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Psychosocial Adaptation NCLEX Review Questions Answers and Rationale

admin — Mon, 06 Sep 2010 02:06:53 +0000

1.    Answer D. Diaphoresis and tremors occur in the first phase of alcohol withdrawal. The blood pressure and heart rate increase in the first phase of alcohol withdrawal. Illusions are common in persons withdrawing from alcohol. Illusions occur most often in dim artificial lighting where the environment is not perceived accurately. Delusions of grandeur are symptomatic of manic clients, not clients withdrawing from alcohol. The symptoms and history of alcohol abuse suggest this client is in alcohol withdrawal.
2.    Answer D. Food and fluids are necessary. However, Mr. Wilson’s hyperactivity does not allow him to sit quietly to eat. Finger foods "on the run” will provide needed nourishment. When hyperactivity decreases, then approach Mr. Wilson’s. regarding hygiene and grooming needs. Medications will be ordered. However, a thorough evaluation must be done first. Mr. Wilson has been assaultive with the landlord and it is reasonable to expect that he may be with peers and staff. His mental illness produces a hyperactive state and poor judgment and impulse control. External controls such as limiting of unit privileges will assist in feelings of security and safety.
3.    Answer B. Reduced levels of anxiety do not indicate an improvement in depressive symptoms. Vegetative signs such as insomnia, anorexia, psychomotor retardation, constipation, diminished libido, and poor concentration are biological responses to depression. Improvement in these signs indicates a lifting of the depression. Compliance with medications does not indicate improvement in depression. Requests to talk to the nurse vary. Requests may show trust in the nurse but are not a sign that depression has diminished.
4.    Answer C. An underlying depression does not cause sundown syndrome. There is not sufficient evidence to suggest he has inadequate cerebral blood flow. Because the confusion occurs at sundown, the cause is probably changes in the sensory environment. Sundown syndrome is related to environmental and sensory abnormalities that lead to acute confusion. Fluctuating levels of oxygen exchange do not cause sundown syndrome.
5.    Answer A. Beneficial effects of ECT usually are evident after the first several treatments. Since treatments are administered at intervals of 48 hours, these effects are apparent after one week of therapy. Beneficial effects of ECT therapy are usually seen before three weeks. It takes three to four weeks for tricyclic antidepressants to take effect. Beneficial effects of ECT therapy are usually seen before four weeks. It takes three to four weeks for tricyclic antidepressants to take effect. Beneficial effects of ECT therapy are usually seen after the first few treatments.
6.    Answer D. Information about mood changes is important to assess, as bulimia is often associated with affective disorders. Family functioning is the most essential point to assess, as it reveals if binge eating is triggered by conflict within the family. Information about ability to socialize with peers is important to assess, as it is possible the problem initiated with peer relationships. It is inappropriate to ask about her sexual relationships.
7.    Answer D. Indecisiveness and fear of being wrong are common in depression. Depression creates feelings that nothing will ever improve. The risk of depression is increased when there is a family history. Interest in sex is markedly decreased in depression.
8.    Answer A. The ability to use relaxation is basic to treatment of phobia. Clients with phobias are resistant to insight therapy. Riding the elevator accompanied by the nurse is an appropriate long-term goal. Role playing may be appropriate after the client has learned relaxation.
9.    Answer C. This is an open-ended question which is nonjudgemental and allows for further discussion. The topic is also nonthreatening yet will give the nurse insight into the client’’s view of events leading up to admission. It is the only option that is client centered. The other options focus on the pills.
10.    Answer D. Infant baptism is madatory in the Roman Catholic belief especially if a neonate is not expected to live. Anyone may perform this if an infant or child is gravely ill. Option A refers to the Christian Science belief. Option B is a belief of Russian Orthodoxy. Mormons believe of devine healing with the laying on of hands, as represented in option C.
11.    Answer D. Victims develop a high tolerance for abuse. They blame themselves for being victimized. All members in the family suffer from the effects of abuse, even if they are not the actual victims. For these reasons, victims often have an extensive history of abuse and struggle for a long time before they can leave permanently.
12.    Answer A. Giving broad opening statements and making observations are examples of therapeutic communication. The other options are too specific or focused to be therapeutic.
13.    Answer C. Activity groups are used to enhance the therapeutic milieu and to meet the clinical and social needs of clients, e.g., to minimize withdrawal and regression, to develop self care skills, etc.
14.    Answer D. This gradually engages the client in interactions with others and uses positive behavioral expectation.
15.    Answer D. This type of identification band easily tracks the client’s movements and ensures safety while wandering on the unit.
16.    Answer C. This actions presents reality.
17.    Answer D. Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan.
18.    Answer B. When learning to manage stress, it is helpful to believe that one has the ability to control one’s response to stress. It is impossible to avoid stress, which is a normal experience. Stress can be positive and growth enhancing as well as harmful. The belief that one has some control can minimize the stress response.
19.    Answer C. Nonverbal, gentle touch is an important tool here. Providing appropriate forms of touch to reinforce caring feelings. Because tactile contacts vary considerably among individuals, families, and cultures, the nurse must be sensitive to the differences in attitudes and practices of clients and self.
20.    Answer D. A dispositional crisis is a response to an external situational crisis. External anger at work is the dispositional crisis displaced to his wife through abuse. An anticipated life transition crisis is a crisis that is normal in the life cycle; transitional is one over which the person has no control. Developmental crisis occurs in response to triggering emotions related to unresolved conflict in one’s life. This is called a developmental crisis based on Freudian psychology. Psychiatric emergency crisis is when the individual’s general functioning has been severely impaired, and the individual has been rendered incompetent.

Psychosocial Adaptation NCLEX Review Questions

admin — Sat, 04 Sep 2010 03:50:06 +0000

1.    A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission, he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience?
a.    Diaphoresis and tremors.
b.    Increased blood pressure and heart rate.
c.    Illusions.
d.    Delusions of grandeur.

2.    Mr. Wilson, 35, is admitted for bipolar illness, manic phase, after assaulting his landlord in an argument over Mr. Wilson’s staying up all night playing loud music. Mr. Wilson’s is hyperactive, intrusive, and has rapid, pressured speech. He has not slept in three days and appears thin and disheveled. Which of the following is the most essential nursing action at this time?
a.    Providing a meal and beverage for Mr. Wilson to eat in the dining room.
b.    Providing linens and toiletries for Mr. Wilson to attend to his hygiene.
c.    Consulting with the psychiatrist to order a hypnotic to promote sleep.
d.    Providing for client safety by limiting his privileges.

3.    Which of the following would best indicate to the nurse that a depressed client is improving?
a.    Reduced levels of anxiety.
b.    Changes in vegetative signs.
c.    Compliance with medications.
d.    Requests to talk to the nurse.

4.    An elderly man is admitted to the hospital. He was alert and oriented during the admission interview. However, his family states that he becomes disruptive and disoriented around dinnertime. One night he was shouting furiously and didn’t know where he was. He was sedated and the next morning he was fine. At dinnertime the disruptive behavior returned. The client is diagnosed as having sundown syndrome. The client’s son asks the nurse what causes sundown syndrome. The nurse’s best response is that it is attributed to
a.    an underlying depression.
b.    inadequate cerebral flow.
c.    changes in the sensory environment.
d.    fluctuating levels of oxygen exchange.

5.    The nurse is discussing electroconvulsive therapy (ECT) with a client who asks how long it will be before she feels better. The nurse explains that the beneficial effects of ECT usually occur within
a.    one week.
b.    three weeks.
c.    four weeks.
d.    six weeks.

6.    The nurse is assessing a 17-year-old female who is admitted to the eating disorders unit with a history of weight fluctuation, abdominal pain, teeth erosion, receding gums, and bad breath. She states that her health has been a problem but there are no other concerns in her life. Which of the following assessments will be the least useful as the nurse develops the care plan?
a.    Information regarding recent mood changes.
b.    Family functioning using a genogram.
c.    Ability to socialize with peers.
d.    Whether she has a sexual relationship with a boyfriend.

7.    A 34-year-old woman is admitted for treatment of depression. Which of these symptoms would the nurse be least likely to find in the initial assessment?
a.    inability to make decisions.
b.    feelings of hopelessness.
c.    family history of depression.
d.    increased interest in sex.

8.    The nurse is planning care for a client who has a phobic disorder manifested by a fear of elevators. Which goal would need to be accomplished first? The client
a.    demonstrates the relaxation response when asked.
b.    verbalizes the underlying cause of the disorder.
c.    rides the elevator in the company of the nurse.
d.    role plays the use of an elevator.

9.    A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be
a.    "These pills aren’t antacids since they are all different."
b.    "Some teenagers use pills to lose weight."
c.    "Tell me about your week prior to being admitted."
d.    "Are you taking pills to change your weight?"

10.    A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do?
a.    The refusal of any treatment for self and the neonate until she talks to a reader
b.    The placement of a rosary necklace around the neonate’s neck and not to remove it unless absolutely necessary
c.    Arrange for a church elder to be at the emergency department when the ambulance arrives so a "laying on hands" can be done
d.    Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen."

11.    Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence?
a.    "I am determined to leave my house in a week."
b.    "No one else in the family has been treated like this."
c.    "I have only been married for 2 months."
d.    "I have tried leaving, but have always gone back."

12.    Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?
a.    "You look upset. Would you like to talk about it?"
b.    "I’d like to know more about your family. Tell me about them."
c.    "I understand that you lost your partner. I don’t think I could go on if that happened to me."
d.    "You look very sad. How long have you been this way?"

13.    When planning the therapeutic milieu, it is MOST important to select group activities which
a.    Match the clients’ preferences
b.    Are consistent with clients’ skills
c.    Achieve clients’ therapeutic goals
d.    Build skills of group participation

14.    A client was admitted to the psychiatric unit for severe depression. After several days, the client continues to withdraw from other clients. Which of the following would be the MOST appropriate statement by the nurse to promote interaction with other clients?
a.    "Your doctor thinks its good for you to spend time with others."
b.    "It is important for you to participate in group activities."
c.    "Painting this picture will help you feel better."
d.    "Come play Chinese Checkers with Gerry and me."

15.    The nurse can BEST ensure the safety of a demented client who wanders from the room by
a.    Repeatedly reminding the client of time and place
b.    Explaining the risks of becoming lost
c.    Using soft restraints
d.    Attaching a wander-guard sensor band to the client’s wrist

16.    A client with paranoid thoughts refuses to eat because he believes the food is poisoned. The MOST appropriate initial action is to
a.    Taste the food in the client’s presence
b.    Suggest that food be brought from home
c.    Simply state the food is not poisoned
d.    Inform the client he will be tube fed if he does not eat

17.    The nurse is caring for a severely depressed client who has just been admitted to the in-client psychiatric unit. Which of the following is a PRIORITY of care?
a.    Nutrition
b.    Elimination
c.    Rest
d.    Safety

18.    A nurse is teaching a stress-management program for client. Which of the following beliefs will the nurse advocate as a method of coping with stressful life events?
a.    Avoidance of stress is an important goal for living.
b.    Control over one’s response to stress is possible.
c.    Most people have no control over their level of stress.
d.    Significant others are important to provide care and concern.

19.    A student nurse is caring for a 75-year-old client who is very confused. The student’s communication tools should include:
a.    written directions for bathing.
b.    speaking very loudly.
c.    gentle touch while guiding ADLs (activities of daily living).
d.    flat facial expression.

20.    When a husband takes out his work frustrations and anger by abusing his wife at home, the nurse would identify this crisis as which type?
a.    psychiatric emergency crisis
b.    developmental crisis
c.    anticipated life transition
d.    dispositional crisis

Answer and Rationale will be posted soon…

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Psychosocial Adaptation NCLEX Review Questions Answers and Rationale View Questions 1. Answer D. Diaphoresis and tremors occur in...
Physiological Adaptation NCLEX RN Practice Test 1. An adult with chronic renal failure is receiving peritoneal...

Physiological Adaptation NCLEX RN Practice Test Answers and Rationale

admin — Thu, 26 Aug 2010 05:22:40 +0000

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1.    Answer C. Hemodilution can produce a drop in hematocrit. However, if the cause of the decrease in hematocrit were fluid retention, one would expect to find corresponding decreases in serum sodium. If the dialysis has corrected the electrolyte balance, it is unlikely that the client would retain sufficient fluid to cause this drop in hematocrit. Hemodilution does not usually produce such a drop in hemoglobin. The cause of anemia in persons with chronic renal failure is lack of erythropoietin. Erythropoietin produced by the kidneys is necessary to stimulate the bone marrow to produce red blood cells. In chronic renal failure this hormone is not produced. Hemolysis does not occur with peritoneal dialysis because red blood cells do not move outside the client’s own blood vessels, so there are no mechanical forces to harm them.
2.    Answer A. A comminuted fracture usually results from a crush injury and results in fractured and crushed bones. The bone is broken in several places. A displaced bone occurs when the two ends of the fractured bone are pulled apart and separated from each other. A compound or open fracture occurs when the bone has been broken in two and one end of the bone breaks through the skin. A greenstick or incomplete fracture is when only one side of the bone is broken. A greenstick fracture happens in children whose bones are still soft.
3.    Answer B. Cool, clammy skin is seen in hypoglycemia. Ketoacidosis causes dehydration that results in flushed, dry skin. Diaphoresis is seen in hypoglycemia. Silky skin is not seen in ketoacidosis.
4.    Answer D. Bronchi normally expand and lengthen during inspiration and shorten during expiration. Asthma causes spasm of the smooth muscles in the bronchi and bronchioles, resulting in an even tighter airway on exhalation and prolonged exhalation. Inspirations increase in rate in an effort to relieve hypoxia. At the beginning of the attack, the cough is nonproductive and results from bronchial edema. Then the mucus becomes profuse and rattly, with a cough producing frothy, clear sputum. Gas trapping is the central feature of asthma. It is caused by allowing more air to enter alveoli than can escape from them through the narrowed airways. Gas trapping also causes an increased depth and rate of respirations. The wheeze starts during the expiratory phase because of the extreme narrowing of the bronchus on exhalation. As obstruction increases, wheezes become more high pitched and continuous.
5.    Answer D. Weakness and fatigue are common in congestive heart failure. Dyspnea is common in congestive heart failure. Tachycardia is common in congestive heart failure. Oliguria is not usually seen in congestive heart failure. Diuretics are a mainstay treatment in congestive heart failure. The nurse would expect urine output. Weakness, fatigue, dyspnea, and tachycardia are clinical manifestations of congestive heart failure.
6.    Answer B. Blood pressure is generally not elevated in nephrotic syndrome except in a child with severe renal insufficiency. A normal blood pressure in a two-and-a-half-year-old should be between 80 and 85 systolic and 50 and 60 diastolic. In nephrotic syndrome (nephrosis) plasma proteins are excreted in the urine due to an abnormal permeability of the glomerular basement membrane of the kidney to protein molecules, particularly albumin. The cause of nephrosis is unknown. The average age of onset is two and a half years and it is more common in boys than girls. Dark urine is not seen in nephrotic syndrome. A history of a streptococcal infection is associated with glomerulonephritis.
7.    Answer C. While low serum albumin is common with liver disease, it does not weaken the existing structures of the body. Weakness of the esophageal wall is not the problem. Since the esophageal vessels lie close to the surface, under the mucous membranes, the esophageal wall does not support them at the inner surface. The liver is located to the right of the esophagus. When it enlarges, it is more likely to compromise expansion of the right lung than to affect the esophagus. The fibrosed liver obstructs flow through portal vessels, which normally receive all blood circulating from the gastrointestinal tract. The increased pressure in portal vessels shunts some of the blood into the lower pressure veins around the lower esophagus. Since these veins are not designed to handle the high-pressure portal blood flow, they develop varicosities, which often rupture and bleed. Enlargement of the liver does not displace the esophagus.
8.    Answer A. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Sepsis is unlikely with a closed head injury. The assessments are classic for hypothalamus injury. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Normal saline is isotonic and would not cause these fluid shifts.
9.    Answer C. The major pulmonary problem with CF is thick tenacious secretions. CPT moves the secretions from the small airways to the large where they can be coughed out. Options a and b are used but are secondary to option c; the oral enzymes that CF patients take are for digestion, not pulmonary reasons.
10.    Answer A. Until the lung incision seals, there will be air leaking from it, which will be collected and drained by the chest tube; option b would be correct if the air leak had stopped and later reappeared; the suction control chamber is separate from the water seal chamber in a typical chest drainage device.
11.    Answer D. Smaller more frequent meals help decrease reflux. The patient shouldn’t eat within 3 hours of bedtime; her head should be elevated-either put bed up on 6-inch blocks or use a wedge; alcohol is contraindicated-it relaxes the GE sphincter and increases reflux.
12.    Answer A. Opioids slow transit through the GI tract; older patients and those being treated chronically are at increased risk. Opioids slow not speed transit through the GI tract; patients with chronic pain often lack appetite from their pain and will eat better when it is relieved; nausea, not heartburn is often seen in the upper GI tract with opioid usage.
13.    Answer C. These clients have a potential for an inability to have voluntary and involuntary muscle movement or activity. Thus, options a and b are inadequate with this problem in mind. Option d is not specific for prevention of complications associated with the lung.
14.    Answer A. Until the health care provider has determined that your ejaculate doesn”t contain sperm, continue to use another form of contraception. All of these options are correct information. The most important point to reinforce is the need to take additional actions for birth control.
15.    Answer A. S3 ventricular gallop      An S3 ventricular gallop is caused by blood flowing rapidly into a distended non-compliant ventricle. Most common with congestive heart failure.
16.    Answer C. Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse or to leave the room for equipment. The client’s advanced directives should have been filed on admission and choices known prior to starting CPR.
17.    Answer D. In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining 3 choices indicate mild fluid overload and are not medical emergencies.
18.    Answer: B. Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.
19.    Answer B. In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia.
20.    Answer B. All of the questions should be asked. However, the one about the problem is the most important to start with at this time.

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Physiological Adaptation NCLEX RN Practice Test

admin — Mon, 23 Aug 2010 03:02:47 +0000

1.    An adult with chronic renal failure is receiving peritoneal dialysis. His acid-base balance and electrolyte levels are now within normal limits. His hemoglobin is 9.2 and his hematocrit is 30. The most likely cause of his anemia is:
a.    hemodilution secondary to fluid retention.
b.    eating insufficient protein due to taste changes that occur with dialysis.
c.    failure of his kidneys to produce the hormone necessary to stimulate bone marrow to produce red blood cells.
d.    hemolysis of red blood cells as they move past the membrane containing the dialysis solution.

2.    An adult client has a comminuted fracture of the ulnar bone. He asks the nurse what type of fracture this is. The nurse’s response is based on which of these understandings?
a.    The ulnar bone has been crushed and broken in several places.
b.    The two ends of the fractured ulnar bone are pulled apart and separated from each other.
c.    The ulnar bone has been broken in two and one end of the bone broke through the skin.
d.    Only one side of the ulnar bone is broken.

3.    The nurse is assessing a client admitted in ketoacidosis. The nurse can expect the client’s skin to be:
a.    clammy.
b.    flushed.
c.    diaphoretic.
d.    silky.

4.    A child has been brought to the emergency room with an asthma attack. What signs and symptoms would the nurse expect to see?
a.    A prolonged inspiratory time and a short expiratory time.
b.    Frequent productive coughing of clear, frothy, thin mucus progressing to thick, tenacious mucus heard only on auscultation.
c.    Hypoinflation of the alveoli with resulting poor gas exchange from increasingly shallow inspirations.
d.    Swelling of the bronchial mucosa, with wheezes starting on expiration and spreading to continuous.

5.    The nurse is assisting a child with congestive heart failure. Which of the following would the child be least likely to manifest?
a.    Weakness and fatigue.
b.    Dyspnea.
c.    Tachycardia.
d.    Oliguria.

6.    A child who is two years and six months old has had one bout of nephrosis (nephrotic syndrome). His mother suspected a recurrence when she observed swelling around his eyes. The nurse helps to confirm this condition by recognizing what additional symptom?
a.    Blood pressure of 140/90.
b.    Marked proteinuria.
c.    Cola-colored urine.
d.    A history of positive streptococcal infection.

7.    The nurse is caring for a client with cirrhosis of the liver who has developed esophageal varices. The nurse understands that the best explanation for development of esophageal varices is which of the following?
a.    Chronic low serum protein levels result in inadequate tissue repair, allowing the esophageal wall to weaken.
b.    The enlarged liver presses on the diaphragm, which in turn presses on the esophageal wall, causing collapse of blood vessels into the esophageal lumen.
c.    Increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to the esophageal vessels, increasing their pressure and causing varicosities.
d.    The enlarged liver displaces the esophagus toward the left, tearing the muscle layer of the esophageal blood vessels, which allows small aneurysms to form along the lower esophageal vessels.

8.    A client has a closed head injury. Vital signs are T 103°F rectally; pulse 100; respirations 24; B.P. 110/84. Hourly urine output is 200 ml/hr. What is the best understanding of the cause of these findings?
a.    Damage to the hypothalamus resulting in decreased hormone production.
b.    Movement of fluid from the tissue into the intravascular space, resulting from sepsis.
c.    An increase in antidiuretic hormone (ADH) as a result of injury to the hypothalamus.
d.    Fluid shifts from the tissue into the intravascular space due to administration of normal saline used during fluid resuscitation.

9.    One of the most important pulmonary treatments in cystic fibrosis is:
a.    inhaled beta agonists.
b.    inhaled corticosteroids.
c.    chest physiotherapy.
d.    oral enzymes.

10.    The RN is caring for a patient with a chest tube after a right upper lobectomy. On the day of surgery, the RN notes bubbling in the water-seal chamber. What is this, and what should the RN do?
a.    air leak, expected finding
b.    air leak, notify physician
c.    suction control, expected finding
d.    suction control, decrease wall suction

11.    The RN has finished teaching a patient about treatment of GERD. The RN knows the patient has understood the teaching if she states:
a.    “I should eat a small bedtime snack each night.”
b.    “I should lie flat in bed.”
c.    “I can have red wine with dinner.”
d.    “I should eat six small meals daily.”

12.    The nurse is caring for a 73-year-old patient with chronic pain being treated with opioids. One complication to be monitored for is:
a.    constipation.
b.    diarrhea.
c.    anorexia.
d.    heartburn.

13.    Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?
a.    Active and passive range of motion exercises twice a day
b.    Every 4 hours incentive spirometer
c.    Chest physiotherapy twice a day
d.    Repositioning every 2 hours around the clock

14.    A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?
a.    Until the health care provider has determined that your ejaculate doesn’t contain sperm, continue to use another form of contraception.
b.    This procedure doesn’t impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.
c.    Involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
d.    The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

15.    The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal
a.    S3 ventricular gallop
b.    Apical click
c.    Systolic murmur
d.    Split S2

16.    A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse?
a.    Relieve the nurse performing CPR
b.    Go get the code cart
c.    Participate with the compressions or breathing
d.    Validate the client’s advanced directive

17.    The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action?
a.    Lower extremity pitting edema
b.    Rales
c.    Jugular vein distension
d.    Weakness in left arm

18.    A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse’s priority should be
a.    Cover the areas with dry sterile dressings
b.    Assess for dyspnea or stridor
c.    Initiate intravenous therapy
d.    Administer pain medication

19.    Which these findings would the nurse more closely associate with anemia in a 10 month-old infant?
a.    Hemoglobin level of 12 g/dI
b.    Pale mucosa of the eyelids and lips
c.    Hypoactivity
d.    A heart rate between 140 to 160

20.    A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?
a.    What are you taking for pain and does it provide total relief?
b.    What does the skin on the testicles look and feel like?
c.    Do you have any questions about your care?
d.    Did you know a consequence of epididymitis is infertility?

Answers and Rationale

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admin — Thu, 12 Aug 2010 06:26:08 +0000

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1.    Answer B. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
2.    Answer D. Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest
3.    Answer D. Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.
4.    Answer B. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
5.    Answer B. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
6.    Answer A. The findings are indicative of circulatory impairment. The physician (or practitioner) must be notified immediately.
7.    Answer C. A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client’s death.
8.    Answer C. Reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the physician immediately. This is an emergency post surgical situation.
9.    Answer B. A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.
10.    Answer D. Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.
11.    Answer D. Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.
12.    Answer B. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
13.    Answer C. Client’s having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
14.    Answer C. Pulse oximetry should not be lower than 90.
15.    Answer B. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
16.    Answer B. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
17.    Answer B. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
18.    Answer B. Deep air excursion by turning, coughing, and deep breathing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.
19.    Answer B. A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could be as serious as seizures.
20.    Answer C. Loss of the pulse in the extremity would indicate impaired circulation.

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1.    When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
a.    Relaxation and sleep
b.    Deep breathing and coughing
c.    Incisional healing
d.    Range of motion exercises

2.    A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
a.    Clamp the chest tube
b.    Call the surgeon immediately
c.    Prepare for blood transfusion
d.    Continue to monitor the rate of drainage

3.    The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
a.    Blood urea nitrogen 50 mg/dl
b.    Hemoglobin of 10.3 mg/dl
c.    Venous blood pH 7.30
d.    Serum potassium 6 mEq/L

4.    The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
a.    Blanch nail beds for color and refill
b.    Assess for post operative arrhythmias
c.    Auscultate for pulmonary congestion
d.    Monitor equality of peripheral pulses

5.    A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
a.    “The tube will drain fluid from your chest.”
b.    “The tube will remove excess air from your chest.”
c.    “The tube controls the amount of air that enters your chest.”
d.    “The tube will seal the hole in your lung.”

6.    A four year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do FIRST?
a.    Notify the physician
b.    Readjust the traction
c.    Administer the ordered prn medication
d.    Reassess the foot in fifteen minutes

7.    A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 L/min, his color is flushed and his respirations are 8/min. What should the nurse do FIRST?
a.    Obtain a 12-lead EKG
b.    Place client in high Fowler’s position
c.    Lower the oxygen rate
d.    Take baseline vital signs

8.    The nurse is assessing a client two hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s FIRST action should be to:
a.    Wrap the leg with elastic bandages
b.    Apply pressure at the bleeding site
c.    Reinforce the dressing and elevate the leg
d.    Remove the dressings and re-dress the incision

9.    The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the FIRST action the nurse should perform?
a.    Disconnect the client from the ventilator and use a manual resuscitation bag
b.    Perform a quick assessment of the client’s condition
c.    Call the respiratory therapist for help
d.    Press the alarm re-set button on the ventilator

10.    The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported IMMEDIATELY?
a.    Blood urea nitrogen 50 mg/dl
b.    Hemoglobin of 10.3 mg/dl
c.    Venous blood pH 7.30
d.    Serum potassium 6 mEq/L

11.    A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action?
a.    Clamp the chest tube
b.    Call the surgeon immediately
c.    Prepare for blood transfusion
d.    Continue to monitor the rate of drainage

12.    When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
a.    Relaxation and sleep
b.    Coughing and deep breathing
c.    Incisional healing
d.    Range of motion exercises

13.    The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
a.    Pallor
b.    Increased temperature
c.    Dyspnea
d.    Involuntary muscle spasms

14.    The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for IMMEDIATE action by the nurse?
a.    Breath sounds can be heard bilaterally
b.    Mist is visible in the T-Piece
c.    Pulse oximetery of 88
d.    Client is unable to speak

15.    A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take PRIORITY in planning care?
a.    Esophagitis
b.    Leukopenia
c.    Fatigue
d.    Skin irritation

16.    A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client?
a.    “The tube will drain fluid from your chest.”
b.    “The tube will remove excess air from your chest.”
c.    “The tube controls the amount of air that enters your chest.”
d.    “The tube will seal the hole in your lung.”

17.    The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a PRIORITY?
a.    Blanch nail beds for color and refill
b.    Assess for post operative arrhythmias
c.    Auscultate for pulmonary congestion
d.    Monitor equality of peripheral pulses

18.    The MOST effective nursing intervention to prevent atelectasis from developing in a post operative client is to:
a.    Maintain adequate hydration
b.    Assist client to turn, cough and deep breathe
c.    Ambulate client within 12 hours
d.    Splint incision

19.    The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?
a.    “I can’t lie in one position for more than thirty minutes.”
b.    “I am allergic to shrimp.”
c.    “I suffer from claustrophobia.”
d.    “I developed a severe headache after a spinal tap.”

20.    A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?
a.    Increased blood pressure
b.    Increased heart rate
c.    Loss of pulse in the extremity
d.    Decreased urine output

Answers and Rationale