic or have mild ventilatory restriction, and has evidence of fibrosis on chest x-ray. Pulmonary function studies reveal some decreases in vital capacity and total lung volume. There is no evidence of massive fibrosis at this stage. This disease is restricted to the respiratory system only. Test-Taking Strategy: Use the process of elimination. Option 4 has the least amount of “fit” with a disorder that is described as simple or uncomplicated, and therefore is eliminated as a possible option first. Because silicosis is a pulmonary disease, option 1 is also eliminated. Option 2 does not make sense; it would be difficult for one to have shortness of breath but yet have normal pulmonary function studies. Review the pathophysiology associated with simple silicosis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 546. 386. A client has been taking pyrazinamide (Pyrazinamide) for 1 month. The client asks the nurse if the therapy is due to be terminated soon. The nurse determines that the medication probably will be continued based on a positive finding on which of the following reports? 1. Blood culture 2. Sputum culture 3. Urine culture 4. Wound culture Answer: 2 Rationale: Pyrazinamide is an antitubercular medication that is given in conjunction with other antitubercular medications. Its use might not be discontinued if sputum cultures continue to be positive. Options 1, 3, and 4 are not tests that would determine discontinuation of the medication. Test-Taking Strategy: Use the process of elimination and knowledge of the purpose and action of this medication. Recalling that this medication is an antitubercular medication
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helps you to eliminate each of the incorrect options. If this question was difficult, review this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 735. 387. A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The most appropriate nursing action would be to: 1. Document the findings 2. Notify the registered nurse 3. Medicate the client for pain 4. Reposition the client Answer: 2 Rationale: The nurse would notify the registered nurse who would then contact the physician. The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client’s central venous pressure (CVP) rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter. Test-Taking Strategy: Use the process of elimination. Noting the key words severe pain and dyspnea will assist in directing you to option 2. Review the complications associated with flail chest 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/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 487-488. 388. A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which of the following results, which are consistent with this disorder? 1. PaO2 58 mm Hg, PaCO2 32 mm Hg 2. PaO2 60 mm Hg, PaCO2 45 mm Hg 3. PaO2 49 mm Hg, PaCO2 52 mm Hg 4. PaO2 73 mm Hg, PaCO2 62 mm Hg Answer: 3 Rationale: Respiratory failure is described as a PaO2 of 50 mm Hg or less and a PaCO2 of 50 mm Hg or greater in a client with no history of respiratory disease. In a client with a history of respiratory disorder with hypercapnea, elevations of 5 mm Hg or more from the client’s baseline are considered diagnostic. Test-Taking Strategy: Use the process of elimination. Knowing that the carbon dioxide level in respiratory failure is above 50 mm Hg helps you to eliminate options 1 and 2
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first. You would choose option 3 over option 4 because the arterial oxygen level in respiratory failure is less than 50 mm Hg. Review the blood gas findings in a client with respiratory failure 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 490. 389. A nurse is encouraging an older female client’s participation in recreational therapy. What nursing intervention would the nurse consider performing first? 1. Change the client’s soiled disposable brief 2. Have the client’s nails manicured 3. Have the client’s hair washed and cut 4. Ask the client to wear supportive shoes Answer: 1 Rationale: Basic physiological needs are a priority in administering nursing care. Although options 2, 3, and 4 address the client’s needs, the priority would be to keep the client clean and dry and to avoid embarrassment. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Option 1 addresses a basic physiological need. Review the physiological needs of the older client if you had difficulty with this question. Level of Cognitive Ability: Application Clients Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, pp. 264266. 390. A client diagnosed with pleurisy is being started on medication therapy with indomethacin (Indocin). The nurse tells the client that this medication is a: 1. Topical anesthetic that alleviates surface pain 2. Mild narcotic analgesic to allow the client to deep breathe 3. Corticosteroid to decrease the inflammatory response at the site 4. Nonsteroidal anti-inflammatory medication to enhance coughing and deep breathing Answer: 4 Rationale: Indomethacin is a nonsteroidal anti-inflammatory medication that has an analgesic effect, and allows the client to cough and deep breathe more effectively. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination. Knowing that the medication needed to treat this condition would be an anti-inflammatory helps you to eliminate options 1 and 2. In order to select between options 3 and 4, you should recall that indomethacin is a nonsteroidal anti-inflammatory agent. This medication is also used to treat inflammation of the epicardium in the pericardial sac, which is called pericarditis. If you are unfamiliar with this medication, review its uses and actions.
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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, pp. 565-566. 391. A nurse is assisting in caring for a postoperative pneumonectomy client. The nurse monitors the client for which adverse finding indicating acute pulmonary edema? 1. Respiratory rate of 20 breaths per minute 2. Pain with deep breathing 3. Frothy sputum 4. Increased chest tube drainage Answer: 3 Rationale: The client developing pulmonary edema after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. A respiratory rate of 20 breaths per minute is within normal limits. Pain with deep breathing is expected, and managed with analgesics. The client with pneumonectomy does not usually have a chest tube. Test-Taking Strategy: Use the process of elimination. Increased chest drainage indicates hemorrhage, not pulmonary edema, and is eliminated first. Additionally, the client with pneumonectomy usually does not have a chest tube. A respiratory rate of 20 breaths per minute is normal and pain with deep breathing is expected in the immediate postoperative period, so these options may be eliminated next. The presence of frothy sputum indicates pulmonary edema, and is the correct option. Review the signs of pulmonary edema 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/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 321. 392. A nurse is assisting in admitting a client to the emergency room with suspected carbon monoxide poisoning. The nurse understands that which of the following manifestations is least reliable for determining the oxygenation status of this client? 1. Complaints of a headache 2. Muscular weakness 3. Palpitations 4. Skin color Answer: 4 Rationale: Skin color is the least reliable sign for determining the oxygenation status of the client with carbon monoxide poisoning. Skin color may vary and range from pink to cherry red, or pale to cyanotic. Other signs that result from the lack of oxygen include dizziness, headache, muscular weakness, palpitations, and mental confusion, which can progress rapidly to coma.
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Test-Taking Strategy: Note the key words least reliable. Without specific knowledge of this condition, this question may be difficult to answer. Because palpitations could accompany tachycardia (which is expected with hypoxia), you may conclude that this sign is reliable. Because headache is a central nervous (CNS) symptom and the CNS relies heavily on a ready oxygen supply, this option may be eliminated also, because this should be a reliable sign. Muscular weakness is an example of the effects of hypoxia at the tissue level, and therefore should be considered reliable also. By the process of elimination, skin color is the unreliable sign, because it may vary considerably. Review the clinical manifestations associated with carbon monoxide poisoning 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 200. 393. A client with carbon dioxide narcosis has a potassium level of 6.2 mEq/L. The nurse interprets that this result is: 1. Unexpected, and indicates a concurrent history of renal insufficiency 2. Unexpected, and indicates a deficit of hydrogen ions in the bloodstream 3. Expected, and indicates the result of massive hemolysis 4. Expected, and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out Answer: 4 Rationale: With the severe respiratory acidosis that occurs in carbon dioxide narcosis, compensatory mechanisms fail. As hydrogen ion concentrations continue to rise, they are driven into the cell, forcing intracellular potassium out. This is an expected finding in this situation. Test-Taking Strategy: To answer this question, an understanding of the effects of acidosis on the body is required. With buildup of carbon dioxide, the body attempts to eliminate hydrogen ions from the circulation, because they are another source of body acid. The blood buffer system tries to buffer them as the first line of defense. With a rapid buildup of carbon dioxide, this is insufficient, and the body needs to find another way to lose hydrogen ions. Because the renal system does not “kick in” for almost 24 hours, the hydrogen ions are driven into the cells, and potassium comes out (hydrogen and potassium are both cations). With these concepts in mind, hyperkalemia is an expected finding, which eliminates options 1 and 2. Because this disorder has nothing to do with hemolysis, the only correct choice is option 4. Review the effects of carbon dioxide narcosis on the body if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 669,
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1833. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 384. 394. A nurse is assisting in evaluating the respiratory status of the client with carbon dioxide narcosis, who is being mechanically ventilated. Upon evaluation of a set of arterial blood gases, the nurse notes that the client’s carbon dioxide level has dropped significantly. The nurse then monitors the client for which adverse effect of this rapid change? 1. Tachypnea 2. Hyponatremia 3. Seizure activity 4. Confusion Answer: 3 Rationale: With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete bicarbonate ions at the same pace. The client can experience rebound metabolic alkalosis, with resulting seizure activity. The nurse evaluates the client’s status carefully during this period. Test-Taking Strategy: To answer this question accurately, an understanding of how the body maintains acid/base balance is needed. With a drop in carbon dioxide levels, the body also needs to drop bicarbonate levels correspondingly. Otherwise, the body is in a state of metabolic alkalosis. However, it is difficult for the body to do this, because bicarbonate must be eliminated by the kidneys, which do not “kick in” to restore acid/ base balance for approximately 24 hours. Because of this, rapid declines in carbon dioxide levels often do result in metabolic alkalosis, putting the client at risk for seizure activity. This is a difficult question to answer unless you understand these concepts. Review the effects of carbon dioxide narcosis on the body 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 References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 18321833. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 384-385. Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 460. 395. A client has been admitted to the nursing unit with pulmonary sarcoidosis. The nurse monitors the client for which of the following signs indicating a complication of the disorder? 1. Bilateral lung crackles 2. Flat neck veins 3. Peripheral edema
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4. Shrunken liver Answer: 3 Rationale: Pulmonary sarcoidosis can lead to cor pulmonale (or right-sided heart failure), which is characterized by distended neck veins, elevated central venous pressure, engorged liver, and peripheral edema. Bilateral crackles would indicate left-sided heart failure, not right-sided heart failure. Test-Taking Strategy: To answer this question accurately, it is necessary to know that sarcoidosis is a restrictive lung disease. A complication of restrictive lung disease is cor pulmonale, because the right side of the heart has to work hard on a continuous basis to overcome pulmonary resistance. Knowing this, you would eliminate options 2 and 4, because they are the opposite of the symptoms expected with right-sided heart failure. You would choose option 3 over option 1 by knowing how to discriminate between leftand right-sided heart failure. Review the complications of pulmonary sarcoidosis and the signs of right- and left-sided heart failure 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 507. 396. A nurse is collecting data on a client with silicosis. The nurse asks the client if he wears which of the following items during periods of exposure to silica particles? 1. Mask 2. Gown 3. Gloves 4. Eye protection Answer: 1 Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. Options 2, 3, and 4 are not necessary to prevent exposure to these particles. Test-Taking Strategy: To answer this question, it is necessary to know that exposure to silica dust causes the illness. The dust is inhaled into the respiratory tract. Knowing this, each of the incorrect options can be eliminated. Review the cause of this respiratory disorder if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 547. 397. A client has been taking benzonatate (Tessalon Perles) as prescribed. The nurse determines that the medication is having the intended effect if the client experiences: 1. Decreased anxiety level
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2. Increased comfort level 3. Reduction in nausea and vomiting 4. Decreased frequency and intensity of cough Answer: 4 Rationale: Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex. Options 1, 2, and 3 are not associated with the effects of this medication. Test-Taking Strategy: This question tests your knowledge of the purpose and effects of this medication. Recalling that benzonatate is a locally acting antitussive will direct you to option 4. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 114. 398. A nurse reviews the nursing care plan of a client and notes documentation of a nursing diagnosis of impaired gas exchange related to decreased ventilation and mucous plugs. The nurse understands that which of the following items documented in the client’s health care record most accurately indicates achievement of the expected outcome for this nursing diagnosis? 1. Client demonstrated effective coughing techniques 2. Arterial blood gases indicate a pH of 7.4, PaO2 of 80 mm Hg, and PaCO2 of 40 mm Hg 3. Venous oxygen saturation of 95% 4. Respiratory rate of 20 breaths per minute Answer: 2 Rationale: Demonstration of adequate gas exchange can only be accurately evaluated when both PaO2 and PaCO2 levels are known. The other options do not indicate adequate gas exchange. Remember that the oxygen saturation index is a measure of the percent of oxygen attached to the available hemoglobin. Test-Taking Strategy: Focus on the issue of the question. Note the key words most accurately. Demonstration of adequate gas exchange can only be accurately evaluated when both PaO2 and PaCO2 levels are known. Review the expected outcomes for impaired gas exchange if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation 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, pp. 1880, 1824. 399. A nurse is caring for a client with pheochromocytoma. As part of the nursing care plan, the nurse monitors for hypertensive crisis. In the event that hypertensive crisis
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occurs, the nurse would anticipate that the most likely medication to be prescribed would be: 1. Propranolol (Inderal) 2. Phentolamine mesylate (Regitine) 3. Phenoxybenxamine hydrochloride (Dibenzyline) 4. Prazosin hydrochloride (Minipress) Answer: 2 Rationale: The most likely medication to be ordered in hypertensive crisis is phentolamine (Regitine). This medication is a short-acting alpha-adrenergic blocker and would be given by intravenous bolus or infusion for a hypertensive crisis. Phenoxybenxamine hydrochloride is an oral medication and produces long-acting alphaadrenergic blockade. It is used in the management of pheochromocytoma and is most suitable for preoperative management of hypertension and prevention of hypertensive crisis. Prazosin hydrochloride, an alpha-blocker, is used less frequently for the preoperative pheochromocytoma client because of its shorter duration of action. The physician would not prescribe beta-receptor blocking agents in clients with suspected or confirmed pheochromocytoma until after alpha-adrenergic blockade has been initiated, because these medications may cause the blood pressure to rise. After alpha-adrenergic blockade, low doses of propranolol (Inderal) may be used to treat tachycardia and dysrhythmias. Test-Taking Strategy: Knowledge of the actions and uses of these medications is required to assist you in answering this question. If you knew that phentolamine mesylate is a short-acting medication, then you would select this option. The question asks about hypertensive crisis, and such a situation requires immediate intervention. Review these medications if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological integrity Integrated Process: Nursing Process/Planning Content Area: Adult/Health Endocrine Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 852. 400. Prednisone (Deltasone) 10 mg orally daily has been prescribed for the client. The nurse provides instructions to the client regarding the medication. Which statement by the client indicates that further teaching is necessary? 1. “I need to take the medication every day at the same time.” 2. “I can take acetylsalicylic acid (aspirin) or my antihistamine if I need it.” 3. “If I gain more than 5 pounds a week, I will call my doctor.” 4. “I need to avoid coffee, tea, cola, and chocolate in my diet.” Answer: 2 Rationale: Aspirin and other over-the-counter medications should not be used unless the client consults with the physician. The client is instructed to take the medication every day at the same time. A slight weight gain with improved appetite is expected, but after the dosage is stabilized, an increase in weight of 5 pounds or more weekly should be reported to the physician. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development.
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Test-Taking Strategy: Note the key words further teaching is necessary. These words indicate a false response question and that you need to select the incorrect client statement. Remember, a very important point to remember is that clients should not take other medications, especially over-the-counter medications, without first consulting with their physician. Review 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: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 714.
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