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NEW QUESTION 362
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
- A. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
- B. Potential for injury related to impaired mobility and seizures
- C. Impaired verbal communication related to aphasia
- D. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
NEW QUESTION 363
A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?
- A. Discontinue the medication if nausea occurs.
- B. Restrict fluids to 1000 mL/day.
- C. Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8 juice, and tomato juice.
- D. Restrict foods that contain salt or sodium.
Answer: C
Explanation:
(A) This answer is correct. A balanced diet with adequate salt intake is necessary. (B) This answer is incorrect. The client must drink six to eight full glasses of fluid per day (2000-3000 mL/day). (C) This answer is incorrect. The client should be instructed to avoid fluctuations of sodium intake. Diet should be balanced, with an adequate salt intake. (D) This answer is incorrect. Nausea is a frequent side effect that can be minimized with administration of drug with meals or after eating food.
NEW QUESTION 364
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
- A. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine
- B. Assists the baby's clotting mechanism
- C. Prevents the development of ophthalmia neonatorum
- D. Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. (B) The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. (C) Excessive bilirubin accumulates when the infant's liver cannothandle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. (D) Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
NEW QUESTION 365
Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?
- A. Assess knowledge of respiratory isolation.
- B. Monitor renal function.
- C. Monitor liver function.
- D. Monitor compliance with drug therapy.
Answer: D
Explanation:
(A)
Monitoring liver function will not prevent the development of drug-resistant organisms.
(B)
Monitoring renal function will not prevent the development of drug-resistant organisms.
(C)
Knowledge of respiratory isolation will reduce transmission of tuberculosis but will not prevent development of drug-resistant organisms. (D) Noncompliance with prescribed antituberculosis drug regimen is the primary cause of drug-resistant organisms. Noncompliance permits the mutation of organisms.
NEW QUESTION 366
During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:
- A. Massaging the joints briskly with lotion or liniment after bath
- B. Putting all joints through full range-of-motion twice daily
- C. Immobilizing the joints in functional position using splints, rolls, and pillows
- D. Applying warm water bottle or heating pads over involved joints
Answer: C
Explanation:
Section: Questions Set G
Explanation
Explanation:
(A) Any movement of the joint causes severe pain. (B) Touching or moving the joint causes severe pain. (C) Immobilization in a functional position allows the joint to rest and heal. (D) Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.
NEW QUESTION 367
A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:
- A. Giving clear liquids too soon
- B. The possibility of pneumonia as a complication
- C. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms
- D. Allowing the child to come in contact with other children for 3 days
Answer: C
Explanation:
(A) Aspirin should never be given to children with influenza because of the possibility of causing Reye's syndrome. Pepto- Bismol is also classified as a salicylate and should be avoided. (B) Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. (C) The disease has a 1-3 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. (D) Although viral
pneumonia can be a complication of influenza, this would not be an initial priority.
NEW QUESTION 368
On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:
- A. Xerosteromia
- B. Candidiasis
- C. Stomatitis
- D. Leukoplakia
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Xerostomia is dry mouth. (B) Candidiasis can be rubbed off, but it will bleed. (C) Leukoplakia cannot be rubbed off. (D) Stomatitis is caused by candidiasis and gram-negative bacteria.
NEW QUESTION 369
A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is:
- A. Hypocalcemia
- B. Air embolus
- C. Circulatory overload
- D. Hypokalemia
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Air embolism is a potential complication of blood administration, but it is fairly rare and can be prevented by using good IV technique. (B) Circulatory overload is a potential complication of blood administration, but because this client is actively bleeding, she is not at high risk for overload. (C) Hypocalcemia is a potential complication of blood administration that occurs in situations where massive transfusion has occurred over a short period of time. It occurs because the citrate in stored blood binds with the client's calcium. Another potential complication for which this client is especially at risk is hypothermia, which can be prevented by using a blood warmer to administer the blood. (D) Hypokalemia is not a complication of blood administration.
NEW QUESTION 370
The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back.
The nurse explains that this is to avoid "vena caval syndrome," a condition which:
- A. Occurs when blood pressure increases sharply with changes in position
- B. Results when blood flow from the extremities is blocked or slowed
- C. Is seen mainly in first pregnancies
- D. May require medication if positioning does not help
Answer: B
Explanation:
Explanation
(A) Blood pressure changes are predominantly due to pressure of the gravid uterus. (B) Pressure of the gravid uterus on the inferior vena cava decreases blood return from lower extremities. (C) Inferior vena cava syndrome is experienced in the latter months of pregnancy regardless of parity. (D) There are no medications useful in the treatment of interior vena cava syndrome; alleviating pressure by position changes is effective.
NEW QUESTION 371
The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:
- A. Provide a nutritious diet
- B. Maintain her interest in school
- C. Provide for physical and psychological rest
- D. Maintain contact with her parents
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) This goal is helpful, but rest is essential during the acute phase. (B) Rest is essential for healing to occur and for pain to be relieved. (C) This goal is important, but rest is essential. (D) This goal should be part of the plan of care, but it is not the priority during the acute phase.
NEW QUESTION 372
The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
- A. The child awakening wet from his naps
- B. Patience by the child when wearing soiled diapers
- C. The age at which the child's siblings were trained
- D. Communicating the urge to defecate or urinate
Answer: D
Explanation:
Explanation
(A) Children experience impatience with soiled diapers when readiness for training is apparent. They often desire to be changed immediately. (B) A child must be able to use verbal or nonverbal skills to communicate needs. (C) A readiness indicator would be awaking dry from naps. (D) The age at which a sibling was toilet trained has no implications for training this child.
NEW QUESTION 373
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
- A. Prolonged bed rest
- B. The client's maintaining a semi-Fowler position
- C. IV fluids of 2.5-3 liters in 24 hours
- D. Cerebral hypoxia
Answer: D
Explanation:
(A) Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. (B) The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. (C) Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. (D) Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.
NEW QUESTION 374
A client with a C-3-4 fracture has just arrived in the emergency room. The primary nursing intervention is:
- A. Airway assessment and stabilization
- B. Stabilization of the cervical spine
- C. Normalization of intravascular volume
- D. Confirmation of spinal cord injury
Answer: A
Explanation:
(A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation.
NEW QUESTION 375
Which of the following lab data is representative of a client with aplastic anemia?
- A. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000
- B. White blood cells 3000, hematocrit 27, red blood cells 2.8 million
- C. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000
- D. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million
Answer: C
Explanation:
Section: Questions Set G
Explanation:
(A, B, C) Although all of the lab data are abnormal and although these values are decreased in aplastic anemia, the disorder is defined by severe deficits in red cell, white cell, and platelet counts. (D) Aplastic anemia is typically defined in terms of abnormalities of red blood cell count, usually <1 million, white cell count <2,000, and thrombocytes <20,000.
NEW QUESTION 376
The physician prescribes a medical regimen of isoniazid, rifampin, and vitamin B6 for a tuberculosis client.
The nurse instructs the client that B6 is given because it:
- A. Reduces peripheral neuropathy
- B. Increases activity of isoniazid
- C. Improves nutritional status
- D. Increases activity of rifampin
Answer: A
Explanation:
Explanation
(A) Vitamin B6does not enhance the activity of isoniazid. (B) Vitamin B6does not enhance the activity of rifampin. (C) A vitamin alone does not improve nutritional status. (D) Isoniazid leads to Vitamin B6deficiency, which is manifested as peripheral neuropathy.
NEW QUESTION 377
A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is
10 mg/mL. What dosage of furosemide should the nurse give to this infant?
- A. 5 mg
- B. 0.05 mg
- C. 0.5 mg
- D. 20 mg
Answer: A
Explanation:
Explanation
(A) 1 mg = 0.1 mL, then 0.5 mL X= 55 mg. (B) Thisanswer is a miscalculation. (C) This answer is a miscalculation. (D) This answer is a miscalculation.
NEW QUESTION 378
Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?
- A. Decreased tidal volume and tachypnea
- B. Ventilation-perfusion (V./Q.) mismatch
- C. Mediastinal tissue and organ shifting
- D. Hypoxemia and respiratory acidosis
Answer: C
Explanation:
(A, B, D) These occur in both tension pneumothorax and open pneumothorax. (C) The tension pneumothorax acts like a one- way valve so that the pneumothorax increases with each breath. Eventually, it occupies enough space to shift mediastinal tissue toward the unaffected side away from the midline. Tracheal deviation, movement of point of maximum impulse, and decreased cardiac output will occur. The other three options will occur in both types of pneumothorax.
NEW QUESTION 379
A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:
- A. Fat-restricted diet
- B. Phenylalanine-restricted diet
- C. Lactose-restricted diet
- D. Gluten-restricted diet
Answer: D
Explanation:
Explanation
(A) A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhea. (B) A gluten-restricted diet is the diet for children with celiac disease. (C) A phenylalaninerestricted diet is prescribed for children with phenylketonuria. (D) A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, or pancreas.
NEW QUESTION 380
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking "the blue pill" (haloperidol) in the morning and evening, and "the white pill" (benztropine) right before bedtime. The nurse might suggest to the client that she try:
- A. Taking the benztropine in the morning
- B. Doubling the daily dose of benztropine
- C. Decreasing the haloperidol dosage for a few days
- D. Taking her medication with food or milk
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action.
This action requires a physician's order. (B) To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. (C) This response is an appropriate independent nursing action. Because motorrestlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. (D) Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.
NEW QUESTION 381
The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
- A. "Slide a ruler under the cast and scratch the area."
- B. "Blowing air under the cast using a hair dryer on cool setting often relieves itching."
- C. "Gently thump on cast to dislodge dried skin that causes the itching."
- D. "Guide a towel under and through the cast and move it back and forth to relieve the itch."
Answer: B
Explanation:
(A) Cool air will often relieve pruritus without damaging the cast or irritating the skin. (B)
The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. (C) Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. (D) This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.
NEW QUESTION 382
A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the:
- A. Biparietal diameter is 5 cm above the ischial spines
- B. Presenting part is 2 cm above the level of the ischial spines
- C. Biparietal diameter is at the level of the ischial spines
- D. Presenting part is 2 cm below the level of the ischial spines
Answer: D
Explanation:
(A) Station is the relationship of the presenting part to an imaginary line drawn between the
ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0.
NEW QUESTION 383
An elective saline abortion has been performed on a 3-week primigravida. Following the procedure, the nurse should be alert for which early side effect?
- A. Edema
- B. Thirst
- C. Water satiety
- D. Diabetes insipidus
Answer: B
Explanation:
Section: Questions Set C
Explanation:
(A) If the client is experiencing water satiety, there is no more desire for water. (B) Absorption of saline into circulation rather than into amniotic sac increases serum sodium and desire for water. (C) Edema can be a late side effect caused by water intoxication. (D) Diabetes insipidus occurs as a result of deficient antidiuretic hormone.
NEW QUESTION 384
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