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NEW QUESTION 251
A client on the infectious disease unit is discussing transmission of human immunodeficiency virus (HIV).
The nurse would need to provide more client education based on which client statement?
- A. "HIV can be transmitted to an unborn infant."
- B. "Condoms reduce the transmission of HIV."
- C. "HIV is a virus that is easily transmitted by casual contact."
- D. "HIV is a virus transmitted by sexual contact."
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) HIV is transmitted through unprotected sexual contact. (B) Condoms are an effective barrier to prevent HIV transmission. (C) HIV is not easily transmitted by casual contact. (D) HIV can be transmitted intrauterinely at the time of delivery, and by breast-feeding.
NEW QUESTION 252
A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:
- A. The elevated blood pressure causes photophobia.
- B. Noise or bright lights may precipitate a convulsion.
- C. The client is restless.
- D. External stimuli are annoying to the client with PIH.
Answer: B
Explanation:
Section: Questions Set B
Explanation:
(A) The client may be anxious and hyperresponsive to stimuli but not necessarily restless. (B) This is not a physiological response to an elevated blood pressure in PIH. (C) The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. (D) External stimuli might induce a convulsion but are not annoying to the client with PIH.
NEW QUESTION 253
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
- A. Dysfunction in one part affects every other part.
- B. Healthy families are enmeshed.
- C. A family system has no boundaries.
- D. The parts of a system are only minimally related.
Answer: A
Explanation:
(A) The parts of a system are interrelated. (B) Any change in any part of the system affects all other parts. (C) A family system, like any other system, has boundaries. (D) Healthy families are neither enmeshed nor disengaged.
NEW QUESTION 254
The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?
- A. "This is going to hurt a lot; close your eyes and hold my hand."
- B. "This is a terrible procedure, so don't look."
- C. "This will hurt only a little; try to be a big boy."
- D. "Some say this feels like a pinch or a bug bite. You tell me what it feels like."
Answer: D
Explanation:
(A)
Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse should allow the child his own sensory perception and evaluation of the procedure. (B) The nurse should avoid absolute descriptive statements and allow the child his own perception of the procedure.
(C)
The nurse should avoid evaluative statements or descriptions and give the child control in describing his reactions. (D) False statements regarding a painful procedure will cause a loss of trust between the child and the nurse.
NEW QUESTION 255
A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16-20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis
B. After a brief hospital stay, she is discharged to her parent's home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client's family. The nurse explains necessary precautions, which include:
- A. Laundering clothes separately in cold water with a chloride solution
- B. No necessary precautions because she is beyond the contagious phase
- C. Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution
- D. Isolation of the client from the remainder of the family
Answer: C
Explanation:
Section: Questions Set E
Explanation:
(A) Isolation is not necessary, even in the acute phase. (B) Separate bathroom facilities are recommended. If unavailable, daily cleansing with a chloride solution is recommended. (C) Precautions continue to be necessary while the client is in the active phase of hepatitis. (D) Clothes are to be laundered separately in hot water with a chloride solution.
NEW QUESTION 256
The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
- A. The child awakening wet from his naps
- B. Patience by the child when wearing soiled diapers
- C. The age at which the child's siblings were trained
- D. Communicating the urge to defecate or urinate
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Children experience impatience with soiled diapers when readiness for training is apparent. They often desire to be changed immediately. (B) A child must be able to use verbal or nonverbal skills to communicate needs. (C) A readiness indicator would be awaking dry from naps. (D) The age at which a sibling was toilet trained has no implications for training this child.
NEW QUESTION 257
The physician orders medication for a client's unpleasant side effects from the haloperidol. The most appropriate drug at this time is:
- A. Thiothixene
- B. Benztropine
- C. Lorazepam
- D. Triazolam (Halcion)
Answer: B
Explanation:
(A) Lorazepam is a benzodiazepine, or antianxiety agent, that potentiates the effects of _aminobutyric acid in the CNS, which is not the CNS neurotransmitter EPS. (B) Triazolam is a benzodiazepine sedative-hypnotic whose action is mediated in the limbic, thalamic, and hypothalamic levels of the CNS by - aminobutyric acid. (C) Benztropine is an anticholinergic agent, and the drug of choice for blocking CNS synaptic response, which causes EPS. (D) Thiothixene is an antipsychotic and neuroleptic drug that blocks dopamine neurotransmission at the CNS synapses, thereby causing EPS.
NEW QUESTION 258
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
- A. Pulse rate
- B. Urine output
- C. Blood pressure
- D. Serum potassium level
Answer: B
Explanation:
Explanation
(A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation. (C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
NEW QUESTION 259
A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side.
The nurse identifies the most likely cause of this as:
- A. Left-sided pneumothorax
- B. Inappropriate endotracheal tube size
- C. Right mainstem bronchus intubation
- D. Pneumonia
Answer: C
Explanation:
Explanation
(A) Appropriate endotracheal tube sizes for adults range from 7.0-8.5 mm. (B) Pneumothorax could be indicated by an absence of breath sounds on the affected side. However, in a recently intubated client, the first priority would be to consider tube malposition. (C) During intubation, the right mainstem bronchus can be inadvertently entered if the endotracheal tube is inserted too far. Left mainstem bronchus intubation almost never occurs because of the angle of the left mainstem bronchus. (D) Breath sounds for someone with pneumonia may be decreased over the areas of consolidation. However, in a recently intubated client, the first priority would be to consider tube malposition.
NEW QUESTION 260
A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:
- A. Hold the morning lithium dose and continue to observe the client
- B. Administer the morning lithium dose as scheduled
- C. Obtain an order for benztropine (Cogentin)
- D. Notify the physician immediately
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. (B) There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. (C) The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. (D) Benztropine is an antiparkinsonism drug frequently given to counteractextrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium).
NEW QUESTION 261
A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having:
- A. Type II diabetes mellitus
- B. Type I diabetes mellitus
- C. Gestational diabetes mellitus
- D. Insulin-dependent diabetes
Answer: C
Explanation:
(A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before the age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is not related to onset during pregnancy. (B) Non-insulin-dependent diabetes (type II diabetes) usually appears in older adults. It has a slow onset and progression of symptoms. (C) This type of diabetes is the same as insulin-dependent diabetes. (D) Gestational diabetes mellitus has its onset of symptoms during pregnancy and usually disappears after delivery. These symptoms are usually mild and not life threatening, although they are associated with increased fetal morbidity and other fetal complications.
NEW QUESTION 262
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
- A. Vaginal discharge or rubra, serosa, then rubra
- B. Pulse rate of 50-70 bpm by her third postpartum day
- C. Diaphoresis by her third postpartum day
- D. Diuresis by her second or third postpartum day
Answer: A
Explanation:
Explanation
(A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.
NEW QUESTION 263
Primary nursing diagnoses for the antisocial client are:
- A. Alteration in perception and altered self-concept
- B. Impaired social interaction, ineffective individual coping, and altered self-concept
- C. Altered body image and altered thought processes
- D. Altered communication processes and altered recreational patterns
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 264
In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:
- A. Palpating for presence of crepitus
- B. Auscultating heart sounds
- C. Auscultating bilateral breath sounds
- D. Palpating for trachial deviation
Answer: D
Explanation:
(A) No change in the breath sounds occurs as a direct result of the mediastinal shift. (B) Crepitus can occur owing to the primary disorder, not to the mediastinal shift. (C) Mediastinal shift occurs primarily with tension pneumothorax, but it can occur with very large hemothorax or pneumothorax. Mediastinal shift causes trachial deviation and deviation of the heart's point of maximum impulse. (D) No change in the heart sounds occurs as a result of the mediastinal shift.
NEW QUESTION 265
A group of nursing students at a local preschool day care center are going to screen each child's fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?
- A. Caldwell Home Inventory
- B. Denver Development Screening Test
- C. Revised Prescreening Developmental Questionnaire
- D. Goodenough Draw-a-Person Screening Test
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The Revised Prescreening Developmental Questionnaire is more age appropriate and offers simplified parent scoring and easier comparison. It is used by parents instead of professionals. (B) The Goodenough Draw-a-Person test is used to assess intellectual development. (C) The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a concise, easy-to-administer, systematic approach to assessing the preschool child. It is widely used because of its reliability and validity. (D) The Caldwell Home Inventory is used to assess the home environment in areas of social, emotional, and cognitive supports.
NEW QUESTION 266
A behavioral modification program is recommended by the multidisciplinary team working with a 15-year-old client with anorexia nervosa. A nursing plan of care based on this modality would include:
- A. Restriction to the unit until she has gained 2 lb
- B. Encouraging her to verbalize her feelings concerning food and food intake
- C. Provision for a high-calorie, high-protein snack between meals
- D. Role playing the client's eating behaviors
Answer: A
Explanation:
(A) This answer is incorrect. Role playing is based on learning but is not based on the behavioral modification model. (B) This answer is correct. The behavioral modification model is based on negative and positive reinforcers to change behavior. (C) This answer is incorrect. Verbal catharsis is not an intervention based on behavioral modification. (D) This answer is incorrect. Although an acceptable nursing intervention, it is not based on behavioral modification.
NEW QUESTION 267
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
- A. Take a warm shower and express milk from both breasts until empty
- B. Apply ice packs to the breasts and wear a supportive, well-fitting bra
- C. Allow the infant to breast-feed at the next feeding time to empty the breasts
- D. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes
Answer: B
Explanation:
(A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast-feeding every 112-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottlefeeding mother. (C) Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. (D) Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.
NEW QUESTION 268
When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
- A. Regular
- B. Long acting
- C. Human or pork
- D. NPH
Answer: A
Explanation:
Explanation
(A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. (C) Only regular insulin can be given IV.
NEW QUESTION 269
Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible damage after submersion in water is the:
- A. Kidney (urinary system)
- B. Brain (nervous system)
- C. Heart (circulatory system)
- D. Lungs (respiratory system)
Answer: B
Explanation:
(A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible damage after 4-6 minutes of water submersion. (C) The heart can survive up to 30 minutes of water submersion. (D) The lungs can survive up to 30 minutes of water submersion.
NEW QUESTION 270
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain.
She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
- A. Associated symptoms of indigestion and nausea
- B. Restlessness and apprehensiveness
- C. History of hypertension treated with pharmacological therapy
- D. Inability to tolerate assessment session with the admitting nurse
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. (B) Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. (C) It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. (D) A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
NEW QUESTION 271
A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?
- A. Assess suicide potential.
- B. Assess the history of physical abuse.
- C. Assess drug and alcohol use.
- D. Assess the level of anxiety, coping responses, and support systems.
Answer: A
Explanation:
Section: Questions Set E
Explanation:
(A) Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. (B) A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. (C) Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. (D) The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.
NEW QUESTION 272
One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is:
- A. Cerebral edema resulting in hydrocephalus
- B. Syndrome of inappropriate antiduretic hormone
- C. Auditory nerve damage resulting in permanent hearing loss
- D. Peripheral circulatory collapse
Answer: D
Explanation:
Explanation
(A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (D) Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome.
NEW QUESTION 273
The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following?
- A. The blood glucose level should be 100 mg or below before exercise is begun.
- B. Hyperglycemia may occur 2-4 hours after exercise.
- C. A snack may be needed before and/or during exercise.
- D. Exercise should be performed 30 minutes before meals.
Answer: C
Explanation:
(A) Exercise should not be performed before meals because the blood sugar is usually lower just prior to eating; therefore, there is an increased risk for hypoglycemia. (B) Exercise lowers blood sugar levels; therefore, a snack may be needed to maintain the appropriate glucose level. (C) Exercise lowers blood sugar levels. (D) Exercise lowers blood sugar levels. If the blood glucose level is 100 mg or below at the start of exercise, the potential for hypoglycemia is greater.
NEW QUESTION 274
A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?
- A. Regular insulin by IV infusion
- B. NPH insulin SC
- C. Sweetened grape juice by mouth
- D. D50W by IV push
Answer: A
Explanation:
Explanation
(A) This action would further increase the client's blood sugar. (B) NPH insulin is an intermediate-acting insulin, with an average of 4-6 hours before onset of action. The client needs insulin that will act immediately.
During a ketoacidotic state, the client is dehydrated, so any insulin administered SC will be poorly absorbed.
(C) Regular insulin is the fastest acting-insulin; when given IV, it will immediately act to decrease blood sugar. Regular insulin is given to decrease blood glucose levels by promoting metabolism of glucose, inhibiting lipolysis and formation of ketone bodies. (D) This action would further increase the client's blood sugar.
NEW QUESTION 275
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