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Practice Examination Four Part One You will have two hours and 30 minutes to complete Part One. 1. Which of the following describes a preterm neonate? A. A neonate weighing less than 2,500 g (5 lb, 8 oz). B. A low-birth-weight neonate. C. A neonate born at less than 37 weeks' gestation regardless of weight. D. A neonate diagnosed with intrauterine growth retardation. 2. A client with type 1 (insulin-dependent) diabetes mellitus has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide? A. "Insulin requirements don't change during pregnancy. Continue your current regimen. " B. "Insulin requirements usually decrease during the last two trimesters. " C. "Insulin requirements usually decrease during the first trimester. " D. "Insulin requirements increase greatly during labor. " 3. A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of A. right-sided heart failure. B. acute pulmonary edema. C. pneumonia. D. cardiogenic shock. 4. What's the most appropriate nursing diagnosis for a client exhibiting obsessive-compulsive behavior? A. Ineffective coping. B. Imbalanced nutrition: Less than body requirements. C. Imbalaneed nutrition: More than body requirements. D. Interrupted family processes. 5. The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to A. restrict fluid intake to 1 qt (1,000 mL)/day. B. drink liquids only with meals. C. don't drink liquids 2 hours before meals. D. drink liquids only between meals. 6. A client seeks care for low back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk? A. Pain that radiates down the posterior thigh. B. Back pain when the knees are flexed. C. Atrophy of the lower leg muscles. D. Positive Homans' sign. 7. A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is A. psychotherapy. B. total abstinence. C. Alcoholics Anonymous (AA). D. aversion therapy. 8. A 23-month-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress? A. Intercostal retractions. B. Bradycardia. C. Decreased level of consciousness. D. Flushed skin. 9. A 20-year-old mother of a premature newborn smoked cigarettes during her pregnancy. Her son is a client in a neonatal intensive care unit and has a diagnosis of acute respiratory distress syndrome. Because the mother is Roman Catholic, which nursing intervention would be most appropriate for the nurse to discuss with her? A. Baptism of the infant. B. Circumcision of the infant. C. Last rites for the infant. D. Sacraments of the sick for the mother. 10. A client with shock brought on by hemorrhage has a temperature of 97.6°F (36.4℃), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mmHg. For this client the nurse should question which physician order? A. "Monitor urine output every hour. " B. "Infuse IV fluids at 83 mL/hr" C. "Administer oxygen by nasal cannula at 3 L/min" D. "Draw samples for hemoglobin and hematocrit every 6 hours. " 11. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because A. reducing sodium promotes urea nitrogen excretion. B. reducing sodium decreases edema. C. reducing sodium improves her glomerular filtration rate. D. reducing sodium increases potassium absorption. 12. The nurse is evaluating a client who is complaining of shortness of breath. The client's respiratory rate is 26 breaths per minute so the nurse documents that he is tachypneic. The nurse understands that tachypnea means A. frequent bowel sounds. B. heart rate greater than 100 beats/minute C. hyperventilation. D. respiratory rate greater than 20 breaths/minute 13. A client who has cervical cancer is scheduled to undergo internal radiation. In teaching the client about the procedure, the nurse would be most accurate in telling the client A. she'll be in a private room with unrestricted activities. B. a bowel-cleansing procedure will precede radioactive implantation. C. she'll be expected to use a bedpan for urination. D. the preferred positioning in bed will be semi-Fowler's. 14. Before administering a tube feeding to a toddler, which of the following methods should the nurse use to check the placement of a nasogastric (NG) tube? A. Abdominal X-rays. B. Injection of a small amount of air while listening with a stethoscope over the abdominal area. C. A check of the pH of fluid aspirated from the tube. D. Visualization of the measurement mark on the tube made at the time of insertion. 15. While assessing a 2-month-old child's airway, the nurse finds that the child isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should A. attempt rescue breaths. B. attempt to reposition the airway a third time. C. administer five back blows. D. attempt to ventilate with a handheld resuscitation bag. 16. Which of the following statements summarizes the underlying principle for the development of a parenbchild relationship? A. The parents to-be had good role models in their childhood. B. The relationship is part of the adult maturational process. C. The development is directly related to the physical needs of the neonate. D. The relationship is based on the need for early and frequent parent-infant contact. 17. During the night, a 50-year-old Vietnam veteran with posttraumatic stress syndrome wakens shaking and tells you that someone is trying to smother him. What is the appropriate response for the nurse in this situation? A. "It was a bad dream. You are safe. I'll stay here with you until you go back to sleep. " B. "We can talk about it tomorrow. Try to see if you can get back to sleep. " C. "It was only a dream. There's nothing to be frightened about. " D. "I'll call the physician and see whether I can get you medication to help you go back to sleep. " 18. Physical assessment findings in the eyes of elderly people may include A. decreased lens thickness. B. decreased visual acuity. C. lightening of the skin around the orbits. D. unequal pupillary light reflex. 19. During a morning assessment, the nurse percusses tympany. The nurse understands that tympany is a loud, high-pitched, moderately long sound with a drumlike, musical quality that's most commonly heard over the A. heart. B. liver. C. pancreas. D. stomach. 20. The nurse is caring for a client who complains of lower back pain. Which instructions should the nurse give to this client to prevent back injury? A. Bend over the object you're lifting. B. Narrow the stance when lifting. C. Push or puI1 an object using your arms. D. Stand close to the object you're lifting. 21. The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? A. Heparin sodium (Hep-Lock). B. Dexamethasone (Deeadron). C. Methyldopa (Aldomet). D. Phenytoin (Dilantin). 22. The nurse is caring for a client who recently underwent a total hip replacement. The nurse should A. ease the client onto a low toilet seat. B. allow the client's legs to be crossed at the knees when out of bed. C. use soft chairs when the client is sitting out of bed. D. limit client hip flexion when sitting. 23. After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic would most suggest this diagnosis? A. Supportive child-parent interaction (speaking, listening, touching, and eye-to-eye contact). B. Parents' active participation in child's physical or emotional care. C. Parents' failure to use available support systems or agencies to assist in coping. D. Evidence of adaptation to parental role changes. 24. The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's A. foot. B. ankle. C. lower thigh. D. knee. 25. Which vaginal infection doesn't require treatment for sexual partners? A. Neisseria gonorrhoeae. B. Candida albicans. C. Trichomonas vaginalis. D. Chlamydia trachomatis. 26. Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should A. insert an oral airway. B. withhold food and fluids. C. position the client on his side. D. introduce a nasogastric (NG) tube. 27. A child, age 5, with an IQ of 65 is admitted to the hospital for evaluation. When planning care, the nurse should keep in mind that this child is A. within the lower range of normal intelligence. B. mildly retarded but educable. C. moderately retarded but trainable. D. completely dependent on others for care. 28. A client tells the nurse that she has been working hard for the last 3 months to control her type 2 (non-insulin-dependent) diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check A. urine glucose level. B. fasting blood glucose level. C. serum fructosamine level. D. glycosylated hemoglobin (Hb) level. 29. A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence of pulmonary edema. The specific type of MI the client had is most probably A. anterior. B. posterior. C. lateral. D. inferior. 30. Which of the following functions would the nurse expect to be unrelated to the placenta? A. Production of estrogen and progesterone. B. Detoxification of some drugs and chemicals. C. Exchange site for food, gases, and waste. D. Production of maternal antibodies. 31. Which action should the nurse include in a plan of care for a client with a fiberglass cast on the right arm? A. Keep the casted arm warm with a light blanket. B. Avoid handling the cast for 24 hours or until dry. C. Assess pedal and posterior tibial pulses every 2 hours. D. Assess movement and sensation in the fingers of the right hand. 32. Following coronary artery bypass grafting, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead Ⅱ electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is A. narrowing complex. B. widening complex. C. amplitude increase. D. amplitude decrease. 33. After delivering her second child, the client tells the nurse that she wants to breast-feed. She indicates that she was unsuccessful at breast-feeding her first child and that she bottle- fed after 3 days of trying to nurse. Which of the following responses would best support this client's breast-feeding efforts? A. "I'll make sure that you're seen by the lactation consultant before you're discharged. " B. "It's important to room-in with your neonate so that you can respond to her nursing: cues, " C. "Don't worry, every baby is different, and I'm sure that you'll be successful this time. " D. "Breast-feeding is possible but you must be committed to it. " 34. The nurse is teaching the mother of a neonate. The nurse should instruct the mother to introduce her infant to solid foods at what age? A. 2 months. B. 4 months. C. 6 months. D. 8 months. 35. When caring for a client who is having her second baby, the nurse can anticipate the client's labor will be which of the following? A. Shorter than her first labor. B. About half as long as her first labor. C. About the same length of time as her first labor. D. A length of time that can't be determined based on her first labor. 36. A client asks the nurse what PSA is. The nurse should reply that it stands for A. prostate-specific antigen, used to screen for prostate cancer. B. protein serum antigen, used to determine protein levels. C. pneumococcal strep antigen, a bacteria that causes pneumonia. D. papanicolaou-specific antigen, used to screen for cervical cancer. 37. A physician schedules an invasive procedure for a client with acquired immunodeficiency syndrome-related dementia. He lives with his male companion, who is present. His mother, who lives in another state, is also present. The nurse anticipates that the consent form should be signed by A. the companion. B. the mother. C. the client. D. two physicians. 38. A client admitted for a hysterectomy has a secondary diagnosis of Ménière s disease. Which of the following nursing interventions should the nurse include in the client's plan of care to decrease the effects of tinnitus? A. Reduce the amount of glucose and cholesterol in the diet. B. Encourage the client to listen to the radio with earphones. C. Encourage a weight-reduction diet. D. Administer antihypertensive medications as ordered. 39. A 35-year-old female client who complains of weight gain, facial hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushing's syndrome. Cushing's syndrome is most likely caused by which of the following? A. An ectopic corticotropin-secreting tumor. B. Adrenal carcinoma. C. A corticotropin-secreting pituitary adenoma. D. An inborn error of metabolisrn. 40. The nurse is caring for a client undergoing a cystoscopy to diagnose bladder cancer. Following the test, the client returns to his room. Which signs should alert the nurse to a potential complication? A. Chills and tachycardia. B. Urinary frequency and burning on urination. C. Dizziness and fainting. D. Pink-tinged urine and bladder spasms. 41. When teaching the parents of a toddler with a congenital heart defect, the nurse should explain all medical treatments and should emphasize which instruction about their child? A. Reduce the caloric intake to decrease cardiac demand. B. Relax discipline and limit setting to prevent crying. C. Avoid contact with small children to reduce overstimulation. D. Try to maintain the usual lifestyle to promote normal development. 42. After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. The nurse suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for? A. Infection of the lung. B. Kinked or obstructed chest tube. C. Excessive water in the water-seal chamber. D. Excessive chest tube drainage. 43. The nurse is caring for a primigravida who is scheduled for a fetal acoustic stimulation test (FAST). The nurse should explain to the client that the primary purpose of this test is to A. induce contractions. B. induce fetal heart rate accelerations. C. shorten the contraction stress test. D. determine fluid volume. 44. Which of the following activities should a 2-year-old child to be able to do? A. Build a tower of eight cubes. B. Point out a picture. C. Wash and dry his hands. D. Remove a garment. 45. A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac isn't bubbling. Which nursing assumption would be most invalid? A. The tubing from the client to the chamber is blocked. B. There is a leak somewhere in the tubing system. C. The client's affected lung has reexpanded. D. The tubing needs to be cleared of fluid. 46. A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action? A. Make an appointment because the client needs to be evaluated. B. Explain that these are expected problems for the latter stages of pregnancy. C. Arrange for the client to be admitted to the birth center for delivery. D. Tell the client to go to the hospital; she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume. 47. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1,500 mL for the 1st hour and the same for the 2nd hour. The nurse should suspect A. Cushing's syndrome. B. diabetes mellitus. C. adrenal crisis. D. diabetes insipidus. 48. The nurse assesses a client with urticaria. The nurse understands that urticaria is another name for A. hives. B. a toxin. C. a tubercle. D. a virus. 49. The nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include A. diminished or absent breath sounds on the affected side. B. paradoxical chest wall movement with respirations. C. tracheal deviation to the unaffected side. D. muffled or distant heart sounds. 50. A client with a history of heart failure is examined in the outpatient department to investigate the recent onset of peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema? A. Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours. B. Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours. C. A 5-to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling. D. A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling. 51. A client who has a potassium level of 6 mEq/L should be treated with A. antacids. B. IV fluids. C. fluid restriction. D. sodium polystyrene sulfonate (Kayexalate). 52. Which laboratory test results would the nurse expect to find in a client diagnosed with Hashimoto's thyroiditis? A. Thyroxine (T4), 22μg/dL; triiodothyronine (T3), 320ng/dL; thyroid-stimulating hormone (TSH) undetectable. B. T4, 22μg/dL; T3, 200ng/dL; TSH,0.1μIU/mL. C. T4, 2μg/dL; T3, 200ng/dL; TSH,5.9μIU/mL. D. T4, 2μg/dL; T3, 35ng/dL; TSH,45μIU/mL. 53. During a client's chemotherapy regimen for breast cancer, which is important for the nurse to include in her plan of care? A. Instruct the client to consume plenty of raw fruits and vegetables. B. Take rectal temperatures for greater accuracy. C. Tell the client to avoid crowds and infected individuals. D. Ask friends and relatives not to visit during the course of chemotherapy. 54. A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by A. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. B. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. C. draining urine from the drainage bag into a sterile container. D. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine. 55. A 33-year-old male client is admitted with an exacerbation of ulcerative colitis. The nurse is performing an admission assessment and assessing the teaching needs regarding appropriate diet and lifestyle modifications for the client. To develop an effective teaching plan, the nurse must solicit which of the following input from the client? A. Details about his childhood phobias. B. His feelings, beliefs, and attitudes about his chronic illness. C. Information about his financial status. D. Information about his relationship with his wife. 56. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is A. impending coma. B. manipulating behavior. C. suppression. D. perceptual disorders. 57. When caring for children who are sick, who have sustained traumas, or who are suffering from nutritional inadequacies, the nurse should know the correct hemoglobin (Hb) values for children. Which of the following ranges would be inaccurate? A. Neonates. 10.6 to 16.5. B. 3 months. 10.6 to 16.5. C. 3 years. 9.4 to 15.5. D. 10 years. 10.7 to 15.5. 58. A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesia, and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should A. place a heating pad around the affected calf. B. elevate the affected leg as high as possible. C. keep the affected leg level or slightly dependent. D. shave the affected leg in anticipation of surgery. 59. A client who has discovered a breast lump is tearful and expresses concern over her situation. The best way for the nurse to respond to her is by A. encouraging a discussion of her problems and fears. B. asking her if she would like to talk to the chaplain. C. giving her reassurance. D. recommending a support group. 60. A client delivered a healthy full-term female neonate 2 hours ago by cesarean delivery. When assessing this client, which finding requires immediate nursing action? A. Tachycardia and hypotension. B. Gush of vaginal blood when the client stands up. C. Blood stain 2" (5 cm) in diameter on the abdominal dressing. D. Complaints of abdominal pain. 61. A client in acute renal failure is admitted to the nephrology unit. The period of oliguria in these clients usually lasts about t0 days. Which of the following assessments of kidney function would the nurse make during the oliguric phase? A. No urine output; kidneys in a state of suppression. B. Urine output of 30 to 60 mL/hr. C. Urine output of less than 400 to 600 mL in 24 hours. D. Urine output directly related to the amount of IV fluids infused. 62. During a late stage of acquired immunodeficiency syndrome (AIDS), a client demonstrates signs of AIDS-related dementia. The nurse should give the highest priority to which nursing diagnosis? A. Bathing or hygiene self-care deficit. B. Ineffective cerebral tissue perfusion. C. Dysfunctional grieving. D. Risk for injury. 63. After taking glipizide (Glucotrol) for 9 months, a client experiences secondary failure. Which of the following would the nurse expect the physician to do? A. Initiate insulin therapy. B. Switch the client to a different oral antidiabetic agent. C. Prescribe an additional oral antidiabetic agent. D. Restrict carbohydrate intake to less than 30% of the total caloric intake. 64. A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds onto furniture when he walks. The nurse should ask the mother A. how long the child has been like this. B. if the child can walk without holding onto furniture. C. how the child's condition today differs from his normal condition. D. if the child always drools. 65. As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is not a goal of the report? A. Staff involved so they're reprimanded for their actions. B. Learning needs of staff to prevent recurrence of incidents. C. Patterns of client care problems. D. Facts surrounding each incident. 66. Following a fall from a horse during rodeo practice, an 18- year-old client is seen in the emergency department. He has a large, dirty laceration on his leg. The wound is vigorously cleaned, closed, and dressed. In the past, the client has received the full immunization regimen for tetanus toxoid. The nurse asks the client about his tetanus immunization history and he says, "I had my last shot when I was 11 years old. " The nurse should A. advise the client to get a tetanus vaccine within 3 years. B. request the physician to order a serum tetanus titer. C. plan on administering a dose of tetanus vaccine. D. teach the client that he has life-long immunity to tetanus. 67. The nurse brings a new mother her neonate for the first time approximately 1 hour after the neonate's birth. After checking the identification, the nurse hands the neonate to the mother. Within a few minutes, the mother begins to undress her neonate. Which of the following should the nurse do? A. Call the pediatrician and report the behavior. B. Anticipate and support the behavior as a normal part of bonding. C. Encourage the mother to rewrap the neonate because the room is cold. D. Take the neonate back to the nursery and recheck the neonate's temperature. 68. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to A. avoid shopping for large amounts of food. B. control eating impulses. C. identify anxiety-causing situations. D. eat only three meals per day. 69. Which pregnancy-related physiologic change would place the client with a history of cardiac disease at the greatest risk for developing severe cardiac problems? A. Decreased heart rate. B. Decreased cardiac output. C. Increased plasma volume. D. Increased blood pressure. 70. Because antianxiety agents such as chlordiazepoxide (Librium) can potentiate the effects of other drugs, the nurse should incorporate which of the following instructions in her teaching plan? A. Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants. B. Avoid taking antianxiety agents at bedtime. C. Avoid taking antianxiety agents on an empty stomach. D. Avoid consuming aged cheese when taking antianxiety agents. 71. A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child? A. Providing fluids. B. Maintaining protective isolation. C. Applying cool compresses to affected joints. D. Administering antipyretics, as prescribed. 72. A client with three children who is still in her childbearing years is admitted for surgical repair of a prolapsed bladder. The nurse would find that the client understood the surgeon's preoperative teaching when the client states, A. "If I should become pregnant again, the child would be delivered by cesarean delivery. " B. "If I have another child, the procedure may need to be repeated. " C. "This surgery may render me incapable of conceiving another child. " D. "This procedure is accomplished in two separate surgeries. " 73. The nurse is interviewing a client admitted to the facility with a diagnosis of schizophrenia. The client states, "I run apple, train, grass, window. " This response by the client is known as A. echopraxia. B. a word salad. C. flight of ideas. D. neologisms. 74. A nurse is caring for a client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μL. The client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150mL/hr. He reports severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, the nurse should avoid which route? A. Oral. B. IV. C. IM. D. Subcutaneous (SC). 75. An 82-year-old female is transferred to the hospital from a long-term care facility because of severe diarrhea. She is weak and dehydrated. Which acid-base imbalance could the client develop as a result of diarrhea? A. Respiratory acidosis. B. Metabolic acidosis. C. Carbonic acid deficit. D. Metabolic alkalosis. 76. The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress? A. Avoiding the use of illicit drugs and alcohol. B. Refraining from telling anyone about the diagnosis. C. Following safer-sex practices. D. Telling potential sex partners about the diagnosis, as required by law. 77. A female neonate delivered by elective cesarean birth to a 25-year-old mother weighs 3,265g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which of the following? A. Temperature instability due to type of birth. B. Respiratory distress due to lack of contractions. C. Signs of acrocyanosis. D. Unstable blood sugars. 78. When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately? A. Complaints of intense thirst. B. Moderate to severe pain. C. Urine output of 70 mL the 1st hour. D. Hoarseness of the voice. 79. A client is admitted with atrial fibrillation. The physician noted a pulse deficit. The pulse deficit measures which of the following? A. The difference between apical and radial pulse rates. B. The difference between systolic and diastolic blood pressures. C. The amount of blood ejected from the left ventricle per minute. D. The percentage of blood emptied from the ventricle during contraction. 80. On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure? A. Taking daily walks. B. Engaging in anaerobic exercise. C. Reducing daily fat intake to less than 45% of total calories. D. Avoiding foods that increase levels of high-density lipoproteins (HDLs). 81. The physician prescribes amoxicillin suspension 100 mg every 8 hours for a child who weighs 33 lb (15 kg). The drug is supplied in a bottle labeled 250 rag/teaspoon (1mL=50 mg). How many milliliters should the nurse administer? A. 2 mL. B. 2.5 mL. C. 5 mL. D. 7.5 mL. 82. When examining school-age and adolescent children, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening? A. Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed. B. Listen for a clicking sound as the child abducts the hips. C. Have the child run the heel of one foot down the shin of the other leg while standing. D. Have the child shrug the shoulders as the nurse applies mild pressure to the shoulders. 83. A client, age 59, complains of leg pain brought on by walking several blocks--a symptom that first arose several weeks ago. The client's history includes diabetes mellitus and a two-pack-a-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and prescribes pentoxifylline (Trental), 400 mg three times daily with meals. The nurse should provide which instruction concerning long-term care? A. "Practice meticulous foot care. " B. "Consider cutting down on your smoking. " C. "Reduce your level of exercise. " D. "See the physician if complications occur. " 84. The nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using A. antiembolism stockings. B. oxygen. C. diuretics. D. anticoagulants. 85. The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution, the nurse can anticipate that he'll require A. monitoring of arterial oxygen saturation (SaO2). B. arterial blood gas (ABG) studies. C. chest auscultation. D. a chest X-ray. 86. The nurse is teaching a parent how to administer antibiotics at home to a child with acute otitis media. Which statement by the parent indicates that teaching has been successful? A. "I'll give the antibiotics for the full 10-day course of treatment. " B. "I'll give the antibiotics until my child's ear pain is gone. " C. "Whenever my child is cranky or pulls on an ear, I'll give a dose of antibiotics. " D. "If the ear pain is gone, there's no need to see the physician for another ear examination. " 87. A client is scheduled to have a descending colostomy. He's very anxious and has many questions concerning the surgical procedure, care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team? A. Social worker. B. Registered dietitian. C. Occupational therapist. D. Enterostomal nurse therapist. 88. A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an IV infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her plan of care? A. Carefully titrating the oxytocin based on her pattern of labor. B. Monitoring vital signs, including assessment of fetal well- being, every 15 to 30 minutes. C. Allowing the client to ambulate as tolerated. D. Helping the client use breathing exercises to manage her contractions. 89. Which of the following would not be an indication of placental detachment? A. An abrupt lengthening of the cord. B. An increase in the number of contractions. C. Relaxation of the uterus. D. Increased vaginal bleeding. 90. A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast care? A. Cover the cast with a blanket until the cast dries. B. Keep your right leg elevated above heart level. C. Use a knitting needle to scratch itches inside the cast. D. A foul smell from the cast is normal. 91. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) ? A. Administer 2 to 3 L of IV fluid rapidly. B. Administer 6 L of IV fluid over the first 24 hours. C. Administer a dextrose solution containing normal saline solution. D. Administer IV fluid slowly to prevent circulatory overload and collapse. 92. When caring for a client with preeclampsia, which action is a priority? A. Monitoring the client's labor carefully and preparing for a fast delivery. B. Continually assessing the fetal tracing for signs of fetal distress. C. Checking vital signs every 15 minutes to watch for increasing blood pressure. D. Reducing visual and auditory stimulation. 93. A 68-year-old male client has been hospitalized repeatedly for chronic obstructive pulmonary disease (COPD). During this latest admission, he has refused to participate in his self-care. Every time the nurse approaches him, the client states, "I just want to die. I'm no good to anyone anymore. " The nurse realizes that he's experiencing A. self-actualization. B. confabulation. C. reaction formation. D. grief. 94. Which of the following should be the nurse's initial action immediately following the birth of the neonate? A. Aspirating mucus from the neonate's nose and mouth. B. Drying the infant to stabilize the neonate's temperature. C. Promoting parental bonding. D. Identifying the neonate. 95. Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of A. antisocial behavior. B. manipulation. C. poor boundaries. D. passive-aggressive behavior. 96. The nurse is providing care to a 5-year-old client with a fractured femur whose nursing diagnosis is Imbalanced nutrition: less than body requirements related to impaired physical mobility. Which of the following is most likely to occur with this condition? A. Decreased protein catabolism. B. Increased calorie intake. C. Increased digestive enzymes. D. Increased carbohydrate need. 97. Acarbose (Precose), an alpha-glucosidase inhibitor, is prescribed for a client with type 2 diabetes mellitus. During discharge planning, the nurse would be aware that the client has understood teaching when the client states, A. "If I have hypoglycemia, I should eat some sugar, not dextrose. " B. "The drug makes my pancreas release more insulin. " C. "I should never take insulin while I'm taking this drug. " D. "It's best if I take the drug with the first bite of a meal. " 98. In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says, A. "The baby can get the virus from my placenta. " B. "I'm planning on starting on birth control pills. " C. "Not everyone who has the virus gives birth to a baby who has the virus. " D. "I'll need to have a C-section if I become pregnant and have a baby. " 99. When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which of the following denotes the child's level of consciousness? A. No motor or verbal response to noxious (painful) stimuli. B. Remains in a deep sleep; responsive only to vigorous and repeated stimulation. C. Can be aroused with stimulation. D. Limited spontaneous movement; sluggish speech. 100. The nurse is teaching the mother of an infant with tetralogy of Fallot. The mother asks what to do when her infant becomes very blue and has trouble breathing after crying. The nurse should tell the mother, A. "Leave the infant alone until the crying stops. " B. "Put the infant in the knee-chest position. " C. "Offer the infant a bottle of formula. " D. "Take the infant for a ride in the car. " 101. In an industrial accident, a client who weighs 155 lb (70. 3 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client? A. A urine output consistently above 100 mL/hr. B. A weight gain of 4 lb (1.8 kg) in 24 hours. C. Body temperature readings all within normal limits. D. An electrocardiogram (ECG) showing no arrhythmias. 102. When a client experiences a loss of vibratory sense on examination, this indicates A. injury to the cranial nerves. B. injury to the peripheral nerves. C. intact cranial nerves. D. intact peripheral nerves. 103. A client with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannuta. The client's history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these findings, the nurse closely monitors the oxygen flow and the client's respiratory status. Which complication may arise if the client receives a high oxygen concentration? A. Apnea. B. Anginal pain. C. Respiratory alkalosis. D. Metabolic acidosis. 104. What is the nurse's most important role in caring for a client with a mental health disorder? A. To offer advice. B. To know how to solve the client's problems. C. To establish trust and rapport. D. To set limits with the client. 105. A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The most appropriate response to her would be, A. "You seem angry. Would you like to talk about it?" B. "Calm down. You know that stress will make your symptoms worse. " C. "Would you like to talk about the problem with the nursing supervisor?" D. "I can see you're angry. I'll come back when you've calmed down. " 106. During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of A. somatic delusions. B. waxy flexibility. C. neologisms. D. nihilistic delusions. 107. After striking his head on a tree while falling from a ladder, a young man is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A. Give him a barbiturate. B. Place him on mechanical ventilation. C. Perform a lumbar puncture. D. Elevate the head of his bed. 108. After a client receives an IM injection, he complains of burning pain in the injection site. Which nursing action would be the best to take at this time? A. Apply a cold compress to decrease swelling. B. Apply a warm compress to dilate the blood vessels. C. Massage the area to promote absorption of the drug. D. Instruct the client to tighten his gluteal muscles to promote better absorption. 109. The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (ACS) guidelines, the nurse should recommend that the women A. perform breast self-examination annually. B. have a mammogram annually. C. have a hormonal receptor assay annually. D. have a physician conduct a clinical examination every 2 years. 110. When caring for a client with a 3-cm stage 1 pressure ulcer on the coccyx, which of the following actions can the nurse institute independently? A. Using a povidone-iodine wash on the ulceration three times per day. B. Using a normal saline solution and applying a protective dressing as necessary. C. Applying an antibiotic cream to the area three times per day. D. Massaging the area with an astringent every 2 hours. 111. A school-age child is admitted to the hospital with a diagnosis of acute lymphoblastic leukemia. The nurse formulates a nursing diagnosis of Risk for infection. Which of the following is the most effective way for the nurse to reduce the child's risk of infection? A. Implementing reverse isolation. B. Maintaining standard precautions. C. Requiring staff and visitors to wear masks. D. Practicing thorough hand washing. 112. The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following? A. Poor clotting mechanism. B. High hemoglobin (Hb) levels between 14 and 20 g/dL per 100 mL of blood. C. Persistent fetal circulation. D. Large, immature liver. 113. The nurse is teaching the parents of a school-age child. Which teaching topic should take priority? A. Preventing accidents. B. Keeping a night light on to allay fears. C. Explaining normalcy of fears about body integrity. D. Encouraging the child to dress without help. 114. A 45-year-old auto mechanic comes to the physician's office because an exacerbation of his psoriasis is making it difficult to work. He tells the nurse that his finger joints are stiff and sore in the morning. The nurse should respond by A. inquiring further about this problem because psoriatic arthritis can accompany psoriasis vulgaris. B. suggesting he take aspirin for relief because it's probably early rheumatoid arthritis. C. validating his complaint but assuming it's an adverse effect of his vocation. D. asking him if he has been diagnosed or treated for carpal tunnel syndrome. 115. A client with Hashimoto's thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client's cardiac history, the nurse would expect that the client's initial dose for the thyroid replacement would be which of the following? A. 25 g/day, initially. B. 100 g/day, initially. C. Delayed until after thyroid surgery. D. Initiated before thyroid surgery. 116. The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first A. establish unresponsiveness. B. call for help. C. open the airway. D. assess the client for a carotid pulse. 117. A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instructions? A. "Weigh yourself daily and report a loss of 1 lb in 1 day. " B. "Eat a high-sodium diet. " C. "Weigh yourself daily and report a gain of 2 lb in 1 day. " D. "Maintain bedrest. " 118. The nurse is teaching a client recently diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by A. genetic dysfunction. B. upper and lower motor neuron lesions. C. decreased conduction of impulses in an upper motor neuron lesion. D. a lower motor neuron lesion. 119. A 28-year-old woman is scheduled for a glucose tolerance test (GTT). She asks the nurse what result indicates diabetes mellitus. The nurse should respond that the minimum parameter for indication of diabetes mellitus is a 2-hour blood glucose level greater than A. 120 mg/dL B. 150 mg/dL C. 200 mg/dL D. 250 mg/dL 120. A client with thyroid cancer undergoes a thyroidectomy. After surgery, the client develops peripheral numbness and tingling and muscle twitching and spasms. The nurse should expect to administer A. thyroid supplements. B. antispasmodics. C. barbiturates. D. IV calcium. 121. The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should A. encourage verbalizations about fears and stressful life situations. B. agree with the client because she feels a specific physical feature is awful. C. ignore the comment and talk about less threatening issues. D. compliment the client on her appearance. 122. Which of the following observations signals the onset of puberty in male adolescents? A. Appearance of pubic hair. B. Appearance of axillary hair. C. Testicular enlargement. D. Nocturnal emissions. 123. Which of the following statements should be included when teaching clients about monoamine oxidase (MAO) inhibitor antidepressants? A. Don't take prescribed or over-the-counter medications without consulting the physician. B. Avoid strenuous activity because of the cardiac effects of the drug. C. Have blood levels screened weekly for leukopenia. D. Don't take with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). 124. The nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat A. hypernatremia. B. hypokalemia. C. hyperkalemia. D. hypercalcemia. 125. For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which of the following questions about the pain should the nurse include in the assessment? A. "Does the pain worsen in the morning upon rising?" B. "Does the pain increase with activity and lessen with rest?" C. "Is the pain relieved by position changes?" D. "Is the pain worse with the toes pointed toward the knee?" 126. A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take? A. Clear the client's airway. B. Make the client comfortable. C. Start eardiopulmonary resuscitation. D. Stop the feeding and remove the NG tube. 127. A client who survived an airplane crash has a diagnosis of posttraumatic stress disorder (PTSD). He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief for his symptoms? A. The opportunity to verbalize memories of trauma to a sympathetic listener. B. Family support. C. Prescribed medications taken as ordered. D. Alcoholics Anonymous (AA) meetings. 128. While performing rounds, a nurse finds that a client is receiving the wrong IV solution. The nurse's initial response should be to A. remove the IV catheter and call the physician. B. write up an incident report describing the mistake. C. slow the IV flow rate and hang the appropriate solution. D. wait until the next bottle is due and then change to the proper solution. 129. During the admission interview, a client reports that she frequently has nightmares and memories of a rape that occurred 3 years ago. She feels depressed and asks the nurse, "Do you think I will ever get better? I don't know what is wrong with me. " The nurse's most supportive response would be A. "It sounds like you have some unresolved pain about the trauma. Take time here to talk and allow yourself to heal. " B. "I'm not sure what is wrong, but the medication will help you soon enough. " C. "It's important to talk to your physician about an issue such as this. " D. "Don't feel bad; the treatment will help you. " 130. A 70-year-old client with a diagnosis of left-sided cerebrovaseular accident is admitted to the facility. To prevent the development of disuse osteoporosis, which of the following objectives is most appropriate? A. Maintaining protein levels. B. Maintaining vitamin levels. C. Promoting weight-bearing exercises. D. Promoting range-of-motion (ROM) exercises. 131. Two middle-aged sisters have been diagnosed with Huntington's disease. The children of these clients want to know what their chances are of developing this genetic disorder. The nurse's best response would be. A. "Only women become symptomatic. " B. "This disorder is an autosomal dominant disorder, so each child has a 50% chance of inheriting it. " C. "This disorder is an autosomal recessive disorder, so each child has a 25% chance of inheriting it. " D. "Women are symptomatic and men are carriers of this disorder. " 132. A 26-year-old male is admitted to an inpatient psychiatric hospital after having been picked up by the local police while walking around the neighborhood at night without shoes in the snow. He appears confused and disoriented. Which of the following is the most immediate nursing action? A. Assess and stabilize the client's medical needs. B. Assess and stabilize the client's psychological needs. C. Attempt to locate the nearest family member to get an accurate history. D. Arrange a transfer to the nearest medical facility. 133. The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement? A. Give the medication on an empty stomach. B. Warn the client that he'll experience mouth dryness. C. Schedule the medication before meals. D. Administer the medication for complaints of muscle weakness or difficulty swallowing. 134. A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds to the client, "You may want to talk about your employment situation in group today. " The nurse is using which therapeutic technique? A. Restating. B. Making observations. C. Exploring. D. Focusing. 135. The nurse is providing home care instructions to a client who has recently had a skin graft. Which instruction is most important for the client to remember? A. Use cosmetic camouflage techniques. B. Protect the graft from direct sunlight. C. Continue physical therapy. D. Apply lubricating lotion to the graft site. 136. A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary caregiver? A. Breast tenderness. B. Breakthrough bleeding within first 3 months of use. C. Decreased menstrual flow. D. Blurred vision and headache. 137. A child, age 4, is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the child has A. patent ductus arteriosus. B. coarctation of the aorta. C. a ventricular septal defect. D. truncus arteriosus. 138. When a client being seen in a fertility clinic doesn't respond to the clomiphene citrate, the physician prescribes IM menotropins (Pergonal). This drug increases her risk of producing multiple follicles that could mature to ovulation. To reduce the high risk of multifetal pregnancy and its possible adverse effects the nurse should monitor A. ultrasound study results and serum estradiol levels. B. ultrasound study results and serum progesterone levels. C. results of tests to detect luteinizing hormone (LH) in urine. D. serum levels of human chorionic gonadotropin (HCG). 139. A 21-year-old client with a history of ulcerative colitis is hospitalized for an exacerbation. When planning dietary teaching, the nurse should recommend that the client consume A. high-protein foods, such as eggs, meat, and cheese. B. whole milk and other dairy products. C. raw fruits and vegetables. D. products containing caffeine. 140. The nurse is caring for a toddler in respiratory arrest. The nurse will assist with endotracheal intubation and use an uncurled tube because the A. vocal cords provide a natural seal. B. trachea is shorter. C. larynx is anterior and cephalad. D. cricoid cartilage is the narrowest part of the larynx. 141. A client is admitted to the hospital with an exacerbation of his chronic gastritis. When assessing his nutritional status, the nurse should expect a deficiency in A. vitamin A. B. vitamin B6. C. vitamin B12. D. vitamin C. 142. The nurse is caring for a 40-year-old woman who is a black Muslim. Which of the following choices is a concept on which black Muslims focus? A. Celibacy. B. Prophecy. C. Reincarnation. D. Self-esteem. 143. One day after an appendectomy, a 9-year-old rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on the child's chart? A. The child is in no apparent distress, and no pain medication is needed at this time. B. The child rates pain at 4 out of 5. Pain medication administered as prescribed. C. The child doesn't understand the pain scale. Performed teaching to help child match his pain rating to how he appears to be feeling. D. The child rates his pain at 4 out of 5; however, he appears to be in no distress. Reassess when he's visibly showing signs of pain. 144. The physician orders supplemental oxygen for a client with a respiratory problem. To provide the highest possible oxygen concentration, the nurse expects to use which oxygen delivery device? A. Nasal cannula. B. Venturi mask. C. Partial rebreathing mask. D. Nonrebreathing mask. 145. An 18-month-old child is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches him. The nurse needs to assess the child's breath sounds. The best way to approach the child is to A. expose the child's chest quickly and auscultate breath sounds as quickly and efficiently as possible. B. ask the mother to wait briefly outside until the assessment is over. C. tell the child the nurse is going to listen to his chest with the stethoscope. D. allow the child to handle the stethoscope before listening to his lungs. 146. A client reveals to the nurse that he's sexually impotent. Which statement best expresses what the nurse should understand her client to mean? A. He's disinterested in sexual intimacy. B. He's unable to attain or retain an erection. C. His ejaculate is void of sperm. D. His semen isn't potent enough to impregnate. 147. A 32-year-old black man is admitted to the hospital in vaso- occlusive sickle cell crisis. He complains of chest pain, shortness of breath, severe myalgia, and arthralgia. Which of the following may be effective in relieving the client's joint pain? A. Applying ice packs to the joints. B. Performing active resistive range-of-motion exercises. C. Applying warm compresses to the joints. D. Applying transcutaneous electrical nerve stimulation (TENS). 148. What is the most appropriate nursing diagnosis for the client with acute pancreatitis? A. Deficient fluid volume. B. Excess fluid volume. C. Decreased cardiac output. D. Ineffective gastrointestinal tissue perfusion. 149. When planning care for a 7-year-old boy with Down syndrome, the nurse should A. plan interventions at the developmental level of a 7-year-old child because that is the child's age. B. plan interventions at the developmental level of a 5-year-old because the child will have developmental delays. C. assess the child's current developmental level and plan care accordingly. D. direct all teaching to the parents because the child can't understand. 150. A client hospitalized with a pneumothorax has the following arterial blood gas (ABG) analysis: pH, 7.19; partial pressure of arterial carbon dioxide (PaCO2), 63 mmHg; and , 22 mEq/L. A chest tube was inserted and oxygen administered at 4 L/min by nasal cannula. One hour after the initiation of treatment, ABG analysis reveals: pH, 7.28; PaCO2, 52 mmHg; and , 22 mEq/L. This change in ABG analysis indicates A. respiratory alkalosis. B. impending respiratory arrest. C. the need for intubation. D. improved respiratory status. Part Two You will have one hour and 50 minutes to complete Part Two. 151. The nurse is caring for a client whom she suspects is paranoid. How would the nurse confirm this assessment? A. Indirect questioning. B. Direct questioning. C. Lead-in sentences. D. Open-ended sentences. 152. A client is admitted to the emergency department with a suspected overdose of an unknown drug. The client's arterial blood gas values indicate respiratory acidosis. What should the nurse do first? A. Prepare to assist with ventilation. B. Monitor the client's heart rhythm. C. Prepare to begin gastric lavage. D. Obtain urine for drug screening. 153. Which of the following would be least likely to indicate anticipated bonding behaviors by new parents? A. The parents' willingness to touch and hold the neonate. B. The parents' expression of interest about the size of the neonate. C. The parents' indication that they want to see the neonate. D. The parents' interactions with each other. 154. A client is admitted to the hospital in the manic phase of bipolar disorder. When placing a diet order for the client, which foods would be most appropriate? A. A bowl of soup, crackers, and a dish of peaches. B. A cheese sandwich, carrot sticks, fresh grapes, and cookies. C. Roast chicken, mashed potatoes, and peas. D. A tuna sandwich, an apple, and a dish of ice cream. 155. The nurse is caring for a client who complains of chronic pain. Given this complaint, why would the nurse simultaneously evaluate both general physical and psychosocial problems? A. Depression is commonly characterized by pain disorders and somatic complaints. B. Combining evaluations will save time and allow for quicker delivery of health care. C. Most insurance plans won't cover evaluation of both as separate entities. D. The physician doesn't have the training to evaluate for psychosocial considerations. 156. Which of the following would be the best approach when trying to take a crying toddler's temperature? A. Ignore the crying and screaming. B. Encourage the mother to hold the child. C. Talk to the mother first and then to the toddler. D. Bring extra help so it can be done quickly. 157. A client is admitted to the hospital for treatment of Prinzmetal's angina. When developing the client's plan of care, the nurse should remember that this type of angina is triggered by A. coronary artery spasm. B. an unpredictable amount of activity. C. activities that increase oxygen demand. D. an unknown source. 158. In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most commonly related to A. vestibular dysfunction. B. sudden vascular fluid shifting. C. postural hypotension. D. bradyrhythmia. 159. The nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the blood? A. pH B. PaO2 C. PaCO2 D. 160. Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should A. keep the client warm. B. maintain room temperature at 78°F (25.6℃). C. keep the client uncovered. D. match the room temperature with the client's body temperature. 161. A nurse is evaluating the effectiveness of dietary instructions in a client with diverticulitis. Regular consumption of which food would indicate that the client hasn't understood instructions? A. Fiber. B. Bananas. C. Cucumbers. D. Milk products. 162. When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following provides the most accurate picture of retention with overflow? A. Frequent trips to the bathroom with an average output of 200 to 300 mL per void. B. Intense urge to urinate with an average output of 250 mL. C. A varying urge to urinate with an average output of 100 mL. D. Uterus displaced to the right with increased vaginal bleeding. 163. A 10-year-old diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which of the following is a part of the child's care? A. Taking vital signs every 4 hours and obtaining daily weight. B. Obtaining a blood sample for electrolyte analysis every morning. C. Checking every urine specimen for protein and specific gravity. D. Ensuring that the child has accurate intake and output and eats a high-protein diet. 164. It's important to assess the maturity of enzyme systems (kidney and liver) in which pediatric population before administering medications? A. Adolescents. B. Neonates. C. Premature infants. D. Toddlers. 165. During her first prenatal visit, a client expresses concern about gaining weight. Which of the following would be the nurse's best action? A. Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet. B. Be alert for a possible eating problem and do a further in- depth assessment. C. Report the client's concerns to her caregiver. D. Ask her to come back to the clinic every 2 weeks for a weight check. 166. The least serious form of brain trauma, characterized by a brief loss of consciousness and period of confusion, is called A. contusion. B. concussion. C. coup. D. contrecoup. 167. The physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the past 6 months. The nurse should take which of the following actions? A. Administer the medication as ordered. B. Discontinue the medication. C. Question the order with the physician. D. Inform the client that he should discuss the MI with the physician. 168. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to A. avoid focusing on his weight. B. increase his activity level. C. follow a regular diet. D. continue leading a high-stress lifestyle. 169. Which nursing intervention would most likely lead to a hyposmolar state? A. Performing nasogastric (NG) tube irrigation with normal saline solution. B. Weighing the client daily. C. Administering tap water enema until the return is clear. D. Encouraging the client with excessive perspiration to drink broth. 170. A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations for all procedures and medications. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort? A. Making decreased eye contact. B. Asking to see family members. C. Joking about the present condition. D. Sleeping undisturbed for 3 hours. 171. An elderly client's lithium level is 1.4 mEq/L. She complains of diarrhea, tremors, and nausea. The nurse's first action is to A. hold the lithium (Lithobid) and notify the physician. B. reassure the client that these are normal adverse effects. C. administer another lithium dose. D. discontinue the lithium. 172. A client is admitted with a suspected diagnosis of an acute myocardial infarction. When providing care for the client, the nurse should avoid which route when taking a temperature? A. Oral. B. Rectal. C. Axillary. D. Tympanic. 173. A client is admitted to the emergency department with complaints of chest pain and shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distention, it's typically due to A. a neck tumor. B. an electrolyte imbalance. C. dehydration. D. fluid overload. 174. An otherwise healthy adolescent has meningitis and is receiving IV and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause A. cerebral edema. B. dehydration. C. heart failure. D. hypovolemic shock. 175. Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for which condition? A. Hypocortisolism. B. Hypoglycemia. C. Hyperglycemia. D. Hypercalcemia. 176. Otorrhea and rhinorrhea are most commonly seen with which type of skull fracture? A. Basilar. B. Temporal. C. Occipital. D. Parietal. 177. A 4-year-old child with pain and itching around the rectum has just been diagnosed with a pinworm infestation. The physician prescribes mebendazole (Vermox). When teaching the child's parents about the treatment regimen, the nurse should emphasize which instruction? A. Look for white patches in the child's mouth. B. Make sure that all family members are treated. C. Encourage the child to drink lots of apple juice. D. Limit dairy products until the pinworms are eradicated. 178. Which of the following describes the rationale for administering vitamin K to every neonate? A. Neonates don't receive the clotting factor in utero. B. The neonate lacks intestinal flora to make the vitamin. C. It boosts the minimal level of vitamin K found in the neonate. D. The drug prevents the development of phenylketonuria (PKU). 179. A client is diagnosed with hyperthyroidism. The nurse should expect clinical manifestations similar to A. hypovolemic shock. B. adrenergic stimulation. C. benzodiazepine overdose. D. Addison's disease. 180. The nurse is providing care for a pregnant client. The client asks the nurse how she can best deal with her fatigue. The nurse should instruct her to A. take sleeping pills for a restful night's sleep. B. try to get more rest by going to bed earlier. C. take her prenatal vitamins. D. tell her not to worry because the fatigue will go away soon. 181. For a client with a head injury whose neck has been stabilized, the preferred bed position is A. Trendelenburg's. B. 30-degree head elevation. C. flat. D. side-lying. 182. The uterus returns to the pelvic cavity in which time frame? A. 7th to 9th day postpartum. B. 2 weeks postpartum. C. End of the 6th week postpartum. D. When the lochia changes to alba. 183. A client diagnosed with anxiety disorder is prescribed buspirone (BuSpar). Teaching instructions for newly prescribed buspirone should include which of the following? A. A warning that immediate sedation can occur with a resultant drop in pulse. B. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug. C. A warning about the incidence of neuroleptic malignant syndrome (NMS). D. A warning about the drug's delayed therapeutic effect, which is from 14 to 30 days. 184. The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by A. suctioning the tracheostomy tube frequently. B. using a cuffed tracheostomy tube. C. using the minimal air leak technique with cuff pressure less than 25 cmH2O. D. keeping the tracheostomy tube plugged. 185. A client with fecal impaction typically exhibits which clinical manifestation? A. Liquid or semiliquid stools. B. Hard, brown, formed stools. C. Loss of urge to defecate. D. Increased appetite. 186. A client reports substernal chest pain. Test results show electrocardiograph changes and an elevated cardiac troponin level. Which of the following should be the focus of nursing care? A. Improving myocardial oxygenation and reducing cardiac workload. B. Confirming a suspected diagnosis and preventing complications. C. Reducing anxiety and relieving pain. D. Eliminating stressors and providing a nondemanding environment. 187. A 28-year-old nurse has complaints of itching and a rash of both hands. Contact dermatitis is initially suspected. The diagnosis is confirmed if the rash appears A. erythematous with raised papules. B. dry and scaly with flaking skin. C. inflamed with weeping and crusting lesions. D. excoriated with multiple fissures. 188. When administering gentamicin to a preschooler, which of the following monitoring schedules is best for determining the drug's effectiveness? A. A serum trough level every morning. B. A serum peak level after the second dose. C. A serum trough and peak level around the third dose. D. Serial serum trough levels after three doses (24 hours). 189. A client has been diagnosed with type A hepatitis. What special precautions should the nurse take when caring for this client? A. Put on a mask and gown before entering the client's room. B. Wear gloves and a gown when removing the client's bedpan. C. Prevent the droplet spread of the organism. D. Use caution when bringing food to the client. 190. The nurse reinforces the physician's description of a fasciotomy for a client. When a fasciotomy is performed to alleviate compartment syndrome, the fascia is opened along the length of the muscle compartment and A. the skin is sutured loosely. B. a pressure dressing is applied. C. the skin is left open. D. a skin graft is placed. 191. The nurse inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has A. extravasation. B. osteomalacia. C. petechiae. D. uremia. 192. A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing A. a delusion. B. flight of ideas. C. ideas of reference. D. a hallucination. 193. A client refuses his evening dose of haloperidol (Haldol) then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to A. check the client's medical record for an order for an IM as needed dose of medication for agitation. B. place the client in full leather restraints. C. call the physician and report the behavior. D. remove all other clients from the day room. 194. The nurse is interviewing a client who is currently under the influence of a controlled substance and shows signs of becoming agitated. What should the nurse do? A. Use confrontation. B. Express disgust with the client's behavior. C. Be aware of hospital security. D. Communicate a scolding attitude to intimidate the client. 195. Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following? A. Muscle weakness. B. Tremors. C. Diaphoresis. D. Constipation. 196. Pericardiocentesis is performed on a client with cardiac tamponade. This procedure would be deemed effective if A. aspirated blood clots rapidly. B. blood pressure decreases. C. blood pressure increases. D. heart sounds become muffled. 197. An adolescent girl who is receiving chemotherapy for leukemia is admitted for pneumonia. The adolescent's platelet count is 50,000 μL. Which of the following would be inappropriate to include in the plan of care? A. A sign over the bed that reads "NO NEEDLE STICKS AND NOTHING PER RECTUM". B. Two peripheral IV intermittent infusion devices, one for blood draws and one for infusions. C. Administration of oxygen at a rate of 4 L/min using a nonhumidified nasal cannula. D. Use of a tympanic membrane sensor to measure the client's temperature at the bedside. 198. Conditions necessary for the development of a positive sense of self-esteem include A. consistent limits. B. critical environment. C. inconsistent boundaries. D. physical discipline. 199. When developing a plan of care for a toddler with a seizure disorder, which of the following would be inappropriate? A. Padded side rails. B. Oxygen mask and bag system at bedside. C. Arm restraints while asleep. D. Cardiopulmonary monitoring. 200. When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris? A. "The pain lasted for about 45 minutes. " B. "The pain resolved after I ate a sandwich. " C. "The pain worsened when I took a deep breath. " D. "The pain occurred while I was mowing the lawn. " 201. Which toy would be most appropriate for a 3-year-old? A. A bicycle. B. A puzzle with large pieces. C. A pull toy. D. A computer game. 202. A client is to be discharged from an acute care facility after treatment of right leg thrombophlebitis. The nurse notes that the client's leg is pain free, without redness or edema. The nurse's actions reflect which step in the nursing process? A. Assessment. B. Analysis. C. Implementation. D. Evaluation. 203. When teaching the mother of a 17-month-old about toilet training, which instruction would initially be most appropriate? A. Place the toddler on the potty chair every 2 hours for t0 minutes. B. Offer a reward every time the child has a bowel movement in the potty chair. C. Remove the diaper and use training pants to begin the process. D. Be sure the child is ready before starting to toilet train. 204. A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should do which of the following? A. Give the baby a pacifier to help soothe him. B. Lie the baby in the prone position. C. Place the infant's arms in soft elbow restraints. D. Avoid touching the suture line, even to clean. 205. To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructions? A. Lie down after meals to promote digestion. B. Avoid coffee and alcoholic beverages. C. Take antacids before meals. D. Limit fluids with meals. 206. Which of these signs suggests that a client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion has developed complications? A. Tetanic contractions. B. Neck vein distention. C. Weight loss. D. Polyuria. 207. A client who is breast-feeding has a temperature of 102°F (38.9℃) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which of the following actions would be inappropriate in managing the client's breast engorgement? A. Applying frozen cabbage leaves to the breasts. B. Encouraging the client to shower with her back to the water. C. Encouraging the client to nurse her baby frequently. D. Applying a breast binder to support the breasts. 208. A client's chest X-ray reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from A. cardiogenic pulmonary edema. B. respiratory alkalosis. C. increased pulmonary capillary permeability. D. renal failure. 209. The nurse applies a fetal monitor to a 15-year-old primagravida admitted to the hospital with possible pregnancy-induced hypertension. Which monitor pattern would the nurse expect to observe if the client is experiencing uteroplacental insufficiency? A. Late deceleration. B. Early deceleration. C. Variable deceleration. D. Fetal acceleration. 210. A boy, age , develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a girl. Which statement by the mother best indicates that she understands the implications of rubella? A. "I told my husband to give my son aspirin for his fever. " B. "I'll ask the physician about giving the baby an immunization shot. " C. "I know that I won't be able to breast-feed my baby now. " D. "I'll call my neighbor who is 2 months pregnant and tell her not to have contact with my son. 211. Lochia normally progresses in which pattern? A. Rubra, serosa, alba. B. Serosa, rubra, alba. C. Serosa, alba, rubra. D. Rubra, alba, serosa. 212. A client complains of a severe, throbbing headache following a lumbar puncture. The priority nursing intervention for this client is to A. restrict fluid intake. B. increase fluid intake. C. raise the head of the bed. D. assess vital signs. 213. A client is receiving an IV infusion of dextrose 5% in water and lactated Ringer's solution at 125 mL/hr to treat a fluid volume deficit. Which of these signs indicates a need for additional IV fluids? A. Serum sodium level of 125 mEq/L. B. Temperature of 99.6 °F(37.6℃). C. Neck vein distention. D. Dark amber urine. 214. When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following? A. Fetal hypoxia. B. The contraction pattern. C. The status of a trapped cord. D. Maternal comfort. 215. The nurse is assessing the puncture site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? A. 15-mm induration. B. Reddened area. C. 10-mm bruise. D. Blister. 216. In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The nurse's best response would be, A. "Will you briefly summarize your point because others need time also?" B. "Your behavior is obnoxious and drains the group. " C. To ignore the behavior and allow him to vent. D. "I'm so frustrated with your behavior. " 217. Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes? A. A neonate who is in good condition. B. A neonate who is mildly depressed. C. A neonate who is moderately depressed. D. A neonate who needs additional oxygen to improve the Apgar score. 218. A 9-month-old infant is admitted with diarrhea and deficient fluid volume. The nurse plans to assess this client's vital signs frequently. What other action would provide the most important assessment information? A. Measuring the infant's body weight. B. Obtaining a stool specimen for analysis. C. Obtaining a urine specimen for analysis. D. Inspecting the infant's posterior fontanel. 219. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instruction? A. "Be sure to eat meat at every meal. " B. "Monitor your fruit intake and eat plenty of bananas. " C. "Restrict your salt intake. " D. "Drink plenty of fluids. " 220. Before undergoing a subtotal thyroidectomy, a client receives potassium iodide (Lugol's solution) and propylthiouracil (PTU). The nurse would expect the client's symptoms to subside A. in a few days. B. in 3 to 4 months. C. immediately. D. in 1 to 2 weeks. 221. The nurse is caring for a bulimic client and an anorectic client. What cognitive characteristics would be similar for both of these clients? A. Perfectionism, preoccupation with food. B. Relaxed personality, but preoccupied with food. C. No similarities. D. Preoccupation with exercise. 222. The nurse is assessing an 8-month-old during a wellness checkup. Which of the following is a normal developmental task for an infant this age? A. Sitting without support. B. Saying two words. C. Feeding himself with a spoon. D. Playing patty-cake. 223. A client being evaluated in the emergency department complains of chest pain that radiates to his neck, shoulders, back, and arms, which decreases when he sits up and leans forward. Based on this assessment, the nurse suspects that he has A. developed another myocardial infarction (MI). B. endocarditis. C. pericarditis. D. myocarditis. 224. A client with myocardial infarction and cardiogenic shock is placed in an intra-aortic balloon pump (IABP). If the device is functioning properly, the balloon inflates when the A. triseupid valve is closed. B. pulmonic valve is open. C. aortic valve is closed. D. mitral valve is closed. 225. Which signs and symptoms are associated with an acoustic neuroma? A. Amenorrhea and obesity. B. Acromegaly. C. Ataxia and intention tremor. D. Unilateral hearing loss and tinnitus. 226. A client who is 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these cramps? A. Suggesting that she walk for 1 hour twice per day. B. Advising her to take over-the-counter calcium supplements twice per day. C. Teaching her to dorsiflex her foot during the cramp. D. Instructing her to increase milk and cheese intake to 8 to 10 servings per day. 227. The nurse is caring for a neonate 12 hours after birth. Which clinical manifestation would be the earliest indication that the neonate may have cystic fibrosis? A. Steatorrhea. B. Meconium ileus. C. Decreased sodium levels. D. Rhinorrhea. 228. A certified nursing assistant (CNA) is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, "How can I keep from catching this from the client?" The nurse reminds the CNA to wash her hands and to ensure the client is placed A. on protective isolation. B. on neutropenic precautions. C. in a negative-pressure room. D. on contact isolation. 229. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia? A. Arm and leg weakness. B. Absence of the gag reflex. C. Difficulty swallowing. D. Inability to speak clearly. 230. After cancer chemotherapy, a client develops nausea and vomiting. For this client, the nurse should give the highest priority to which action in the plan of care? A. Serve small portions of bland food. B. Encourage rhythmic breathing exercise. C. Administer metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed. D. Withhold fluids for the first 4 to 6 hours after chemotherapy administration. 231. A client is experiencing an early postpartum hemorrhage. Which action is inappropriate? A. Inserting an indwelIing urinary catheter. B. Fundal massage. C. Administration of oxytoxics. D. Pad count. 232. A client with a diagnosis of a bleeding gastric ulcer goes to the operating room for a partial gastrectomy. Postoperative nursing care would include A. administering pain medications every 6 hours. B. withholding fluids by mouth until the return of peristalsis. C. positioning the client in high Fowler position. D. flushing the nasogastric (NG) tube with sterile water. 233. A client is admitted to the hospital with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of care? A. Assessing the client's temperature every 8 hours. B. Placing the client in respiratory isolation. C. Monitoring the client's fluid intake and output. D. Wearing gloves during all client contact. 234. A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? A. Inadequate vitamin D intake. B. Inadequate protein intake. C. Inadequate massaging of the affected area. D. Low calcium level. 235. A child is to receive intrathecal methotrexate (Folex) for treatment of meningeal leukemia. For which reason would intrathecal administration be selected? A. The child has very poor veins and is unable to receive drugs IV. B. This drug would be destroyed by gastric acid and so it can't be given by mouth. C. This drug is poorly transported across the blood-brain barrier, so it's administered intrathecally. D. Because the drug is rapidly absorbed if given IM, adverse effects may appear more quickly. 236. Following a cystoscopy that confirmed a diagnosis of bladder cancer, a client is scheduled for chemotherapy and a ileal conduit urinary diversion. The nurse should include which of the following points in the client's preoperative teaching? A. The client's need to perform stoma self-care immediately after surgery. B. The client's need to remain on bed rest for 3 days following surgery. C. The procedure creates a stoma and he must wear a pouch afterward. D. The client will be able to control urine passage through the stoma. 237. A 15-year-old female with a urinary tract infection is admitted to the facility. She tells the nurse she hopes she's pregnant. Which of the following would be the best response by the nurse? A. "Does your mother know about this?" B. "Tell me what pregnancy would mean to you. " C. "Congratulations. Does the baby's father know?" D. "I hope you aren't pregnant; you're too young. " 238. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain related to surgery. B. Deficient fluid volume related to blood and fluid loss from surgery. C. Impaired physical mobility related to surgery. D. Risk for aspiration related to anesthesia. 239. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following? A. High volumes of fluid intake. B. Aerobic exercise programs. C. Caffeine-containing products. D. Foods rich in protein. 240. The nurse is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is A. sedation. B. diarrhea. C. vertigo. D. urticaria. 241. A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention isn't appropriate for this client? A. Acknowledging the client's spiritual distress. B. Inviting the client's clergyman to visit him. C. Encouraging the client to discuss religious beliefs and practices. D. Encouraging the client to discuss concerns with the clergy. 242. The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dL. The nurse should anticipate that the client will need to A. start using insulin. B. start taking an oral antidiabetic drug. C. monitor her urine for glucose. D. be taught about diet. 243. Which behavior would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? A. An increased sense of rectal pressure. B. A decrease in intensity of contractions. C. An increase in fetal heart rate variability. D. Episodes of nausea and vomiting. 244. The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin A. restores the inflammatory response. B. enhances oxygen transport to tissues. C. reduces edema. D. enhances protein synthesis. 245. A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which of the following would be least likely if the neonate developed neonate hemolytic disease? A. Lethargy or irritability. B. Poor feeding patterns including vomiting. C. Weight loss greater than 10%. D. Signs of kernicterus. 246. A client undergoes a total hip replacement. Which statement made by the client would indicate to the nurse that the client requires further teaching? A. "I'll need to keep several pillows between my legs at night. " B. "I need to remember not to cross my legs. It's such a habit. " C. "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed. " D. "I don't know if I'll be able to get off that low toilet seat at home by myself. " 247. The nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can A. prepare the child by positive self-talk. B. establish a time limit to get ready for the procedure. C. hold and rock him and give him a security object. D. count and sing with the child. 248. The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are A. tracheal. B. fine crackles. C. coarse crackles. D. friction rubs. 249. The nurse is caring for a client with a new donor site that was harvested to treat a new burn. The nurse should position the client to A. allow ventilation of the site. B. make the site dependent. C. avoid pressure on the site. D. keep the site fully covered. 250. Emergency medical technicians transport a 28-year-old iron worker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag. " Which intervention by the nurse has the highest priority? A. Assessing the left leg. B. Assessing the pupils. C. Placing the client in Trendelenburg's position. D. Assessing level of consciousness. 251. The nurse notices that a client with obsessive-compulsive disorder washes his hands for long periods each day. How should the nurse respond to this compulsive behavior? A. By designating times during which the client can focus on the behavior. B. By urging the client to reduce the frequency of the behavior as rapidly as possible. C. By calling attention to or attempting to prevent the behavior. D. By discouraging the client from verbalizing anxieties. 252. While assessing a client who complained of lower abdominal pressure, the nurse notes a firm mass extending above the symphysis pubis. The nurse suspects A. a urinary tract infection. B. renal calculi. C. an enlarged kidney. D. a distended bladder. 253. An appropriate-for-gestational-age neonate should weigh A. between the 10th and the 90th percentiles for age. B. at least 2,500 g (5 lb, 8 oz). C. between 2,000 and 4,000 g (4 lb, 6 oz and 8 lb, 12 oz). D. in the 50th percentile. 254. During a parenting group meeting, a mother reveals that she has observed her 6-year-old son playing with his penis during his bath. She asks the nurse how she should respond to the situation. What would be the nurse's most appropriate response? A. "Avoid characterizing it as bad because that's normal at his age. " B. "If he does it often, you might consider disciplining him. " C. "Ignore it and hope that he outgrows it. " D. "Supervise his baths and encourage him to stop doing it. " 255. A client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to A. prevent leaning. B. distribute weight away from the involved side. C. maintain stride length. D. prevent edema. 256. The nurse is interviewing a client about his medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? A. Duodenal ulcers. B. Hemorrhoids. C. Weight gain. D. Polyps. 257. Which of the following is not a contributing factor to unstable blood sugars in the neonate? A. Prematurity. B. Respiratory distress. C. Postdated infant. D. Cesarean delivery. 258. A client with cancer undergoes a total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond? A. Notify the physician. B. Reposition the NG tube. C. Irrigate the NG tube. D. Increase the suction level. 259. When assessing an infant for changes in intracranial pressure (ICP), it's important to palpate the fontanels. Where the nurse should palpate to assess the anterior fontanel? A. A B. B C. C D. D Multiple-correct answer item Directions. The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number. While providing care to a 26-year-old married female, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, "Oh, I tripped. " How should the nurse respond? 260. (Select A or B. ) Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. 261. (Select A or B. ) Report suspicions of abuse to the local authorities. 262. (Select A or B. ) Assist the client in developing a safety plan for times of increased violence. 263. (Select A or B. ) Call the client's husband to discuss the situation. 264. (Select A or B. ) Tell the client that she needs to leave the abusive situation as soon as possible. 265. (Select A or B. ) Provide the client with telephone numbers of local shelters and safe houses. Answers and Rationales 1. C A preterm infant is a neonate born at less than 37 weeks' gestation regardless of what the neonate weighs. Infants weighing less than 2,500 g are described as low-birth-weight neonate. A full- term neonate can be diagnosed with intrauterine growth retardation. 2. C Maternal insulin requirements usually decrease during the first trimester due to rapid fetal growth and maternal metabolic changes, necessitating adjustment of the insulin dosage. Maternal insulin requirements fluctuate throughout pregnancy; after decreasing during the first trimester, they rise again during the second and third trimesters when fetal growth slows. During labor, insulin requirements diminish due to extreme maternal energy expenditure. 3. B Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. A client in cardiogenic shock would show signs of hypotension and tachycardia. 4. A The client's coping skills are ineffective when anxiety increases. The other diagnoses don't correspond to the observed behavior. 5. D A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals. 6. A Disk herniation may compress spinal nerve roots, causing sciatic nerve inflammation, which produces pain that radiates down the leg. Slight knee flexion should relieve lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Positive Homans' sign is more indicative of phlebothrombosis. 7. B Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain. 8. A Clinical manifestations of respiratory distress include intercostal retractions, tachypnea, tachycardia, restlessness, dyspnea, and cyanosis. 9. A The Roman Catholic practice is to baptize infants soon after birth, especially if they are ill and hospitalized. Circumcision may be performed on the infant of a Roman Catholic, but it isn't considered a Roman Catholic practice. Last rites or sacraments of the sick wouldn't be appropriate for the mother of the child. 10. B Because shock signals a severe fluid volume loss (700 to 1300 mL) its treatment includes rapid IV fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An IV infusion rate of 83 mL/hr wouldn't begin to replace the necessary fluids and reverse the problem. The other options are appropriate for this client. 11. B Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which changes blood vessel permeability and allows plasma to move into interstitial tissue, causing edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium intake doesn't affect the glomerular filtration rate. Potassium absorption is improved only by increasing the glomerular filtration rate; it isn't affected by sodium intake. 12. D A respiratory rate greater than 20 breaths/minute is tachypnea. A heart rate greater than 100 beats/minute is tachycardia. Frequent bowel sounds refers to hyperactive bowel sounds. Hyperventilation may increase respirations, but it also refers to deep, large breaths. 13. B The client will receive an enema before the procedure because bowel motility during cervical radiation implant therapy can disrupt or dislodge the implants. The client will be in a private room, and activities will be restricted in order to keep the implants in place. To keep the bladder empty, an indwelling catheter will be used. Positioning in bed shouldn't exceed a 20-degree elevation because sitting up can cause the implants to move from their intended locations. Semi-Fowler's position is 45 degrees. 14. C Intestinal, gastric, and respiratory fluids have different pH values. Therefore, checking the pH of fluid aspirated from the tube is the most reliable technique for checking proper NG tube placement without taking X-rays before each feeding. X-rays can't be performed multiple times every day. Because auscultation of air can be heard when the tube is in the esophagus as well as in the stomach, this isn't the best test for checking placement. Observing the insertion measurement mark isn't a good check either because the mark may remain the same even though the tube has migrated up or down into the esophagus, lungs, or intestines. 15. C The child's airway is blocked despite attempts to establish it. The next step is to clear the airway with back blows and chest thrusts. Breaths can't be administered until the airway is patent. After two attempts to position the airway, the nurse can assume the airway is blocked. The nurse can't ventilate the child with a handheld resuscitation bag until the airway is patent. 16. D Early and frequent contact promotes love and satisfaction and can support the learned parental behavior that enhances parenting abilities and reduces ambivalence and feelings of resentment. Having good role models in childhood may be helpful but isn't the primary principle. Part of the adult maturational process excludes adolescents, who can form strong infant attachments. The relationship isn't directly related to the neonate's physical needs because human contact is needed for the infant to survive. 17. A The important intervention is to assist the client to feel safe. Staying with him until he's able to sleep again or listening to him if he wants to talk is the most appropriate action for the nurse to take in this situation. Talking about it in the morning won't comfort the client when he's most upset. Stating that it was only a dream trivializes his experience. Calling the physician for a sleeping aide doesn't help the client cope with stress. 18. B Decreased visual acuity is common in elderly people. Additional assessment findings include increased lens thickness and opacity, darkening of the skin around the orbits, and an equal but slowed pupillary reflex. 19. D Tympany is produced by air-containing structures, such as the stomach and the bowel. 20. D Standing close to an object being lifted moves the body's center of gravity closer to the object, allowing the legs, rather than the back, to bear the weight. No one should bend over an object when lifting; instead, the back should be straight, and bending should be at the hips and knees. When lifting, spreading the legs apart widens the base of support and lowers the center of gravity, providing better balance. Pushing or pulling an object using the weight of the body, rather than the arms or back, prevents back strain. Using a larger number of muscle groups distributes the workload. 21. A Administration of heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. For a client with hemorrhagic shock, dexamethasone may be used to decrease cerebral edema and pressure; methyldopa, to decrease blood pressure; and phenytoin, to prevent seizures. 22. D Instruct the client to limit hip flexion to 90 degrees while sitting. Supply an elevated toilet seat so the client can sit without having to flex his hip more than 90 degrees. Instruct the client not to cross his legs, to avoid dislodging or dislocating the prosthesis. Caution the client against sitting in chairs that are too low or too soft; these chairs increase flexion, which is undesirable. 23. C A failure to use available support systems or agencies is one of the defining characteristics of this diagnosis. Supportive child-parent interaction, parents' active participation in the child's care, and evidence of adaptation to parental role changes don't suggest this diagnosis. 24. A An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee doesn't promote venous return. 25. B C. albicans is treated with nystatin (Mycostatin) and doesn't require treatment for sexual partners. N. gonorrhoeae, T. vaginalis, and C. trachomatis are sexually transmitted diseases that require that partners be treated. 26. B Following a transesophageal echocardiogram in which the client's throat has been anesthetized, food and fluid should be withheld until the gag reflex returns. There is no indication for oral airway placement. The client should be in the upright position, and inserting an NG tube is unnecessary. 27. B According to the American Association on Mental Deficiency, a person with an IQ between 50 and 70 is classified as mildly mentally retarded but educable. One with an IQ between 36 and 50 is classified as moderately retarded but trainable. One with an IQ below 36 is severely and profoundly impaired, requiring custodial care. 28. D Because some of the glucose in the bloodstream attaches to some of the Hb and stays attached during the 120-day life span of red blood cells, glycosylated Hb levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels give information about glucose levels only at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks. 29. A An anterior MI causes left ventrieular dysfunction and can lead to manifestations of heart failure, which include pulmonary crackles and dyspnea. The other types of MI aren't usually associated with heart failure. 30. D Fetal immunities are transferred through the placenta, but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus, which the mother's body considers a foreign protein. Thus, the placenta isn't responsible for the production of maternal antibodies. The placenta produces estrogen and progesterone, detoxifies some drugs and chemicals, and exchanges nutrients and electrolytes. 31. D The nurse should assess a casted arm every 2 hours for finger movement and sensation to ensure that the cast isn't restricting circulation. To reduce the risk of skin breakdown, the nurse should leave a casted arm uncovered to allow for air circulation through the cast pores to the skin below. Unlike plaster casts, fiberglass casts dry quickly and can be handled without damage soon after application. The nurse should assess the brachial and radial pulses distal to the cast--not the pedal and posterior tibial pulses, which are found in the legs. 32. D Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing or widening complexes and amplitude increase aren't expected on the ECG of an individual with cardiac tamponade. 33. B One way to help support this client's wishes to breast-feed is to instruct her to room-in with her neonate so she can respond to the neonate's cues. Sending the neonate to the nursery lessens the mother's ability to learn her neonate's breast-feeding cues. The other options don't support the client's need for guidance. 34. C Solid foods are typically introduced around age 6 months. They aren't recommended at an earlier age because of the protrusion and sucking reflexes and the immaturity of the infant's GI tract and immune system. By age 8 months, the infant usually has been introduced to iron-fortified infant cereal and vegetables and will begin to try fruits. 35. B A woman having her second baby can anticipate a labor about half as long as her first labor. The other options are incorrect. 36. A PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. 37. B The mother should sign the consent form because she's the closest living relative. The client can't sign because of his diagnosis. The companion, although a close significant other, can't sign because he isn't a blood relative. Two physicians need not sign a consent form when a relative is available. 38. B Listening to the radio with earphones is one way to override the buzzing sound in the ears caused by tinnitus. Diet regulation may affect the occurrence of attacks of Ménière's but not the effects of tinnitus. The client wouldn't take antihypertensive medications for this disorder. 39. C A corticotropin-secreting pituitary adenoma is the most common cause of Cushing's syndrome in women ages 20 to 40. Ectopic corticotropin-secreting tumors are more common in older men and are often associated with weight loss. Adrenal carcinoma isn't usually accompanied by hirsutism. A female with an inborn error of metabolism wouldn't be menstruating. 40. A Chilis and tachycardia may indicate bladder infection and should be reported to the physician immediately. Clients commonly feel burning on urination and urinary frequency after cystoscopy as a result of irritation from the cystoscope. Orthostatic dizziness and fainting may occur after the legs have been removed from stirrups, which are used to maintain the client in a lithotomy position. Pink- tinged urine and bladder spasms may be expected after cystoscopy. Note, however, that the occurrence of bright red blood may be an indication of hemorrhage. 41. D Parents of a child with a heart defect should treat the child normally and allow self-limited activity. Reducing the child's caloric intake doesn't necessarily reduce cardiac demand. Altering disciplinary patterns and deliberately preventing crying or interactions with other children can foster maladaptive behaviors. Contact with peers promotes normal growth and development and therefore should be encouraged. 42. B Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won't cause a tension pneumothorax. Excessive water won't affect the chest tube drainage. 43. B The FAST is being used more commonly. This noninvasive technique induces fetal heart rate accelerations by using low- frequency vibrations on the maternal abdomen over the fetal head. It can shorten the length of the nonstress test. The FAST isn't used to induce contractions, shorten the length of the contraction stress test, or determine fluid volume. 44. D According to the Denver Ⅱ Developmental Screening test, most 2-year-olds are able to remove one garment. A -year-old can build a tower of eight cubes and point out a picture. A 3-year-old can wash and dry his hands. 45. B Bubbling in the second chamber of a Pleur-evac system signifies that air is moving from the collection chamber to the water seal chamber. It's normal for bubbling to occur during inspiration, but continuous bubbling signifies a leak in the closed system. Absence of bubbling in the second chamber signifies a block in the system. It can also mean that the affected lung has reexpanded. 46. B The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. The client doesn't need to be seen or admitted for delivery. The client's signs aren't indicative of heart failure. 47. D Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension. 48. A Hives and urticaria are two names for the same skin lesion. A toxin is a poison. A tubercle is a tiny round nodule produced by the tuberculosis bacillus. A virus is an infectious parasite. 49. A In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in pericardial tamponade. 50. A Pitting edema is documented as +1 when depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4. 51. D Sodium polystyrene sulfonate (Kayexalate) is a resin that pulls potassium into the bowel and is excreted with defecation. Antacids, IV fluids, and restriction of fluids won't reduce the potassium level. 52. D Normal thyroid function tests are as follows: T4, 5 to 12 μg/dL; T3, 65 to 195 μg/dL; TSH 0.3 to 5.4μIU/mL. With Hashimoto's thyroiditis, T4 and T3 levels are typically subnormal and TSH is elevated. With primary hyperthyroidism, T4 and T3 levels are elevated and TSH is subnormal (options A and B). With hypothyroidism, T4 is subnormal and T3 and TSH levels are elevated (option C). 53. C The client receiving chemotherapy is susceptible to infection from bone marrow suppression and granulocytopenia. Clients should be instructed to avoid malls, movie theaters, and infected individuals. Raw fruits and vegetables may be contaminated by pathogens and should be avoided during severe neutropenia or washed in hot soapy water. Although rectal temperatures may be more accurate, they aren't appropriate for the neutropenic client. Taking temperatures rectally increases the risk of rectal abscess due to rectal trauma. Meticulous hand washing by staff and visitors will prevent the spread of infection; there is no need for sterile garb and no need to avoid visiting-the client will need emotional support from family at this time. 54. B Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there is no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect. 55. B Assessment data should include information regarding the client's feelings, beliefs, and attitudes about his illness. Although the other options are partially correct, option B is the best answer. 56. D Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but not a sign of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics. 57. A To sustain them until active erythropoiesis begins, neonates have Hb concentrations higher than those of older children. The normal value of Hb for neonates is 18 to 27g/dL. Disease as well as such nonpathologic conditions as age, sex, altitude, and the degree of fluid retention or dehydration can affect Hb values. The values for a 3-month-old, a 3-year-old, and a 10-year-old are correct as stated above. 58. C While the physician makes treatment decisions, the nurse should maintain the client on bedrest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg may cause accidental trauma from cuts or nicks. 59. A Discussing problems and fears is an appropriate nursing intervention to assist a client with coping with or adapting to her illness. The nurse should express interest in the client and her concerns regarding her present state. After allowing the client to express her needs, it may be appropriate to ask her if she would like to see the chaplain or attend a support group. Giving the client reassurance is inappropriate at this time. 60. A A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartum client who has been sitting and may suddenly gush out when she stands up. A 2" blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. A client who has had a cesarean delivery usually feels pain at the incision site after her anesthesia has worn off. 61. C The three phases of acute renal failure are the oliguria phase (less than 400 to 600 mL of urine produced in 24 hours), diuresis, and recovery. The kidneys aren't in a state of suppression, the average output isn't 30 to 60 mL/hr, and the amount of output isn't related to IV fluids infused. 62. D In a client with AIDS, deterioration of the central nervous system (CNS) can lead to AIDS-related dementia. Because this type of dementia impairs cognition and judgment, it places the client at risk for injury. Although self-care deficit and dysfunctional grieving can be associated with AIDS, they don't take precedence for a client with AIDS-related dementia. Because CNS deterioration results from infection--not altered tissue perfusion--Ineffective cerebral tissue perfusion isn't an appropriate diagnosis. 63. B Many clients (25% to 60%) with secondary failure respond to a different oral antidiabetic agent. Therefore, it wouldn't be appropriate to initiate insulin therapy at this time. However, if a new oral antidiabetic agent is unsuccessful in keeping glucose leveis at an acceptable level, insulin may be used in addition to the antidiabetic agent. A client who has diabetes should get about 70% of his calories from carbohydrates and monounsaturated fats. 64. C Identify the chief complaint from how the child was previously behaving at home. Asking how long the child has been like this may be interpreted poorly by the caregiver. Focus on what the child can do--and not on what he can't do--to preserve the family's self-esteem. Focusing on negative aspects of the child's behavior is inappropriate. 65. A The main goal of an incident report following an adventitious event isn't punishment for those involved in the incident. The purpose of an incident report is threefold: to identify ways to prevent recurrences of incidents, to identify patterns of care problems, and to identify facts surrounding each incident. 66. C If a client has a wound contaminated with soil that may contain animal excrement and he has completed the full childhood tetanus immunization regimen, he should be given a dose of tetanus toxoid if it has been 5 or more years since the most recent dose. (It had been 7 years since the client's last dose. ) Serum tetanus titer levels aren't used to determine whether tetanus toxoid should be administered. No available tetanus immunization confers life-long immunity. 67. B The behavior demonstrated by the mother is normal during the "taking-hold" process. The nurse should anticipate and support this behavior. Because this is normal behavior for establishing a relationship, it doesn't need to be reported. It's highly doubtful that the neonate would become chilled during this brief time of being undressed. Therefore, rewrapping the neonate and taking her back to the nursery to check her temperature isn't necessary. 68. C Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety- causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment. 69. C Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease, but it gradually returns to prepregnancy levels. 70. A Potentiating effect refers to a drug's ability to increase the potency of another drug if taken together. Therefore, the client should be instructed to avoid alcohol while taking Librium because it potentiates the drug's CNS depressant effect. Taken at bedtime, this drug will induce sleep. Librium comes in capsule form and usually can be taken with water. Aged cheese is restricted with monoamine oxidase inhibitors, not Librium. 71. A During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels, causing ischemia and tissue damage. Providing IV and oral fluids promotes hemodilution, which aids the free flow of RBCs through blood vessels. The client must be kept away from known infection sources but doesn't require protective isolation. Warm compresses may be applied to painful joints to promote comfort; cool compresses would cause vasoconstriction, which exacerbates sickling. Antipyretics may be administered to reduce fever but don't play a crucial role in resolving the crisis. 72. B Because the pregnant uterus exerts a lot of pressure on the urinary bladder, the bladder repair may need to be repeated. These clients don't necessarily have to have a cesarean delivery if they become pregnant, and this procedure doesn's render them sterile. This procedure is completed in one surgery. 73. B A word salad is an illogical word grouping. Echopraxia is an involuntary repetition of movements. Flight of ideas is a rapid succession of unrelated ideas. Neologisms are bizarre words that have meaning only to the client. 74. C With a platelet count of 22,000/μL, the client bleeds easily. Therefore, the nurse should avoid using the IM route because the area is highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop. The client already has an IV access, so it would be the best route, especially because IV morphine is effective almost immediately. Oral and SC routes are preferred over IM, but they're less effective for acute pain management than IV. 75. B Diarrhea causes the body to lose bicarbonate, which may cause metabolic acidosis. Respiratory acidosis is caused by alveolar hypoventilation. Carbonic acid excess occurs with respiratory alkalosis. Vomiting could lead to metabolic alkalosis. 76. C AIDS clients must follow safer-sex practices to prevent transmission of the human immunodeficiency virus. Although avoiding the use of alcohol and illicit drugs is helpful, the most important point the nurse can make is that drug users can best avoid transmission by using clean needles and disposing of used needles. The AIDS client has no legal obligation to tell anyone about an AIDS diagnosis. 77. B The squeezing action of the contractions during labor enhances fetal lung maturity. Neonates who aren't subjected to contractions are at an increased risk for developing respiratory distress. The type of birth has nothing to do with temperature or glucose stability, and acrocyanosis is a normal finding. 78. D Hoarseness indicates injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate. 79. A The pulse deficit measures the difference between the apical pulse rate and radial pulse rate. Pulse pressure is the difference between systolic and diastolic blood pressures. Cardiac output is the amount of blood ejected from the left ventricle per minute, and ejection fraction refers to the percentage of blood emptied from the ventricle during contraction. 80. A Daily walks relieve symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may exacerbate these symptoms. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat foods that raise HDL levels. 81. A There are 250 mg in 1 teaspoon (5 mL); therefore, 1 mL=50 mg. The child should receive 2 mL of suspension (100 mg). 250 mg/5 mL= 100 mg/x mL. x=2. 82. A To screen for scoliosis, a lateral curvature of the spine, the nurse has the child stand firmly on both feet with the trunk exposed and examines the child from behind, checking for asymmetry of the shoulders, scapulae, or hips. The nurse then asks the child to bend forward at the hips and inspects for a rib hump, a sign of scoliosis. The nurse would listen for a clicking sound while the child abducts the hips when screening for developmental dysplasia of the hip. The heel-to-shin test evaluates cerebellar function. Having the child shrug the shoulders against mild resistance helps evaluate the integrity of cranial nerve Ⅺ. 83. A Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe the feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-litting shoes, and avoid taking medications unless the physician approves. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. The client must see the physician regularly to evaluate the effectiveness of the therapeutic regimen, not just when complications occur. 84. C Diuretics, such as furosemide, reduce total blood volume and circulatory congestion. Antiembolism stockings prevent venostasis and thromboembolism formation. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but don't decrease fluid volume excess. 85. D Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax, but they typically return to normal in 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest is reexpanded sufficiently. 86. A Antibiotics must be given for the full course of therapy, even if the child feels well, otherwise the infection won't be eradicated. Antibiotics should be taken at prescribed intervals to maintain blood levels and not as needed for pain. A reexamination at the end of the course of antibiotics is necessary to confirm that the infection is resolved. 87. D An enterostomal nurse therapist is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support. Social workers provide counseling and emotional support, but they can't provide preoperative and postoperative teaching. A registered dietitian can review any dietary changes and help the client with meal planning. The occupational therapist can assist a client with regaining independence in activities of daily living. 88. C Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include. 89. C Relaxation isn't an indication for detachment of the placenta. An abrupt lengthening of the cord, an increase in the number of contractions, and an increase in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus. 90. B The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection. 91. A Regardless of the client's medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly prescribed fluids include dextran (in cases of hypovolemic shock), isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline solution. 92. D A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although the other actions are important, they're of a lesser priority. 93. D The client with a chronic illness goes through a grieving process that is related to the loss of his previous level of function. Grief is commonly manifested as loss of motivation and refusal to perform functions of which the client is fully capable. Self- actualization is the process of fulfilling one's potential. Confabulation is a behavioral reaction in which the client creates stories or invents answers to fill in memory gaps in an unconscious attempt to maintain self-esteem. In reaction formation, the client uses behaviors that are the opposite of what he would like to do. 94. B The nurse's first action is to dry the neonate and stabilize the neonate's temperature. Aspiration of the infant's nose and mouth occurs at the time of delivery. Promoting parental bonding and identifying the neonate are appropriate after the neonate has been dried. 95. C The described behaviors indicate poor personal boundaries, which is the inability to differentiate between self and others. Poor boundaries are symptoms of antisocial and passive-aggressive behavior. Manipulation is an attempt to control another person. 96. D Carbohydrate need increases because healing and repair of tissue requires more carbohydrates. Increased--not decreased--protein catabolism is present. Decreased appetite--not increased--is a problem. Digestive enzymes are decreased--not increased. 97. D Acarbose delays glucose absorption, so the client should take an oral form of dextrose rather than a product containing table sugar when treating hypoglycemia. The alpha-glucosidase inhibitors work by delaying the carbohydrate digestion and glucose absorption. It's safe to be on a regimen that includes insulin and an alpha- glucosidase inhibitor. The client should take the drug at the start of a meal, not 30 minutes to an hour before. 98. D The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIV-positive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who is HIV-positive can give birth to a baby who is HIV-negative. 99. C The child is obtunded if he can be aroused with stimulation. If the child shows no motor or verbal response to noxious stimuli, he's comatose. If the child remains in a deep sleep and is responsive only to vigorous and repeated stimulation, he's stuporous. If the child has limited spontaneous movement and sluggish speech, he's lethargic. 100. B The infant is having a "tet" or blue spell, which is an acute spell of hypoxia and cyanosis. This occurs when the infant's oxygen requirements are greater than what is supplied in the blood. Treatment involves placing the infant in the knee-chest position to reduce venous return from the extremities because that blood is desaturated. It also increases systemic vascular resistance, which causes more blood to be shunted to the pulmonary artery. Leaving the infant alone until the crying stops will cause an increase in cyanosis. An infant who is crying and having trouble breathing shouldn't be offered a bottle because of the danger of aspiration. A ride in the car may quiet some infants, but it would be inappropriate in this situation. 101. A In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 mL/(kg · hr). Thus, the expected urine output of a 155 lb client is 35 mL/hr, and a urine output consistently above 100 mL/hr is more than adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4 lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators. 102. B Appropriate perception of vibration indicates intact dorsal column tracts and peripheral nerves. If there's a loss of vibratory sense, an injury to the peripheral nerves is probable. 103. A Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don't cause metabolic acidosis. 104. C It's extremely important that the nurse establish trust and rapport. The nurse shouldn't offer advice. Instead, she should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also important but not as important as developing trust and rapport. 105. A Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express her anger can help the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge her feelings. Offering to get the nursing supervisor also doesn't acknowledge the client's feelings. Ignoring the client's feelings suggests that the nurse has no interest in what the client has said. 106. B The correct answer is waxy flexibility, which is defined as retaining any position that the body has been placed in. Somatic delusions involve a false belief about the functioning of the body. Neologisms are invented meaningless words. Nihilistic delusions are false ideas about self, others, or the world. 107. C The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP. 108. B Applying heat increases blood flow to the area, which, in turn, increases the absorption of the medication. Cold decreases the pain but allows the medication to stay in the muscle longer. Massage is a good intervention but applying a warm compress is better. Tightening the gluteal muscles may cause additional burning if the drug irritates muscular tissues. 109. B According to the ACS guidelines, "Women older than age 40 should have a mammogram annually and a clinical examination at least annually (not every 2 years); all women should perform breast self- examination monthly (not annually). " The hormonal receptor assay is clone on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent. 110. B Washing the area with normal saline solution and applying a protective dressing are within the nurse's realm of interventions and will protect the area. Using a povidone-iodine wash and an antibiotic cream require a physician's order. Massaging with an astringent can further damage the skin. 111. D Acute lymphoblastic leukemia and its treatment cause immunosuppression. Thorough hand washing is the single most effective way to prevent infection in an immunosuppressed cIient. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others need not wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep persons with known infections out of the client's room. 112. D The primary cause of neonate jaundice is the immaturity of the liver and its inability to break down red cells effectively. Poor clotting mechanisms, elevated Hb, and persistent fetal circulation contribute to the jaundice but aren't causes of it. 113. A Accidents are the major cause of death and disability during the school age years. Therefore accident prevention should take priority when teaching parents of school-age children. Preschool children are afraid of the dark, have fears concerning body integrity, and should be encouraged to dress without help (with the exception of tying shoes), but none of these should take priority over accident prevention. 114. A Anyone with psoriasis vulgaris who reports joint pain should be evaIuated for psoriatic arthritis. Approximately 15% to 20% of individuals with psoriasis will also develop psoriatic arthritis, which can be painful and cause deformity. It would be incorrect to assume that his pain is caused by early rheumatoid arthritis or his vocation without asking more questions or performing diagnostic studies. Carpal tunnel syndrome causes sensory and motor changes in the fingers rather than localized pain in the joints. 115. A Elderly clients and clients with cardiac disease should begin with low-dose levothyroxine increased at 2- to 4-week intervals until 100 g/d is reached. This slow titration prevents further cardiac stress. Younger clients would be started on the usual maintenance dose of 100 g/d. Clients with Hashimoto's thyroiditis don't require surgical intervention. 116. A The correct sequence begins with establishing unresponsiveness. The nurse should then call for help, assess the client for breathing while opening the airway, deliver two breaths, and check for a carotid pulse. 117. C COPD causes pulmonary hypertension, leading to right ventricular failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. He should eat a low-sodium diet to avoid fluid retention and should engage in moderate exercise to avoid muscle atrophy. 118. D Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It isn't a genetic disorder. A combined upper and lower neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron. 119. C A GTT indicates a diagnosis of diabetes mellitus when the 2-hour blood glucose level is greater than 200 mg/dL. Confirmation occurs when at least one subsequent result is greater than 200 mg/dL. 120. D Removal of the thyroid gland can cause hyposecretion of parathormone leading to calcium deficiency. Manifestations of calcium deficiency include numbness, tingling, and muscle spasms. Treatment includes immediate administration of calcium. Thyroid supplements will be necessary following thyroidectomy but aren't specifically related to the identified problem. Antispasmodics don't treat the problem's cause. Barbiturates aren't indicated. 121. A Encouraging the client to discuss stressful life situations helps focus on the underlying issues. The client's preoccupation with a specific physical feature is a means of not coping with life. Ignoring the client or complimenting the client won't be helpful. She won't be able to accept the compliment. Agreeing with her strengthens her problem. 122. C Testicular enlargement signifies the onset of puberty in the male adolescent. Then sexual development progresses, causing the appearance of pubic hair and axillary hair and the onset of nocturnal emissions. 123. A MAO inhibitor antidepressants when combined with a number of drugs can cause life-threatening hypertensive crisis. It's imperative that a client checks with his physician and pharmacist before taking any other medications. Activity doesn't need to be limited. Blood dyscrasias aren't a common problem with MAO inhibitors. Aspirin and NSAIDs are safe to take with MAO inhibitors. 124. C Hyperkalemia, a common complication of acute renal failure, is life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate. 125. D The client's symptoms indicate deep vein thrombosis (DVT). Pointing toes toward the knee will elicit discomfort. The time of the day doesn't influence the pain associated with DVT. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. A dependent position will increase venous stasis and the pain associated with DVT. 126. A A living will states that no lifesaving measures are to be used in terminal conditions. There is no indication that the client is terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as choking on an enteral feeding device. The nurse should clear the client's airway. Making the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation isn't indicated and removing the NG tube would exacerbate the situation. 127. A Although talking about their experiences can be difficult, clients with PTSD can obtain the most lasting relief if they verbalize memories of the trauma to a sympathetic listener. Family members are commonly frightened by the information and can't be consistently supportive. Antidepressants may help but these drugs can mask feelings and can't provide lasting relief. Treatment for alcohol abuse, including AA meetings, must be considered when planning care but alone doesn't provide lasting relief. 128. C When a client is getting the wrong IV solution, the nurse should maintain the access and start the proper solution. Removing the catheter is unnecessary and subjects the client to unnecessary needlesticks. Waiting until the next bottle is due is inappropriate and places the client at risk for problems and the nurse in legal jeopardy. An incident report describing the specific error should be completed after the correct solution has been started. 129. A Option A is the most supportive statement. The nurse acknowledges the client's traumatic experience and pain as well as encourages her to talk. Option B ignores the client's need for reassurance. Option C indicates that the nurse isn't capable of helping the client deal with therapeutic issues. Option D could make the client feel guilty for being upset about the trauma. 130. C When the mechanical stressors of weight bearing are absent, disuse osteoporosis can occur. Therefore, if the client does weight- bearing exercises, disuse complications can be prevented. Maintaining protein and vitamins levels is important, but neither will prevent osteoporosis. ROM exercises will help prevent muscle atrophy and contractures. 131. B Huntington's disease is an autosomal dominant disorder; therefore, each child has a 50% chance of inheriting it. Men and women are equally affected. 132. A The possibility of frostbite must be evaluated before the other interventions. Options B, C, and D don't address the client's immediate medical needs. 133. C Because neostigmine's onset of action is 45 to 75 minutes, it should be administered at least 45 minutes before eating to improve chewing and swallowing. Taking neostigmine with a small amount of food reduces GI adverse effects. Adverse effects of the medication include increased salivation, bradycardia, sweating, nausea, and abdominal cramps. Neostigmine must be given at scheduled times to ensure consistent blood levels. 134. D The nurse is using focusing by suggesting that the client discuss a specific issue. She didn't restate the question, ask further questions (exploring), and didn't make an observation. 135. B To avoid burning and sloughing, the client must protect the graft from direct sunlight. The other three interventions are all helpful to the client and his recovery but are less important. 136. D Some adverse effects of birth control pills, such as blurred vision and headaches, require a report to the health care provider. Because these two effects in particular may be precursors to cardiovascular compromise and embolus, the client may need to use another form of birth control. Breast tenderness, breakthrough bleeding, and decreased menstrual flow may occur as a normal response to the use of birth control pills. 137. B Coarctation of the aorta causes signs of peripheral hypoperfusion, such as a weak femoral pulse and a bounding radial pulse. These signs are rare in patent ductus arteriosus, ventricular septal defect, and truncus arteriosus. 138. A The objective of menotropins therapy is to produce one or two healthy follicles; by carefully monitoring the client's ultrasound study results and serum estradiol levels, the nurse can determine the number of maturing follicles. Serum progesterone levels indicate whether ovulation has occurred and correlate well with basal body temperature changes but don't indicate the number of follicles. The test to detect urinary levels of LH is a hormonal assessment of ovulatory function--not an assessment of the number of maturing cells. Serum levels of HCG indicate whether the corpus luteum is producing enough estrogen and progesterone to maintain the pregnancy until the placenta develops further. 139. A Clients with ulcerative colitis should be encouraged to consume foods high in protein and calories to promote healing. Fat intake should be limited, especially if steatorrhea is present. Clients should also be encouraged to avoid raw fruits and vegetables, dried fruit and beans, whole grains, bran, seeds, and nuts to reduce bowel movements. Caffeine-containing and carbonated beverages should be avoided because they stimulate intestinal peristalsis. 140. D The cricoid cartilage in the toddler is the narrowest part of the larynx and provides a natural seal. This keeps the endotracheal tube in place without requiring a cuff. The vocal cords are narrower in an adult. The trachea is shorter and the larynx is anterior and cephalad, but these aren't reasons to choose an uncurled tube. 141. C Injury to the gastric mucosa causes gastric atrophy and impaired function of the parietal cells. This results in reduced production of intrinsic factor, which is necessary for the absorption of vitamin B12. Eventually, pernicious anemia will occur. 142. D Black Muslims stress the importance of cooperation among black business and education in the elevation of the self-esteem of its adherents. Prophecy is a focus of such religions as Seventh-Day Adventism and Fundamental Baptist. Reincarnation is associated with Far Eastern religions, and celibacy is a practice in a number of the world's religions. 143. B Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses passive coping behaviors (such as distraction and cooperation) may rate pain as more intense than children who use active coping behaviors (such as crying and kicking). Nurses frequently make judgments about pain based on behavior, which can result in children being inadequately medicated for pain. 144. D A nonrebreathing mask provides the highest possible oxygen concentration--up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A partial rebreathing mask delivers oxygen concentrations up to 90%. 145. D Toddlers are naturally curious about their environment and letting them handle minor equipment is distracting and helps them gain trust in the nurse. The nurse should only expose one area at a time during assessment, and should approach the child slowly and unhurriedly. The caregiver should be encouraged to hold and console her child. Also, comfort the child with objects with which he's familiar. The child should be given limited choices to allow autonomy, such as "Do you want me to listen first to the front of your chest or your back?" 146. B Impotence is defined as the inability to achieve penile erection. It also involves being unable to maintain an erection to the point of ejaculation. Disinterest in sexual intimacy can be labeled with a number of terms, including celibacy and asexuality. Infertility is the term used when a man's semen is incapable of impregnating a woman. 147. C Warm compresses increase blood flow to the affected joint, relieving pain. Ice causes decreased blood flow to the affected joint, increasing pain. The nurse should turn the client frequently to prevent skin breakdown and conserve the client's energy. TENS application is reserved for chronic pain. 148. A Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock would cause a decrease in cardiac output. Tissue perfusion would be altered if hypovolemic shock occurred, but this wouldn't be the primary nursing diagnosis. 149. C Nursing care should be planned at the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. A child with Down syndrome is capable of learning, especially one with mild limitations. Gear teaching toward the appropriate developmental age. 150. D The original ABG analysis reveals respiratory acidosis commonly seen with a pneumothorax. After chest tube insertion, the client's respiratory status has improved, pH is increasing toward normal, and the PaCO2 is decreasing. ABG analysis in respiratory alkalosis shows an elevated pH and a low PaCO2. Assessment findings are more important than ABG analysis in determining whether the client requires intubation or if respiratory arrest is imminent. 151. B Direct questions (such as "Do you hear voices?" or "Do you feel safe right now?") are the most appropriate technique for eliciting verifiable responses from a psychotic client. The other options may not elicit helpful responses. 152. A Respiratory acidosis is associated with hypoventilation, which in this client suggests intake of a drug that suppresses the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine sample for drug screening. 153. D Parental interaction will provide the nurse with a good assessment of the stability of the family's home life but it has no indication for parental bonding. Willingness to touch and hold the neonate, expressing interest about the neonate's size, and indicating a desire to see the neonate are behaviors indicating parental bonding. 154. B The client may have a difficult time sitting long enough to eat his meal; therefore, finger foods that can be eaten easily are most appropriate. The other foods require the client to sit and eat, a task the client will be unable to achieve at this time. 155. A Psychosocial factors should be suspected when pain persists beyond the normal tissue healing time and physical causes have been investigated. The other choices may or may not be correct but certainly aren't credible in all cases. 156. C When dealing with a crying toddler, the best approach is to talk to the mother and ignore the toddler at first. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse. Ignoring the crying and screaming may be the second step. Having the mother hold the toddler will help if she can do this. The last resort is to bring in assistance so the procedure can be completed quickly. 157. A Prinzmetal's or variant angina is triggered by coronary artery spasm, An unpredictable amount of activity may trigger unstable angina. Activities that increase myocardial oxygen demand may trigger predictable stable angina. 158. D Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope. Vasovagal syncope isn't caused by vestibular (inner ear) dysfunction, vascular fluid shifting, or postural hypotension. 159. A The pH in an ABG report reflects the acid concentration in the blood. The partial pressure of arterial oxygen (PaO2) value indicates the amount of oxygen dissolved in the blood; the partial pressure of arterial carbon dioxide (PaCO2) value represents the amount of carbon dioxide dissolved in the blood. The bicarbonate ( ) value indicates the amount of bicarbonate or base in the blood. 160. A The nurse should keep the client covered and expose only the portion of the client's body that is being assessed. The nurse should also keep the client warm by maintaining his room temperature between 68° and 74°F (20° and 23.3℃). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient and exposing them to vast changes in temperature could influence the client's response. A room temperature of 78°F may be too warm for some clients and too cool for others. Keeping the client uncovered would lead to chilling. Matching the room temperature with the client's body temperature is inappropriate. 161. C In diverticulitis, vegetables with seeds are prohibited in the diet because the seeds can lodge in diverticula and cause flare- ups. Fiber and residue are recommended in the diet. Bananas and milk products aren't contraindicated. 162. C Retention with overflow is a commonly missed nursing assessment. Because the client may be voiding and may not have an urge to void doesn't mean that bladder function has been properly restored. A varying urge to urinate with an average urine output of 100 mL is a classic picture of a client whose bladder is distended and needs to be catheterized to restore normal function. 163. A Because major complications--such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation--can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done, but their frequency is determined by the child's status. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. These are less important nursing measures in this situation. 164. C Factors related to growth and maturation significantly alter an individual's capacity to metabolize and excrete drugs. Thus, the premature infant is at risk for problems because of immaturity. Deficiencies associated with immaturity become more important with decreasing age. Enzyme systems develop quickly, with most increasing to adult levels within I to 8 weeks after birth. Within the 1st year of life, all are probably as active as they will ever be. 165. A Weight gain during pregnancy is a normal concern for most women. The nurse must first teach the client about normal weight gain and diet in pregnancy, then assess the client's response to that information. It's also important for the nurse to determine whether the client has any complicating problems such as an eating disorder. Reporting the client's concern about weight gain to the health care provider isn't necessary at this time. A weight check every 2 weeks also is unnecessary. 166. B Concussions are considered minor with no structural signs of injury. A contusion is bruising of the brain tissue with small hemorrhages in the tissue. Coup and contrecoup are types of injuries in which the damaged area on the brain forms directly below the site of impact (coup) or at the site opposite the injury (contrecoup) due to movement of the brain within the skull. 167. C Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question their use in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician. 168. B The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low- sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis. 169. C Administering a tap water enema until return is clear would most likely contribute to a hyposmolar state. Because tap water is hypotonic, it would be absorbed by the body, diluting the body fluid concentration and lowering osmolality. NG tube irrigation with normal saline solution wouldn't cause a shift in fluid balance. Weighing the client is the easiest, most accurate method to determine fluid changes. Therefore, it helps identify rather than contribute to fluid imbalance. Drinking broth wouldn't contribute to a hyposmolar state because it doesn't replace sodium and water lost through excessive perspiration. 170. D Sleeping undisturbed for a period of time would indicate that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions. 171. A The client has symptoms of lithium toxicity. Therefore, her lithium should be held and the physician notified immediately. These aren't normal adverse effects, and administering another dose would increase the toxic effects. A nurse can't discontinue a medication without a physician's order. 172. B When caring for the client with a cardiac disorder, the rectal route should be avoided. Introducing a thermometer into the rectum may stimulate the vagus nerve, causing vasodilation and bradycardia. The oral, axillary, and tympanic routes are appropriate for measuring the temperature of cardiac clients. 173. D Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the veins to distend and can be seen most obviously in the neck veins. An electrolyte imbalance may result in fluid overload, but it doesn't directly contribute to jugular vein distention. 174. A Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Fluid overload won't cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration was extreme. Hypovolemic shock would occur with an extreme loss of fluid or blood. 175. A The nurse should assess for hypocortisolism. Abrupt withdrawal of endogenous cortisol may lead to severe adrenal insufficiency. Steroids should be given during surgery to prevent hypocortisolism from occurring. Signs of hypocortisolism include vomiting, increased weakness, dehydration and hypotension. After the corticotropin-secreting tumor is removed, the client shouldn't be at risk for hypoglycemia or hyperglycemia. Calcium imbalance shouldn't occur in this situation. 176. A Otorrhea and rhinorrhea are classic signs of a basilar skull fracture. Injury to the dura commonly occurs with this fracture, resulting in cerebrospinal fluid (CSF) leaking through the ears and nose. Any fluid suspected of being CSF should be checked for glucose or have a halo test done. 177. B Because pinworms are highly contagious, all family members should be treated simultaneously. White patches signal oral candidiasis, which is unrelated to pinworm infestation or treatment. Drinking apple juice and limiting dairy products don't affect the outcome of treatment of pinworms. 178. B Neonates are at risk for bleeding disorders during the 1st week of life because their GI tracts are sterile at birth and lack the intestinal flora needed to produce vitamin K, which is necessary for blood coagulation. Vitamin K stimulates the liver to produce clotting factors. Vitamin K doesn't prevent PKU, which is an inherited metabolic disease. 179. B Hyperthyroidism is a hypermetabolic state characterized by signs, such as tachycardia, systolic hypertension, and anxiety--all seen in adrenergic (sympathetic) stimulation. Manifestations of hypovolemic shock, benzodiazepine overdose, and Addison's disease are more similar to a hypometabolic state. 180. B She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus. Vitamins won't take away fatigue. False reassurance is inappropriate and doesn't help her deal with fatigue now. 181. B For clients with increased intracranial pressure (ICP), the head of the bed is elevated to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. Side-lying isn't specifically a therapeutic treatment for increased ICP. 182. A The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. This is known as subinvolution. 183. D The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days. The client must be instructed to continue taking the drug as directed. Blood level checks aren't necessary. NMS hasn't been reported with this drug, but tachycardia is frequently reported. 184. C To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cmH2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support. 185. A The passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the stool can't move past the impaction. Clients usually report the urge to defecate--although they can't pass stool-- and decreased appetite. 186. A The client is exhibiting clinical signs and symptoms of a myocardial infarction (MI); therefore, nursing care should focus on improving myocardial oxygenation and reducing cardiac workload. Confirming the diagnosis of MI and preventing complications, reducing anxiety and relieving pain, and providing a nondemanding environment are secondary to improving myocardial oxygenation and reducing workload. Stressors can't be eliminated, only reduced. 187. A Contact dermatitis is caused by exposure to a physical or chemical allergen, such as cleaning products, skin care products, and latex gloves. Initial symptoms of itching, erythema, and raised papules occur at the site of exposure and can begin within 1 hour of exposure. Allergic reactions tend to be red and not scaly or flaky. Weeping, crusting lesions are also uncommon unless the reaction is quite severe or has been present for a long time. Excoriation is more common in skin disorders associated with a moist environment. 188. C Aminoglycosides such as gentamicin have a narrow range between therapeutic and toxic serum levels. A serum peak and trough level (taken half an hour before the dose and half an hour after the dose has been administered) around the third dose (the third dose provides enough medication build up in the blood stream to be measured) is the most accurate way to determine the correct serum values. A trough level every morning, a serum peak level after the second dose, and serial serum trough levels won't provide sufficient data about the effectiveness of the antibiotic. 189. B The nurse should wear gloves and a gown when removing the client's bedpan because the type A hepatitis virus occurs in stools. It may also occur in blood, nasotracheal secretions, and urine. Type A hepatitis isn't transmitted through the air by way of droplets. Special precautions aren't needed when feeding the client, but disposable utensils should be used. 190. C During fasciotomy, the fascia is opened along the length of the muscle compartment and the skin is left open to prevent further compression from swelling. Sterile dressings are applied but without applying pressure. The wound is watched closely, and usually the compartment can be closed in 3 to 5 days. When the wound is closed, it may be sutured or secured with tape. A skin graft may be needed to complete closure at a later date. 191. C Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood. 192. D A hallucination is a sensory perception, such as hearing voices or seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling his ideas or behavior. 193. D The nurse's first priority is to consider the safety of the clients in the therapeutic setting. The other actions are appropriate responses after ensuring the safety of other individuals. 194. C The nurse, for her own protection, should be aware of hospital security and other assisting personnel. The other options may cause a relatively docile client to become belligerent. 195. A Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and occurs from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia. 196. C Cardiac tamponade is associated with decreased cardiac output, resulting in decreased blood pressure. Removing a small amount of blood may improve cardiac output and blood pressure. Pericardial blood doesn't clot rapidly because it's defibrinated by cardiac motion within the cardiac sac. If blood clots rapidly, the needle may have entered the heart. Clients with cardiac tamponade may have muffled heart sounds. If pericardiocentesis is effective, heart sounds become normal. 197. C Oxygen should be humidified to assure that irritation of the mucosa doesn't occur. This teen's platelet level is decreased, so she's at risk for bleeding. The nose is a vascular region that can bleed easily if the mucosa is dried by the oxygen. A sign to remind others to avoid needle sticks and to not give anything via the rectum, the presence of two peripheral IVs, and the use of a tympanic temperature device are all aspects of care that would decrease the client's risk of bleeding. 198. A A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem. 199. C Restraints should never be used on a child with a seizure disorder because they could harm him if a seizure occurs. Padded side rails will prevent the child from injuring himself during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Cardiopulmonary monitoring should be readily available for checking vital signs during a seizure. 200. D Angina pectoris is chest pain caused by a decreased oxygen supply to the myocardium. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and can precipitate angina. Anginal pain typically is self-limiting and lasts 5 to 15 minutes. Food consumption doesn't reduce this pain, but may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain. 201. B At age 3, children like to color, draw, and put together puzzles. A bicycle is appropriate for a 5- or 6-year-old child; a pull toy, for a toddler; and a computer game, for a school-age child. 202. D The nursing actions described constitute evaluation of expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the client's history, physical examination, and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the plan of care into actiorn. 203. D All of the instructions are appropriate, but knowing whether the child is ready to toilet train is initially most appropriate. Many 17-month-olds don't have the neuromuscular control to be able to be trained. Waiting a few more months until the child is closer to age 2 years allows the child to develop more control. The mother should be taught the signs of readiness for toilet training. 204. C Soft restraints from the upper arm to the wrist prevent the infant from touching his lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such objects as pacifiers, suction catheters, and small spoons shouldn't be placed in a baby's mouth after cleft palate repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair. Dried blood collecting on the suture line can widen the scar. 205. B To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that tend to increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client doesn't need to limit fluids with meals as long as the fluids aren't gastric irritants. 206. B SIADH causes antidiuretic hormone overproduction and leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, which is signaled by neck vein distention. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. 207. D Engorgement in a breast-feeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Binding the breasts isn't appropriate because the constriction will diminish the milk supply. Frozen cabbage leaves work well to reduce the pain and swelling and should be applied every 4 hours. Facing the shower head can stimulate the breasts and intensify the problem. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant. 208. C ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it doesn't cause ARDS. Renal failure also doesn't cause ARDS. 209. A Late deceleration is caused by uteroplacental insufficiency. Early deceleration is caused by head compression, and variable deceleration is caused by umbilical cord compression. Fetal acceleration is a sign of fetal well-being. 210. D Fetal defects can occur during the first trimester of pregnancy if the pregnant woman gets rubella. Aspirin shouldn't be given to young children because it has been implicated in the development of Reye's syndrome. Tylenol should be used instead. Rubella immunization isn't recommended for children until age 12 to 15 months. Exposure to rubella doesn't affect a woman's ability to breast-feed. 211. A As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba). The other options are incorrect. 212. B The nurse should encourage the client to increase her fluid intake to approximately 3 qt (3 L)/day for 24 to 48 hours. The headache is most likely due to decreased cerebrospinal fluid (CSF) circulating around the cranium. This fluid loss allows the brain to move abnormally within the skull. The movement causes tension on the meninges and venous sinuses, causing pain. Extra oral fluid intake will increase CSF production. Lying flat may decrease pain, and raising the head of the bed may worsen the headache. 213. D Normally, urine appears light yellow; dark amber urine is concentrated and, in this client, suggests continued fluid volume deficit. The serum sodium level normally ranges from 135 to 145 mEq/L. A temperature of 99.6°F is only slightly elevated and doesn't indicate fluid volume deficit. Neck vein distention is a sign of fluid volume overload. 214. A These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions won't improve the contraction pattern, free a trapped cord, or improve maternal comfort. 215. A A 10-mm induration strongly suggests a positive response in this tuberculosis screening test--so, a 15-mm induration clearly requires further evaluation. The remaining options aren't positive reactions to the test and require no further evaluation. 216. A Option A redirects the client to focus his comments and allows him to make his point. Option B is judgmental, and option C doesn't help facilitate communication. Option D focuses more on the nurse than on the client's need. 217. A An Apgar score of 8 indicates that the neonate has macte a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress. 218. A Frequent assessment of weight provides important information about fluid balance and the infant's response to fluid replacement. Results of stool or urine analyses may provide information, but they're typically not available for at least 24 hours. The posterior fontanel usually closes between ages 6 and 8 weeks and therefore doesn't reflect fluid balance in a 9-month-old infant. 219. C In a client with chronic renal failure, unrestricted intake of sodium, protein, potassium, and fluids may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit his intake of sodium, meat (high in protein), bananas (high in potassium), and fluid because the kidneys can't secrete adequate urine. 220. D Potassium iodide reduces the vascularity of the thyroid gland and is used to prepare the gland for surgery. Potassium iodide reaches its maximum effect in 1 to 2 weeks. PTU blocks the conversion of thyroxine to triiodothyronine, the more biologically active thyroid hormone. PTU effects are also seen in 1 to 2 weeks. To relieve symptoms of hyperthyroidism in the interim, clients are usually given a beta-adrenergic blocker such as propranolol. 221. A Cognitive distortions are similar in both disorders. Rarely do people with eating disorders have relaxed personalities. The anorectic client is more likely than the bulimic client to overexercise for weight control. 222. A According to the Denver II Developmental Screening test, most infants should be able to sit unsupported by age 7 months. A 15- month-old child should be able to say two words. By 17 months, the toddler should be able to feed himself with a spoon. A 10- month-old should be able to play patty-cake. 223. C Pericarditis is an inflammation of the fibroserous sac that envelops the heart. Unlike the pain of an MI, pericardial pain is commonly pleuritie and eases when the heart is pulled away from the diaphragmatic pleurae of the lungs. The hallmark indication of endocarditis is intermittent fever and malaise resulting from infection of the endocardium. Myocarditis has nonspecific symptoms that reflect the accompanying systemic infection. 224. C An IABP inflates during diastole when the tricuspid and mitral valves are open and the aortic and pulmonic valves are closed. 225. D Unilateral hearing loss that occurs over an extended time and tinnitus are classic signs and symptoms of an acoustic neuroma. Amenorrhea, obesity, and acromegaly are signs of a pituitary tumor. Ataxia and intention tremors are seen with a cerebellar brain tumor. 226. C Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours per day during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a balanced diet, calcium supplements or additional servings of high-calcium foods may be unnecessary. 227. B In cystic fibrosis, the small intestine becomes blocked with thick meconium; therefore, meconium ileus is the earliest indication that a neonate has the disorder. Steatorrhea may be present later and may be used as a guideline for administration of pancreatic enzymes. Infants and children with this disorder have increased sodium levels, and rhinorrhea isn't usually present. 228. DC. difficile can be transmitted from person to person by hands or waste containers such as a bedpan. When in direct contact with the client, the nurse should practice contact isolation, which includes wearing gloves and a gown. Protective isolation is used to protect a client who is immunocompromised, which isn't evident in this case. Neutropenic precautions are for clients with an absolute neutrophil count of 1,000/μL or less; this isn't evident in this case. A negative-pressure room is used when the organism is spread by the airborne route, which isn't true of C. difficile diarrhea. 229. D Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia. 230. C Administration of an antiemetic, such as metoclopramide, and an anti-inflammatory, such as dexamethasone, can reduce the severity of chemotherapy-induced nausea and vomiting. This in turn, helps prevent dehydration, a common complication of chemotherapy. The remaining options are unlikely to be as successful' in achieving this outcome. 231. D By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytoxics may be ordered to promote sustained uterine contraction. 232. B Postoperatively, the client should have nothing by mouth until peristaltic activity returns, to decrease the risk of abdominal distention and obstruction. The client will probably require pain medication more often then every 6 hours. The client should be positioned for comfort (not necessarily the high Fowler position). The NG tube isn't flushed, to avoid disturbing the suture line. 233. B Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Assessing the temperature every 8 hours isn't frequent enough for a client with a fever. Monitoring fluid intake and output may be required, but the client should be placed in isolation first. The nurse should only wear gloves for contact with mucous membranes, broken skin, blood, and body fluids and substances. 234. B A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged. 235. C Because the IV route doesn't allow chemotherapeutic agents to reach all areas invaded by leukemic cells, this medication is administered intrathecally to ensure the entire body receives treatment. Although this medication may be given by mouth, IM, or IV, these routes would be inappropriate in this situation. 236. C The nurse should ensure that the client understands that a stoma will be formed and that he'll need to wear a pouch. The nurse will care for the stoma immediately after surgery; self-care will begin when the client is physically able. The client will be encouraged to get out of bed the first day after surgery to prevent complications of immobility. Urine flow can't be controlled through a stoma. 237. B When talking with adolescents, it's best to get their viewpoints and thoughts first. Doing so promotes therapeutic communication. Asking whether the mother knows or about the baby's father focuses the attention away from the adolescent. Making a statement about her being too young to be pregnant is a value judgment and inappropriate. 238. D Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary. 239. C Caffeine is a stimulant, which can exacerbate palpitations and should be avoided by a client with symptomatic mitral valve prolapse. High-fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren't restricted but high- calorie foods are. 240. B Diarrhea is a common physiological response to stress and anxiety. The other choices could also be related to stress and anxiety but they don't occur as commonly as diarrhea. 241. B The nurse shouldn't invite his clergyman to visit the client, unless the client specifically asks to see that member of the clergy. Acknowledging the client's spiritual distress may help the nurse build a therapeutic relationship with the client. Encouraging the client to discuss religious beliefs and practices is a first step in developing a plan for the client. Encouraging the client to discuss his concerns with the clergy is also appropriate. 242. D The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall diet intake to control her blood glucose level. Oral antidiabetic drugs aren't used in pregnant females. Urine sugars aren't an accurate indication of blood glucose levels. 243. A An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur. 244. D The client should be encouraged to consume foods high in vitamin C because it's essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport. 245. C Although weight loss may be greater than 10%, the most important assessments must include those addressing the problem of a rising bilirubin. Neonates who develop severe jaundice as a result of Rh and ABO incompatibility will exhibit lethargy or irritability and poor feeding patterns. If bilirubin levels are high enough to cross the blood brain barrier (usually 20 mg and higher), the neonate is at serious risk for neurologic impairment due to permanent cell damage (kernieterus). 246. D To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees. 247. C The child with Down syndrome may have difficulty coping with painful procedures and may regress during his illness. Holding, rocking, and giving the child a security object may be comforting to the child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; but the success of these tactics depends on the child. 248. B Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. 249. C A universal concern in the care of donor sites for burn care is to keep the site away from sources of pressure. Ventilation of the site and keeping the site fully covered are practices in some institutions but aren't hallmarks of donor site care. Placing the site in a position of dependence isn't a justified aspect of donor site care. 250. A In the scenario, airway and breathing are established so the nurse's next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site. Neurologic assessment is a secondary concern to airway, breathing, and circulation. The nurse doesn't have enough data to warrant putting the client in Trendelenburg's position. 251. A The nurse should designate times during which the client can focus on compulsive behavior or obsessive thoughts. Frequency of the compulsive behavior should be reduced gradually, not rapidly. The nurse shouldn't call attention to or prevent the behavior; doing so may cause pain and terror in the client. Encouraging the client to verbalize anxieties may help distract his attention from the compulsive behavior. 252. D The bladder isn't usually palpable unless it's distended. The feeling of pressure is usually relieved with urination. Reduced bladder tone due to general anesthesia is a common postoperative complication that causes difficulty in voiding. A urinary tract infection and renal calculi aren't palpable. The kidneys aren't palpable above the symphysis pubis. 253. A Appropriate-for gestational-age neonate weights fall between the 10th and the 90th percentiles for age. Large-for- gestational-age weight is above the 90th percentile, and small-for- gestational-age is below the 10th percentile for age. 254. A Exploring genitalia is normal for a school-age child, and this behavior shouldn't be characterized as "bad. " Disciplining the child for the behavior may have an adverse affect on his psychosocial development. Instructing the parent to "ignore it and hope that he outgrows it" is subtly implying that the child's behavior should be of concern if it doesn't stop by a certain age. Supervising a 6-year- old's bath won't foster the child's initiative, which is the developmental milestone for school-age children. 255. B Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to the body prevents leaning. Use of a cane won't maintain stride length or prevent edema. 256. D Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't a preexisting condition of colorectal cancer. Weight loss--not gain--is an indication of colorectal cancer. 257. D Neonates delivered by cesarean birth without any other contributing factors should have adequate stores of brown fat to control blood glucose levels. Stores of brown fat aren't deposited until 36 weeks, so infants born at less than 36 weeks won't have the necessary stores to maintain a normal blood glucose level. Neonates who have respiratory distress or are postdated will use up their stores of brown fat as a result of these complications. 258. A An NG tube that fails to drain during the postoperative period after gastrectomy should be reported to the physician immediately. The tube may be occluded, which could increase pressure on the suture line because fluid isn't draining adequately. Repositioning or irrigating the tube in a client who has bad gastric surgery can disrupt the anastamosis. Increasing the level of suction may cause trauma to GI mucosa or the suture line. 259. D The anterior fontanel is formed by the junction of the sagittal, frontal, and coronal sutures. It's shaped like a diamond and normally measures 4 to 5 cm as its widest point. A widened,bulging fontanel is a sign of increased ICP. 260. A 261. B 262. A 263. B 264. B 265. A The nurse should objectively document her assessment findings. A detailed description of physical findings of abuse in the medical record is essential if legal action is pursued. All women suspected to be victims of abuse should be counseled on a safety plan, which consists of recognizing escalating violence within the family and formulating a plan to exit quickly. The nurse should not report this suspicion of abuse because the client is a competent adult who has the right to self-determination. Nurses do, however, have a duty to report cases of actual or suspected abuse in children or elderly clients. Contacting the client's husband without her consent violates confidentiality. The nurse should respond to the client in a non- threatening manner that promotes trust, rather than ordering her to break off her relationship.
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