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NEW QUESTION 204
A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?
- A. "I will not drive but ride in the front seat of the car with a seat belt on for my first doctor's appointment."
- B. "When I bathe tomorrow morning, I will be very careful not to get soap on my incision."
- C. "Teach my husband about the diet. He'll be doing all the cooking now."
- D. "I am allowed to exercise by walking for short periods."
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. (B) Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking.
Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization. A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations.
NEW QUESTION 205
A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
- A. Evisceration
- B. Decortication
- C. Excoriation
- D. Dehiscence
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Excoriation is abrasion of the epidermis or of the coating of any organ of the body by trauma, chemicals, burns, or other causes. (B) Dehiscence is a partial or complete separation of the wound edges with no protrusion of abdominal tissue. (C) Decortication is removal of the surface layer of an organ or structure. It is a type of surgery, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. (D) Evisceration occurs when the incision separates and the contents of the cavity spill out.
NEW QUESTION 206
A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:
- A. Facilitate optimal development
- B. Provide respite care for the mother
- C. Provide a demanding and challenging educational program
- D. Prepare child to enter mainstream education
Answer: A
Explanation:
(A)
Respite care for the family may be needed, but it is not the primary goal of a preschool program. (B) Facilitation of optimal growth and development is essential for every child. (C) A demanding and challenging educational program may predispose the child to failure. Children with retardation should begin with simple and challenging educational programs.
(D)
Mental retardation associated with Down syndrome may not permit mainstream education. A preschoolprogram's primary goal is not preparation for mainstream education but continuation of optimal development.
NEW QUESTION 207
Nursing assessment of early evidence of septic shock in children at risk includes:
- A. Respiratory distress, cold skin, and pale extremities
- B. Fever, tachycardia, and tachypnea
- C. Normal pulses, hypotension, and oliguria
- D. Elevated blood pressure, hyperventilation, and thready pulses
Answer: B
Explanation:
Section: Questions Set G
Explanation:
(A) Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. (B) Respiratory distress, cold skin, and pale extremities are later signs of septic shock. (C) Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. (D) Normal pulses, hypotension, and oliguria are not early signs of septic shock.
NEW QUESTION 208
A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:
- A. Anxiety related to threat to self
- B. Decreased cardiac output related to excessive bleeding
- C. Potential for fluid volume excess related to fluid resuscitation
- D. Alteration in parenting related to potential fetal injury
Answer: B
Explanation:
(A) Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. (B) This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. (C) The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. (D) Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely.
NEW QUESTION 209
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. Dressings are placed at the bedside for dressing changes, which are to be done every 2 hours to best detect postoperative bleeding.
- B. Narcotics are readily available and administered when the client returns to her room to prevent excruciating pain.
- C. The nurse should instruct the client as soon as possible on alternative means of communication.
- D. A tracheostomy set, O2, and suction are available at the bedside.
Answer: D
Explanation:
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 210
A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to observe?
- A. Anger
- B. Hostility
- C. Apathy and flatness
- D. Smiling
Answer: C
Explanation:
Explanation
(A) Anger is an emotion that is not necessarily present in schizophrenia. (B) Lack of response to or involvement with environment and distancing are characteristic of schizophrenia. (C) Euphoria is more characteristic of manic-depressive disorder (bipolar disorder). (D) Hostility is an emotion that is not necessarily present in schizophrenia.
NEW QUESTION 211
When providing dietary teaching to an individual who has diabetes mellitus, type II, the nurse discusses the importance of consuming the recommended daily allowance of which of the following electrolytes?
- A. HCO3
- B. Potassium
- C. Magnesium
- D. Sodium
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Potassium intake that meets the recommended daily allowance is important, especially in clients who have a history of cardiac disease. (B) Low levels of magnesium can cause an increase in resistance to insulin and can lead to carbohydrate intolerance. (C) Sodium is an important electrolyte for all clients but has no direct effect on diabetes mellitus. (D) Bicarbonate plays an important role in acid-base balance. It is equally necessary for maintenance of all body functions.
NEW QUESTION 212
A client's physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client's COPD. Instructions that should be given to the client include:
- A. "Do not take your medicine if your pulse is less than 60 beats per minute.''
- B. "Take this medication on an empty stomach.''
- C. "Cigarette smoking may significantly increase the risk for theophylline toxicity.''
- D. "Call your physician if you develop palpitations, dizziness, or restlessness.''
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Indications of theophylline toxicity include palpitations, dizziness, restlessness, nausea, vomiting, shakiness, and anorexia. (B) Cigarette smoking significantly lowers theophylline plasma levels. (C) Theophylline should be taken with food to decrease stomach upset. (D) These instructions are appropriate for someone taking digoxin.
NEW QUESTION 213
Primary nursing diagnoses for the antisocial client are:
- A. Alteration in perception and altered self-concept
- B. Altered body image and altered thought processes
- C. Impaired social interaction, ineffective individual coping, and altered self-concept
- D. Altered communication processes and altered recreational patterns
Answer: C
Explanation:
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 214
To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby's mother to:
- A. Wear a gown and gloves and wash her hands before and after leaving the room.
- B. Avoid touching the baby while in the room.
- C. Wear a mask while in the room.
- D. Stay outside of the baby's room.
Answer: A
Explanation:
(A)
The mother should be allowed and encouraged to touch her baby. (B) With care, transmission can be prevented. There is no need for the mother to stay outside the room.
(C)
Everyone entering the baby's room should take appropriate measures to prevent transmission of pathogens. (D) Wearing a mask will not protect against transmission of pathogens.
NEW QUESTION 215
A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?
- A. Books with colorful pictures
- B. Riding toys
- C. Music
- D. Puppets
Answer: D
Explanation:
Explanation
(A) Books increase cognition, assist with fine motor skills, and augment language development. (B) Music provides auditory stimulation and large-muscle activity. (C) Riding toys provide large-muscle activity. (D) Puppets allow expression of feelings and fears that otherwise could not be directly communicated.
NEW QUESTION 216
When planning care for the passive-aggressive client, the nurse includes the following goal:
- A. Allow the client to have time away from therapeutic responsibilities.
- B. Allow the client to use humor, because this may be the only way this client can express self.
- C. Allow the client to give excuses if he forgets to give staff information.
- D. Allow the client to express anger by using "I" messages, such as "I was angry when . . .," etc.
Answer: D
Explanation:
Section: Questions Set C
Explanation:
(A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of "I" messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. (C) Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.
NEW QUESTION 217
A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:
- A. Wheezing and dry cough
- B. Rhonchi and frothy sputum
- C. Decreased breath sounds on the left and chest pain with movement
- D. Crackles and paradoxical chest wall movement
Answer: C
Explanation:
Section: Questions Set C
Explanation:
(A) Crackles are caused by air moving through moisture in the small airways and occur with pulmonary edema.
Paradoxical chest wall movement occurs with flail chest when a segment of the thorax moves outward on inspiration and inward on expiration. (B) Decreased breath sounds occur when a lung is collapsed or partially collapsed. Chest pain with movement occurs with rib fractures. (C) Rhonchi are caused by air moving through large fluid-filled airways. Frothy sputum may occur with pulmonary edema. (D) Wheezing is caused by fluid in large airways already narrowed by mucus or bronchospasm. Dry cough could indicate a cardiac problem.
NEW QUESTION 218
In the coronary care unit, a client has developed multifocal premature ventricular contractions. The nurse should anticipate the administration of:
- A. Furosemide
- B. Lidocaine
- C. Nitroglycerin
- D. Digoxin
Answer: B
Explanation:
(A) Furosemide is a loop diuretic. (B) Nitroglycerin is a vasodilator. (C) Lidocaine is the drug of choice to treat ectopic ventricular beats. (D) Digoxin slows down the electrical impulses and increases ventricular contractions, but it does not rapidly correct ventricular ectopy.
NEW QUESTION 219
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
- A. "I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness."
- B. "Just don't pay attention to the voices. They'll go away after some medication."
- C. "You can't leave here. This unit is locked and the doctor has not ordered your discharge."
- D. "We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that."
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This response validates the client's experience and presents reality to him. (B) This nontherapeutic response minimizes and dismisses the client's verbalized experience. (C) This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. (D) This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
NEW QUESTION 220
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
- A. December 9th
- B. September 14th
- C. November 23rd
- D. December 26th
Answer: C
Explanation:
(A) Naele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. (B) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. (C) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurringon the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. (D) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14thday of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule.
NEW QUESTION 221
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