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NEW QUESTION 267
After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?
- A. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes.
- B. The nurse counts the instruments and sponges with the scrub nurse.
- C. The physician verifies the exact time of birth.
- D. The nurse makes sure the mother and her newborn have been tagged with identical bands.
Answer: D
Explanation:
(A) The delivery room personnel are responsible for verifying time of birth. (B) The scrub and circulating nurses count sponges and instruments. (C) This intervention is done in the nursery. (D) Tagging the mother and infant with identical bands is of utmost importance. The mother wears one band, and the newborn wears two. Identical numbers on the three bands provide identification for the newborn and the birth mother. Every time the newborn is brought to the mother after delivery, those bands are checked to be sure that the numbers are identical.
NEW QUESTION 268
Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities
- A. 0
- B. 1
- C. 2
- D. 3
Answer: B
Explanation:
Explanation
(A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. (C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. (D) For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point.
NEW QUESTION 269
In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:
- A. Cover the cord with a wet sponge.
- B. Apply a cord clamp to the exposed cord, and cover with a sterile towel.
- C. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.
- D. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.
Answer: C
Explanation:
Section: Questions Set B
Explanation:
(A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.
NEW QUESTION 270
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:
- A. Limit activities which require focusing (close vision)
- B. Wear a patch over one eye
- C. Use artificial tears
- D. Take more frequent naps
Answer: B
Explanation:
(A)
Limiting activities requiring close vision will not alleviate the discomfort of double vision.
(B)
Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia.
(D)
An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex.
NEW QUESTION 271
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?
- A. "I've only been urinating three times a day lately."
- B. "I don't remember anything in particular, I just haven't felt well."
- C. "My legs have been numb for three months."
- D. "I've been having a dull pain at the upper left shoulder."
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. (D) Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
NEW QUESTION 272
Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to improving withdrawn behavior is:
- A. Helping her to make friends
- B. Having her sit with the nurses while they chart
- C. Assigning her to occupational therapy
- D. Facilitating communication
Answer: D
Explanation:
Explanation
(A) The nurse does not make this assignment. (B) One-to-one observation is not appropriate. It does not focus on the client or encourage communication. (C) The client is too suspicious to accomplish this goal. (D) The withdrawn individual must learn to communicate on a one-to-one level before moving on to more threatening situations.
NEW QUESTION 273
A 22-year-old client presents with a diagnosis of antisocial personality disorder and a history of using drugs, writing numerous checks with insufficient funds, and stealing. He appears charming and intelligent, and the other clients are impressed and want to be liked by him. The greatest problem that may arise from this situation is that:
- A. He will cause the other clients to become psychotic
- B. He will become delusional and hallucinate as a result of the excess attention given to him by peers
- C. He may exhibit self-mutilative behavior
- D. He will manipulate the other clients for his own benefit
Answer: D
Explanation:
(A) This answer is correct. Persons with antisocial personality disorder typically are very manipulative. (B) This answer is incorrect. The client's behavior cannot cause another person to become psychotic. (C) This answer is incorrect. Psychosis is not a symptom of antisocial personality. One of the criteria for diagnosis of this disorder is that no psychosis be present. In addition, the client would love the attention. (D) This answer is incorrect. Self-mutilative behavior is characteristic of the borderline personality disorder.
NEW QUESTION 274
Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy?
- A. Diuretics
- B. Positive inotropes
- C. Vasodilators
- D. Antidysrhythmics
Answer: B
Explanation:
Explanation
(A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility. Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C) Diuretics are used with caution to avoid causing hypovolemia. (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias.
NEW QUESTION 275
A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include:
- A. Requiring the client to eat more during meals
- B. Checking the client's room frequently
- C. Establishing routine tasks and activities around mealtimes
- D. Administering medications such as lithium
Answer: C
Explanation:
Explanation
(A) Providing a more structured, supportive environment addresses safety and comfort needs, thereby helping the anorexic client develop more internal control. (B) Medications (commonly antidepressants) are frequently ordered for the anorexic client. However, lithium (used primarily with bipolar disorder) is not commonly used to treat the anorexic client. (C) Requiring and/or demanding that the anorexic client "eat more" at mealtimes increases the client's feelings of powerlessness. (D) Like the previous strategy, checking the client's room frequently contributes to the client's feelings of powerlessness.
NEW QUESTION 276
A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect:
- A. Hyperglycemia
- B. These are normal newborn responses to extrauterine life
- C. Hypoglycemia
- D. Central nervous system damage
Answer: C
Explanation:
Explanation
(A) Central nervous system damage presents as seizures, decreased arousal, and absence of newborn reflexes.
(B) In a diabetic mother, the infant is exposed to high serum glucose. The fetal pancreas produces large amounts of insulin, which causes hypoglycemia after birth. (C) Hypoglycemia is a common newborn problem.
Increased insulin production causes hypoglycemia, not hyperglycemia. (D) These are not normal adaptive behaviors to extrauterine life.
NEW QUESTION 277
A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages?
- A. Intimacy versus isolation
- B. Integrity versus despair
- C. Generativity versus self-absorption
- D. Identity versus role confusion
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Identity versus role confusion is experienced by adolescents making the transition from childhood to adulthood as they attempt to develop a sense of identity. (B) Integrity versus despair is experienced by the elderly as they reflect on their life in an attempt to find meaning. (C) Intimacy versus isolation is experienced by young adults as they establish intimate bonds of love and friendship. (D) Generativity versus self-absorption is experienced by middle-aged adults as they fulfill life goals that involve family, career, and society. The client is experiencing this crisis.
NEW QUESTION 278
The nurse provides a male client with diet teaching so that he can help prevent constipation in the future.
Which food choices indicate that this teaching has been understood?
- A. Bagel with cream cheese
- B. Cooked oatmeal and grapefruit half
- C. Omelette and hash browns
- D. Pancakes and syrup
Answer: B
Explanation:
Section: Questions Set B
Explanation:
(A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation.
(B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk.
NEW QUESTION 279
A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss.
Identify the number-one priority nursing diagnosis.
- A. Fluid volume deficit
- B. Altered bowel elimination
- C. Anxiety
- D. Altered nutrition
Answer: A
Explanation:
Explanation
(A) Fluid volume deficit is the major problem. Symptoms of dehydration are evident. The effects of fluid and electrolyte balance may be life threatening. Rehydration can be accomplished effectively through IV fluids and electrolytes. (B) Vomiting may also signal a nutritional problem. However, the nutritional problem would be secondary to fluid and electrolyte disturbances. The infant may also be placed on NPO status. (C) With vomiting, a decrease in the size and number of stools is expected. (D) The infant cannot verbalize feelings of anxiety. Anxiety would not be an appropriate diagnosis.
NEW QUESTION 280
Nursing care for the parents of a child with a congenital heart defect would include:
- A. Encouraging the parents not to tell the child about the seriousness of the congenital heart defect, so the child will function as normally as possible
- B. Identifying anger and resentment as destructive emotions that serve no purpose
- C. Expressing to the parents after the corrective surgery has been completed successfully that all their grief feelings will resolve
- D. Acknowledging the fear and concern surrounding their child's health and assisting the parents through the grieving process as they mourn the loss of their fantasized healthy child
Answer: D
Explanation:
(A) It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. (B) Parents of children with congenital heart defects go through a grieving process over the loss of their "healthy" child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. (C) Anger and resentment are normal feelings that must be dealt with appropriately. (D) Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the "defective" child who now may be essentially "normal."
NEW QUESTION 281
Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?
- A. Furosemide 20 mg/PO for decreased urine output
- B. Magnesium salicylate to decrease inflammation
- C. Nitroglycerin gr 1/150 for chest pain
- D. Nifedipine 10 mg SL for B/P 140/90
Answer: D
Explanation:
Explanation
(A) It is important to maintain a normal to slightly lower pressure to prevent the graft from blowing and excessive pressure to surgical vascular areas. (B, C, D) None of these drugs is related to managing the problem at hand. Also, none of the problems for which these drugs would be indicated is expected with this type of surgery, except if there is a prior history.
NEW QUESTION 282
A client is diagnosed with organic brain disorder. The nursing care should include:
- A. Long, extended family visits
- B. Organized, safe environment
- C. Detailed explanations of procedures
- D. Challenging educational programs
Answer: B
Explanation:
(A) A priority nursing goal is attending to the client's safety and well-being. Reorient frequently, remove dangerous objects, and maintain consistent environment. (B) Short, frequent visits are recommended to avoid overstimulation and fatigue. (C) Short, concise, simple explanations are easier to understand. (D) Mental capability and attention span deficits make learning difficult and frustrating.
NEW QUESTION 283
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
- A. Diaphoresis by her third postpartum day
- B. Pulse rate of 50-70 bpm by her third postpartum day
- C. Diuresis by her second or third postpartum day
- D. Vaginal discharge or rubra, serosa, then rubra
Answer: D
Explanation:
Explanation/Reference:
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 284
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. Evidence of depression
- C. Detection of tetany
- D. Detection of premature cataract formation
Answer: C
Explanation:
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 285
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
- A. Hang Ringer's lactate as the companion fluid
- B. Take a baseline set of vital signs
- C. Use microdrip tubing for the blood administration
- D. Have the registered nurse in charge assume responsibility for verifying the client and blood product information
Answer: B
Explanation:
Explanation
(A) A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. (B) The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. (C) Only a blood administration set should be used.
A microdrip tube would cause lysis of the red blood cells. (D) Proper identification of the recipient and the blood product must be validated by at least two people.
NEW QUESTION 286
The predominant purpose of the first Apgar scoring of a newborn is to:
- A. Obtain a baseline for comparison with the infant's future adaptation to the environment
- B. Evaluate the infant's vital functions
- C. Determine gross abnormal motor function
- D. Determine the extent of congenital malformations
Answer: B
Explanation:
(A)
Apgar scores are not related to the infant's care, but to the infant's physical condition.
(B)
Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with
Apgar scores.
NEW QUESTION 287
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
- A. Prevent air from entering the pleural space
- B. Provide a means to measure chest drainage
- C. Prevent fluid from entering the pleural space
- D. Provide an indicator of respiratory effort
Answer: A
Explanation:
(A) A chest tube extends from the pleural space to a collection device. The tube is placed below the surface of the saline so that air cannot enter the pleural space. (B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain fluid from the pleural space, but the water seal is not involved in this. (C) Chest drainage should be measured, but the water seal is not involved in this. (D) Fluctuations in the tube in the water-sealed bottle will give an indication of respiratory effort, but that is not the purpose of the water seal.
NEW QUESTION 288
The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:
- A. Covers burn scars and decreases the psychological impact during recovery
- B. Assists with ambulation
- C. Increases venous return and cardiac output by normalizing fluid status
- D. Decreases hypertrophic scar formation
Answer: D
Explanation:
Explanation
(A) Tubular support, such as that received with a Jobst garment, applies tension of 10-20 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 6-12 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status.
NEW QUESTION 289
A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy.
Which of the following strategies should be most effective in encouraging the child to eat?
- A. Schedule procedures immediately after eating so that the child will not be tired or in pain at mealtime.
- B. Offer the child a diet with a wider variety of foods and with more seasoning than her usual diet.
- C. Offer the child smaller meals more frequently than usual, and include as many of her favorite foods as possible.
- D. Provide a well-balanced diet at usual times, and restrict dessert if the child fails to eat well.
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Because the child's appetite is capricious at best, regular servings may be overwhelming. Praise the child for what is eaten. (B) The child will soon learn that procedures follow meals and may play with food rather than eat it to avoid or delay the procedure. (C) Young children usually do not like highly seasoned foods and may need the security of usual foods. Such a change may actually increase anorexia. (D) Small servings appear more achievable to the child, and the inclusion of favorite foods can add a sense of security.
NEW QUESTION 290
A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:
- A. Cutting the skin barrier 112 inches larger than the stoma
- B. Taping a pouch that is leaking
- C. Changing the pouch only when leakage occurs
- D. Using a skin sealant under pouch adhesives
Answer: D
Explanation:
Explanation
(A) When a pouch seal leaks, the pouch should be immediately changed, not taped. Stool held against the skin can quickly result in severe irritation. (B) The skin barrier should be cut only slightly larger than the stoma (one-half inch). (C) The client should be taught to change pouches whenever possible before leakage occurs.
(D) When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant is used, this layer is removed when the tape is removed.
NEW QUESTION 291
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