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NEW QUESTION 363
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
- A. Teaching fifth-grade children the harmful effects of substance abuse
- B. Referring a client who has been on a detoxification unit to a rehabilitation center
- C. Counseling a client with post-traumatic stress disorder
- D. Crisis intervention with an intoxicated teenager whose mother just committed suicide
Answer: A
Explanation:
Section: Questions Set F
Explanation:
(A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
NEW QUESTION 364
The family member of a child scheduled for heart surgery states, "I just don't understand this open-heart or closed-heart business. I'm so confused! Can you help me understand it?" The nurse explains that patent ductus arteriosus repair is:
- A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed.
- B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.
- C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.
- D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine. (B) Patent ductus arteriosus is a ductus arteriosus that does not close shortlyafter birth but remains patent. Repair is a closed-heart procedure involving ligation of the patent ductus arteriosus. (C) Coronary artery bypass graft surgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts. (D) Percutaneous transluminal coronary angioplasty is a closedheart procedure that improves coronary blood flow by increasing the lumen size of narrowed vessels.
NEW QUESTION 365
A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?
- A. Oral poliovirus vaccine
- B. Hepatitis B vaccine
- C. Tetanus toxoid
- D. Inactivated poliovirus vaccine
Answer: C
Explanation:
(A) Oral poliovirus vaccine is given to prevent polio. Polio is transmitted by direct contact with an infected person. (B) Inactivated poliovirus vaccine is given to adults and immunosuppressed individuals. Polio is transmitted by direct contact with an infected person. (C) Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds. (D) Hepatitis B vaccine prevents hepatitis B infection. Hepatitis B is transmitted through contact with infected blood or body fluids.
NEW QUESTION 366
Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:
- A. Check the client's potassium level
- B. Assist the client to do range of motion exercises
- C. Administer the as-needed dose of phenytoin (Dilantin)
- D. Report the findings to the physician
Answer: D
Explanation:
Explanation
(A) Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. (B) Range of motion exercises are not appropriate topresenting symptoms. (C) These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. (D) Phenytoin is indicated for seizure activity mainly of neurological origin.
NEW QUESTION 367
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
- A. 2-2-0-2-2
- B. 3-2-0-0-2
- C. 3-1-1-0-2
- D. 2-1-1-0-2
Answer: C
Explanation:
Section: Questions Set B
Explanation:
(A) This answer is an incorrect application of the GTPAL method.
One prior pregnancy was a preterm birth at 36 weeks (T = 1, P = 1; not T = 2). (B) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T = 1, P = 1; not T = 2), and she has had no prior abortions (A = 0). (C) This answer is the correct application of GTPAL method. The client is currently pregnant for the third time (G = 3), her first pregnancy ended at term (>37 weeks) (T = 1), her second pregnancy ended preterm 20-33 weeks) (P = 1), she has no history of abortion (A = 0), and she has two living children (L = 2). (D) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2).
NEW QUESTION 368
Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:
- A. Reduce secretions
- B. Act as an anesthetic
- C. Relax muscles
- D. Relieve anxiety
Answer: C
Explanation:
Explanation
(A) Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure. (B) Succinylcholine chloride does not relieve anxiety. (C) Atropine is given to reduce secretions. (D) Thiamylal sodium (Surital) or other phenobarbital preparations are used as brief anesthetics.
NEW QUESTION 369
A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
- A. 5 mg
- B. 0.05 mg
- C. 20 mg
- D. 0.5 mg
Answer: A
Explanation:
Section: Questions Set C
Explanation:
(A) 1 mg = 0.1 mL, then 0.5 mL x = 55 mg. (B) Thisanswer is a miscalculation. (C) This answer is a miscalculation. (D) This answer is a miscalculation.
NEW QUESTION 370
When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurse's response should be based on the fact that:
- A. The client can be monitored while cardiac conditioning and heart toning are done
- B. Ischemia can be diagnosed because exercise increasesO2 consumption and demand
- C. The test provides a baseline for further tests
- D. The procedure simulates usual daily activity and myocardial performance
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The purpose of the study is not to provide a baseline for further tests. (B) The test causes an increase in O2 demand beyond that required to perform usual daily activities. (C) Monitoring does occur, but the test is not for the purpose of cardiac toning and conditioning. (D) Exercise ECG, or stress testing, is designed to elevate the peripheral and myocardial needs for O2 to evaluate the ability of the myocardium and coronary arteries to meet the additional demands.
NEW QUESTION 371
Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?
- A. Phenothiazines
- B. Anticholinergics
- C. Tricyclic agents
- D. Anti-Parkinsonian drugs
Answer: B
Explanation:
Explanation
(A) This answer is incorrect. Phenothiazines are antipsychotic drugs and produce the symptoms. (B) This answer is correct. Anticholinergic agents are often used prophylactically for extrapyramidal symptoms. They balance cholinergic activity in the basal ganglia of the brain. (C) This answer is incorrect. Anti- Parkinsonian drugs would increase the symptoms. (D) This answer is incorrect. Tricyclic agents are used for symptoms of depression.
NEW QUESTION 372
Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:
- A. The disorder is a threat to his physical well-being
- B. There is no real psychological basis for his illness
- C. He is unable to participate in planning his care
- D. His priority needs are limited to medical management
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) There may be a medical emergency that takes top priority; however, the basis of the problem is emotional.
(B) The problem is a physical manifestation of an emotional conflict. (C) The bleeding ulcer can be life threatening. (D) For lifestyle change to occur, the client must participate in the planning of his care so that he is committed to changes that will have positive results.
NEW QUESTION 373
A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client's return to her room, which nursing measure best demonstrates the nurse's thorough understanding of possible postthyroidectomy complications?
- A. Narcotics are readily available and administered when the client returns to her room to prevent excruciating pain.
- B. The nurse should instruct the client as soon as possible on alternative means of communication.
- C. Dressings are placed at the bedside for dressing changes, which are to be done every 2 hours to best detect postoperative bleeding.
- D. A tracheostomy set, O2, and suction are available at the bedside.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Dressing changes are done as necessary for bleeding. However, frequently, post-thyroidectomy bleeding may not be visible on the dressing, but blood may drain down the back of the neck by gravity. (B) Narcotics are administered for acute pain as necessary. They are not necessarily given on return of the client to her room. (C) The most serious postthyroidectomy complication is ineffective airway and breathing pattern related to tracheal compression and edema. A tracheostomy set, O2, and suction should be available at bedside for at least the first 24 hours postoperatively. (D) Impaired verbal communication may occur due to laryngeal edema or nerve damage, but most commonly, it occurs due to endotracheal intubation. The client is usually able to communicate but is hoarse.
NEW QUESTION 374
A male client is diagnosed with hypoparathyroidism. He has been on dialysis for several years. He is experiencing symptoms such as numbness of the lips, muscle weakness, carpopedal spasms, and wheezing.
Given the client's symptoms, nursing assessment would focus on:
- A. Detection of hypocalcemia to prevent seizures
- B. Detection of tetany
- C. Detection of premature cataract formation
- D. Evidence of depression
Answer: B
Explanation:
Section: Questions Set D
Explanation:
(A) Assessment should focus on detection of tetany, which is the most common symptom of hypoparathyroidism. Left undetected and untreated, tetany resulting from hypocalcemia can progress to seizures. (B) Hypocalcemia is difficult to detect on nursing assessment alone. Abdominal cramping may be an indication of hypocalcemia, but laboratory data are required to confirm diagnosis. (C) Depression can be a symptom of hypoparathyroidism, but it is not definitive. (D) Premature cataract formation can occur, but it also is not specific to parathyroidism and poses no immediate danger to the client.
NEW QUESTION 375
A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks' gestation, all of the following observations are made. Which would require intervention?
- A. Weight gain of 2 kg in 4 weeks
- B. Subjective data: shortness of breath after showering
- C. Blood pressure of 128/78
- D. Ankle edema reported present in late afternoon and evenings
Answer: B
Explanation:
(A) This is not an excessive weight gain indicative of fluid retention. (B) The blood pressure is within normal range. (C) Showering should not cause shortness of breath. This could be a sign ofcardiac decompensation. (D) Dependent ankle edema is normal late in the day among pregnant women. Progressive edema would be a dangerous development.
NEW QUESTION 376
In an interview for suspected child abuse, the child's mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child's father states, "Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child." Based on this remark, the nurse would make the following nursing diagnosis:
- A. Fear related to retaliation by the father
- B. Altered family process related to physical abuse
- C. Actual injury related to poor impulse control by the father
- D. Ineffective coping
Answer: B
Explanation:
Explanation
(A) There is no evidence of fear as the child is unable to communicate. (B) There is actual injury, but the parents have not yet admitted causing the child's injuries. (C) This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. (D) Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.
NEW QUESTION 377
Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward:
- A. Allowing the client out of bed only in a wheelchair or gurney to minimize weight bearing on the left leg
- B. Moving or turning the client's left leg carefully to minimize pain and discomfort
- C. Instituting physical therapy to ensure restoration of optimal functioning of the leg
- D. Providing the client with a high-protein, high-fiber diet to promote healing
Answer: B
Explanation:
Explanation
(A) Any movement of his affected limb will cause discomfort to the child. (B) No weight bearing will be allowed until healing is well underway to avoid pathological fractures. (C) The child will be anorexic and may experience vomiting. Diet should be simple and high caloric until appetite returns and symptoms subside. (D) Physical therapy is instituted only after infection subsides.
NEW QUESTION 378
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. Self-discipline is required to control caloric intake throughout the pregnancy
- B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
- C. Immediate treatment of mild PIH includes the administration of a variety of medications
- D. The client may not recognize the early symptoms of PIH
Answer: D
Explanation:
(A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH.
NEW QUESTION 379
A client's renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?
- A. High calcium, low phosphorus
- B. Low calcium, high phosphorus
- C. Low calcium and phosphorus, acid ash
- D. Two-gram sodium diet
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) The stones consist of calcium and phosphorus; therefore, these minerals should be avoided. A high- calcium diet is contraindicated. (B) A high-phosphorus diet is contraindicated. (C) A 2-g sodium diet is a cardiac diet. (D) A low-calcium and phosphorus diet will reduce further calculi formation.
NEW QUESTION 380
A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:
- A. Encourages her to breathe slowly and deeply
- B. Offers sips of warm liquids
- C. Dims the lights in her room
- D. Places a large, soft pillow under her head
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) The discomfort of photophobia is alleviated by dimming the lights. (B) Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis.
(C) It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. (D) A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.
NEW QUESTION 381
Following a vaginal delivery, the postpartum nurse should observe for:
- A. Chadwick's sign
- B. Hemorrhage and infection
- C. Fatigue, hemorrhoids
- D. Dystocia, kraurosis
Answer: B
Explanation:
(A) Dystocia is difficult labor. The delivery has occurred. Kraurosis is atrophy and dryness of skin and any mucous membrane (vulva). (B) Chadwick's sign is a bluish color of vaginal mucosa suggestive of pregnancy. (C) Fatigue is a common symptom in the postpartal period. Hemorrhoids may occur with pregnancy. (D) Hemorrhage and infection are potential complications of vaginal delivery. Hemorrhage may result from retained placental fragments or soft uterus. Infection may occur from the introduction of organisms into the uterus during the delivery.
NEW QUESTION 382
A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:
- A. "My stool will be soft like paste."
- B. "I know that I am not supposed to irrigate my colostomy."
- C. "The skin around my stoma may become irritated from the enzymes in my stool."
- D. "My stoma should be red and slightly raised."
Answer: D
Explanation:
Explanation
(A) A left colostomy indicates an ascending colon resection. This type of colostomy can be irrigated. (B) The stool from an ascending colon resection should be formed. (C) The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately. (D) The stool in the ascending colon does not usually have many enzymes in it. Stool from an ileostomy has more enzymes and is more irritating to the skin.
NEW QUESTION 383
The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?
- A. Twenty-four-hour intake 1000 mL/day for past 2 days
- B. Pedal pulses 11 (weak)
- C. Pulse rate 150 bpm
- D. Serum potassium 3.3
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. (B) Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. (C) A potassium level of 3.3 would not be associated with a significant drop in blood pressure.
NEW QUESTION 384
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
- A. IV fluids of 2.5-3 liters in 24 hours
- B. Prolonged bed rest
- C. The client's maintaining a semi-Fowler position
- D. Cerebral hypoxia
Answer: D
Explanation:
(A) Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. (B) The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. (C) Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. (D) Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.
NEW QUESTION 385
A 24-year-old woman who is gravida 1 reports, "I can't take iron pills because they make me sick." She continues, "My bowels aren't moving either." In counseling her based on these complaints, the nurse's most appropriate response would be, "It would be beneficial for you to eat . . .
- A. red meat."
- B. green leafy vegetables."
- C. prunes."
- D. eggs."
Answer: C
Explanation:
Explanation
(A) Prunes provide fiber to decrease constipation and are an excellent source of dietary iron, as the prenatal client is not taking her supplemental iron and iron-deficiency anemia is common during pregnancy. (B) Green leafy vegetables provide a source of fiber and iron; however, prunes are a better source of both. (C) Red meat is a good iron source but will not address the constipation problem. (D) Eggs are a good iron source but do not address the constipation problem.
NEW QUESTION 386
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