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NEW QUESTION 110
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking "the blue pill" (haloperidol) in the morning and evening, and "the white pill" (benztropine) right before bedtime. The nurse might suggest to the client that she try:
- A. Taking the benztropine in the morning
- B. Decreasing the haloperidol dosage for a few days
- C. Taking her medication with food or milk
- D. Doubling the daily dose of benztropine
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action.
This action requires a physician's order. (B) To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. (C) This response is an appropriate independent nursing action. Because motorrestlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. (D) Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.
NEW QUESTION 111
A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?
- A. She is compliant with her diet as previously taught.
- B. She needs further instruction and reinforcement.
- C. She needs to be placed on a restrictive diet immediately.
- D. She needs to increase her caloric intake.
Answer: B
Explanation:
Section: Questions Set A
Explanation:
(A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. (B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy.
A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weight gain, PIH should also be suspected. (C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy.
NEW QUESTION 112
Primary nursing diagnoses for the antisocial client are:
- A. Altered body image and altered thought processes
- B. Impaired social interaction, ineffective individual coping, and altered self-concept
- C. Altered communication processes and altered recreational patterns
- D. Alteration in perception and altered self-concept
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) This answer is incorrect. Perception is not altered because the client is not psychotic. (B) This answer is correct. The antisocial client lacks responsibility, accountability, and social commitment; has impaired problem-solving ability; tends to overuse defense mechanisms; lies and steals; and is often grandiose concerning self. (C) This answer is incorrect. Altered communication processes do not characterize this client. The antisocial person communicates well and tends to have a charming personality. (D) This answer is incorrect. Altered thought processes refer to delusional thinking, which is bizarre and fixed, and do not characterize this client.
NEW QUESTION 113
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale.
When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
- A. Liver
- B. Superior vena cava
- C. Pulmonary system
- D. Left ventricle
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) The foramen ovale permits a percentage of the blood to shunt from the right atrium to the left atrium. The blood then goes to the left ventricle, permitting systemic fetal circulation with blood containing a higher O2 saturation. (B) As the blood shunts from the right atrium to the left atrium, the pulmonary system is bypassed.
The fetus receives O2 from the maternal circulation, thereby permitting the partial bypass of the pulmonary system. (C) The foramen ovale is locatedin the atrial septum of the heart and does not affect the liver. (D) The superior vena cava returns blood to the heart, bringing blood to the location of the foramen ovale.
NEW QUESTION 114
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
- A. Her cervix shows she will likely deliver soon
- B. The nurse should not be alarmed because mild uterine activity is common at 32 weeks' gestation
- C. She most likely has a urinary tract infection (UTI) because this is common with pregnancy
- D. She may be in preterm labor because this is more common with multiple pregnancies
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Her cervical exam is normal. There are no cervical changes at this time. (B) Braxton Hicks contractions may be common throughout pregnancy, but they are not regular. (C) Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern. She may be in preterm labor. (D) UTIs are common in pregnancy due to the enlarging uterus compressing the ureters and the stasis of urine. The woman would be more likely to complain of urinary frequency and urgency, fever or chills, and malodorous urine with a UTI.
NEW QUESTION 115
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
- A. Assess the site for bruising or hematoma
- B. Assess the site for leakage of blood or fluids
- C. Inspect the site for color, warmth, and sensation
- D. Auscultate the site for a bruit
Answer: D
NEW QUESTION 116
A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training?
- A. Explain to the child she is going to "void" and "defecate."
- B. Show disapproval if she does not void or defecate.
- C. Take two or three favorite toys with the child.
- D. Have a child-sized toilet seat or training potty on hand.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement.
(B) A child-sized toilet seat or training potty gives a child a feeling of security. (C) She should use words that are age appropriate for the child. (D) Children should be praised for cooperative behavior and/or successful evacuation.
NEW QUESTION 117
A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to:
- A. Tell the client to attend all structured activities on the unit
- B. Not allow any dependent behaviors by the client because she must learn independence and will have to ask for any assistance from staff
- C. Encourage or direct client to attend activities that offer simple methods to attain success
- D. Increase the client's self-esteem by asking that she make all decisions regarding attendance in group activities
Answer: C
Explanation:
Explanation
(A) The nurse should encourage activities gradually, as client's energy level and tolerance for shared activities improve. (B) Activities that focus on strengths and accomplishments, with uncomplicated tasks, minimize failure and increase self-worth. (C) Asking a client to set a goal to make all decisions about attending group activities is unrealistic, and such decisions are not always under the client's control; this sets up the client for further failure and possibly decreased self-worth. (D) Encouragement toward independence does promote increased feelings of selfworth; however, clients may need assistance with decision making and problem solving for various situations and on an individual basis.
NEW QUESTION 118
A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate?
- A. Give an oral dose of lithium antidote.
- B. Recognize this as an expected response to lithium.
- C. Administer a stat dose of lithium as necessary.
- D. Request an order for a stat blood lithium level.
Answer: D
Explanation:
(A)
These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal.
(B)
These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote.
NEW QUESTION 119
A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:
- A. Pass a nasogastric tube through the left nostril
- B. Place a 4 X 4 gauze in the nares to impede the flow
- C. Gently suction the nasal drainage to protect the airway
- D. Perform a halo test and glucose level on the drainage
Answer: D
Explanation:
Explanation
(A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose.
Insertion of a tube could lead to CSF going into the brain tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy.
NEW QUESTION 120
A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:
- A. A productive cough
- B. Crackles in the lower lobes
- C. Expiratory stridor
- D. Drooling
Answer: D
Explanation:
(A) A productive cough is not associated with epiglottitis. (B) Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. (C) Because of difficulty with swallowing, drooling often accompanies epiglottitis. (D) Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures.
NEW QUESTION 121
A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:
- A. Ask the client if he is still having chest pain
- B. Connect the client to the cardiac monitor
- C. Complete the history profile
- D. Obtain vital signs
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. (B) All are important, but the first priority is to monitor the client's rhythm. (C) If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. (D) Completion of the history profile is the least important of the nursing actions.
NEW QUESTION 122
Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:
- A. Asthma
- B. Otitis media
- C. Conjunctivitis
- D. Tonsillitis
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Because the eustachian tube is short and straight in the infant, formula that pools in the back of the throat attacks bacteria which can enter the middle ear and cause an infection. (B) Asthma is not associated with propping the bottle. (C) Conjunctivitis is an eye infection and not associated with propping the bottle. (D) Tonsillitis is usually a result of pharyngitis and not propping the bottle.
NEW QUESTION 123
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:
- A. Not give the digoxin if the pulse is 100
- B. Monitor for visual disturbances, a side effect of digoxin
- C. Take the apical pulse for a full minute
- D. Not give the digoxin if the pulse is 60
Answer: C
Explanation:
Section: Questions Set G
Explanation:
(A) Digoxin should not be given to adults with an apical pulse < 60 bpm. (B) Digoxin should be given to children with an apical pulse > 100 bpm. With a pulse < 100 bpm, the medication should be withheld and the physician notified. (C) Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. (D) Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.
NEW QUESTION 124
A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mania. What must be included in client education regarding lithium toxicity?
- A. Maintain a normal diet; however, limit salt intake to no more than 3 g/day.
- B. Withhold lithium if experiencing diarrhea, vomiting, or diaphoresis.
- C. For pain or fever, avoid aspirin or acetaminophen (Tylenol). Nonsteroidal antiinflammatory drugs are preferred.
- D. Take lithium between meals to increase absorption.
Answer: B
Explanation:
(A) The client should maintain a normal diet including normal salt intake. A low-sodium diet can cause lithium retention, leading to toxicity. (B) Lithium must be taken with meals because it is irritating to the gastric mucosa. (C) Diarrhea, vomiting, or diaphoresis can cause dehydration, which will increase lithium blood levels. If these symptoms occur, the nurse should instruct the client to withhold lithium. (D) Lithium is not to be taken with over-the-counter drugs without specific instruction. Some drugs raise lithium levels, whereas others lower lithium levels.
NEW QUESTION 125
A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, "The doctor said I have stones that need to be removed; where are they?" The nurse knows that the best explanation for this is to tell her that:
- A. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain
- B. There are stones present in her kidneys
- C. There are stones present in her common bile duct
- D. There are stones present in her gallbladder
Answer: C
Explanation:
(A)Cholelithiasisis the correct term used to describe the presence of stones in the gallbladder. (B)Nephrolithiasis,orrenal calculi,is the correct term used to describe the presence of stones in the kidney. (C)Choledocholithiasisis the correct term used to describe the presence of stones in the common bile duct. (D)Cholecystitisis the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.
NEW QUESTION 126
A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia?
- A. Escherichia colipneumonia
- B. Klebsiellapneumonia
- C. Pneumococcal pneumonia
- D. Legionella pneumophilapneumonia
Answer: C
Explanation:
(A)Klebsiellapneumonia is caused by gram-negative bacteria. (B) Pneumococcal pneumonia is caused by gram-positive bacteria. (C)Legionella pneumophilapneumonia is a nonbacterial pneumonia. (D)E. colipneumonia is caused by gram-negative bacteria.
NEW QUESTION 127
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
- A. Possible harm to self
- B. Impaired thinking
- C. Nutritional status
- D. Rest and activity impairment
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
NEW QUESTION 128
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