A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would

QUESTION 451A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would

 

include which of the following?

 

A. Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8 juice, and tomato juice.

 

B. Restrict fluids to 1000 mL/day.

 

C. Restrict foods that contain salt or sodium.

 

D. Discontinue the medication if nausea occurs.

 

QUESTION 452A 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. Role playing the client’s eating behaviors

 

B. Restriction to the unit until she has gained 2 lb

 

C. Encouraging her to verbalize her feelings concerning food and food intake

 

D. Provision for a high-calorie, high-protein snack between meals

 

QUESTION 453A 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 manipulate the other clients for his own benefit

 

B. He will cause the other clients to become psychotic

 

C. He will become delusional and hallucinate as a result of the excess attention given to him by peers

 

D. He may exhibit self-mutilative behavior

 

QUESTION 454In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the

 

following remark, “Forget all those rules. I always get along well with the nurses.” Which nursing response to him would be most effective?

 

A. “OK, don’t listen to the rules. See where you end up.”

 

B. “I’m pleased that you get along so well with the staff.You must still know and abide by the rules.”

 

C. “It is irrelevant whether you get along with the nurses.”

 

D. “I’m not the other nurses. You better read the rules yourself.”

 

QUESTION 455A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has

 

been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be

 

exhibited by her:

 

A. Two to 4 hours after the last drink

 

B. Six to 8 hours after the last drink

 

C. Immediately on admission

 

D. Twenty-four hours after the last drink

 

QUESTION 456A client has begun to exhibit signs of alcohol withdrawal. Her blood pressure has risen from 120/60 to 190/100, pulse is increased from 88 to 110 bpm, and she is

 

irritable and agitated and has gross motor tremors of the hands. The nurse notifies the doctor. The nurse can anticipate that the doctor will order which of the

 

following?

 

A. An opiate such as propoxyphene napsylate (Darvocet)

 

B. A benzodiazepine such as chlordiazepoxide (Librium)

 

C. A tricyclic antidepressant such as amitriptyline (Elavil)

 

D. A phenothiazine such as chlorpromazine (Thorazine)

 

QUESTION 457A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration. She has been unable to perform activities of daily living

 

without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer’s disease was made. An appropriate nursing intervention to decrease the anxiety

 

of this client would include:

 

A. Allowing the client to perform activities of daily living as much as possible unassisted

 

B. Confronting confabulations

 

C. Reality testing

 

D. Providing a highly stimulating environment

 

QUESTION 458A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours.

 

The planning of nursing care for a delirious client is based on which of the following premises?

 

A. The delirious client is capable of returning to his previous level of functioning.

 

B. The delirious client is incapable of returning to his previous level of functioning.

 

C. Delirium entails progressive intellectual and behavioral deterioration.

 

D. Delirium is an insidious process.

 

QUESTION 459A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy.

 

Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. The nurse informs the family that he will:

 

A. Have transient memory loss, confusion, andheadache

 

B. Be alert and oriented immediately after the treatment

 

C. Have insomnia for the first few days

 

D. Require no special care after the procedure

 

QUESTION 460An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test.

 

The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following

 

are signs of persons who are at risk for abusing an elderly person?

 

A. A family member who is having marital problems and is regularly abusing alcohol

 

B. A person with adequate communication and coping skills who is employed by the family

 

C. A friend of the family who wants to help but is minimally competent

 

D. A lifelong friend of the client who is often confused

 

QUESTION 461A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:

 

A. Must use the least restrictive measure possible to control the behavior

 

B. Should put the client in seclusion until he promises to behave appropriately

 

C. Should apply full restraints until the behavior is under control

 

D. Should allow other clients to observe the acting out so that they can learn from the experience

 

QUESTION 462The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this

 

program are:

 

A. Month-old magazines that are provided by volunteers

 

B. Large maps and posters depicting area of current residence

 

C. A litter of kittens for the clients to pet

 

D. A library of biographical books

 

.QUESTION 463In working with a manipulative client, which of the following nursing interventions would be most appropriate?

 

A. Bargaining with the client as a strategy to control the behavior

 

B. Redirecting the client

 

C. Providing a consistent set of guidelines and rules

 

D. Assigning the client to different staff persons each day

 

QUESTION 464Primary 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 communication processes and altered recreational patterns

 

D. Altered body image and altered thought processes

 

QUESTION 465 A 25-year-old outpatient presents with a diagnosis of compulsive personality disorder. His coworkers become annoyed with his rigid, perfectionistic manner and

 

preoccupation with trivial details and schedules. A nursing intervention appropriate for this client would include:

 

A. Encouraging him to engage in recreational activities

 

B. Avoiding discussion of his annoying behavior

 

C. Encouraging the client to set a time schedule and deadlines for himself

 

D. Contracting with him for the amount of time he will spend on the compulsive behaviors

 

QUESTION 466The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?

 

A. Abstract thinking

 

B. Ability to focus and concentrate thoughts

 

C. Judgment

 

D. Memory

 

QUESTION 467A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer

 

approaches the nurse to report that he has seen the 14- year-old with some of the missing items. The best response of the nurse is to:

 

A. Request that he explain to the group why he took personal items from peers

 

B. Approach him when he is alone to inquire about his involvement in the incident

 

C. Imply to him that you doubt his involvement in the incident and request his denial

 

D. Confront him openly in group and request an apology

 

QUESTION 468A 15-year-old client is admitted to the adolescent unit. The nurse recognizes that encouraging a client to speak openly depends on how clearly questions are

 

phrased. Which of the following statements is most desirable in eliciting information from an adolescent client?

 

A. “Do you get along well with your family?”

 

B. “Do you communicate with your parents?”

 

C. “You don’t hate your family, do you?”

 

D. “What is it like between you and your family?”

 

QUESTION 469A 37-year-old client has been taking antipsychotic medication for the past 10 days. The nurse observes her walking with a shuffling gait and postural rigidity and

 

notes a masklike expression on her face. Which side effect is this client exhibiting?

 

A. Dystonia

 

B. Parkinsonism

 

C. Tardive dyskinesia

 

D. Akathesia

 

QUESTION 470Clients 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. Anti-Parkinsonian drugs

 

D. Tricyclic agents

 

QUESTION 471A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is

 

important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:

 

A. Discuss the disease process and the importance of the medication in prevention of symptoms.

 

B. Inform the client that additional side effects are to be expected and need not be reported.

 

C. Discuss the importance of getting blood drawn weekly to determine medication therapeutics.

 

D. Inform the client to cease taking the medication when all psychotic symptoms have cleared.

 

QUESTION 472A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine

 

oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level

 

before symptoms are totally relieved. Symptom relief is expected to occur within:

 

A. 10 days

 

B. 24 weeks

 

C. 2 months

 

D. 3 months

 

QUESTION 473Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low-tyramine diet. Which of the following are foods that she

 

should avoid?

 

A. Pickled, aged, smoked, and fermented foods

 

B. Fresh vegetables

 

C. Broiled fresh fish and fowl

 

D. Fresh fruit such as apples and oranges

 

QUESTION 474In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug

 

therapy is initiated. One of the first steps in the teaching process is to:

 

A. Explain the side effects of the medication

 

B. Discuss the danger of overmedication

 

C. Distribute written material to supplement verbal instructions

 

D. Explore the client’s perception regarding medication therapy

 

QUESTION 475 A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse’s anger by using a condescending tone of voice with other clients

 

and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client’s behavior?

 

A. “I feel angry when I hear that tone of voice.”

 

B. “You make me angry when you talk to me that way.”

 

C. “Are you trying to get me angry?”

 

D. “Why do you treat me that way?”

 

QUESTION 476The mother of a 7-year-old mental health center client reports that the client has refused to attend gymnastics for the past 2 weeks. Prior to that time, the child liked

 

going to this class and was attending 3 times a week. In talking with the client, the nurse would:

 

A. Ask her why she doesn’t like gymnastics anymore

 

B. Ask her to describe how things were at gymnastics before she started refusing to go

 

C. Tell her that it is OK to be afraid of this activity

 

D. Reassure her that things will get better once she begins the classes again

 

QUESTION 477A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has

 

become pressured. She is exhibiting signs of:

 

A. Depression

 

B. Agitation

 

C. Psychotic ideation

 

D. Anhedonia

 

QUESTION 478A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room. Nursing care would include:

 

A. Forcing the client to attend all unit activities

 

B. Encouraging the client to discuss why he is so sad

 

C. Monitoring elimination patterns

 

D. Providing sensory stimulation

 

QUESTION 479A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He

 

became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to

 

rid himself of the snakes. He was sweating profusely. The admission nurse’s notes indicated that the client admitted to “having a few drinks now and then.” He is

 

probably experiencing which of the following?

 

A. Major psychotic depression

 

B. Delirium tremens

 

C. Generalized anxiety disorder

 

D. Adjustment disorder with mixed features

 

QUESTION 480A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a

 

respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a

 

tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish

 

this by:

 

A. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour

 

B. Avoiding manipulation of the tracheostomy including cuff deflation

 

C. Reporting any signs of crepitus immediately to the physician

 

D. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site

 

QUESTION 481A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder.

 

She arrives in herroom via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced

 

muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the

 

following question:

 

A. “Would you describe the intensity, duration, and symptoms associated with your pain?”

 

B. “Do you experience swelling at the end of the day in the affected and unaffected leg?”

 

C. “Have you had any lesions of the affected leg that have been difficult to heal?”

 

D. “Do your muscle spasms occur following rest, walking, or exercising?”

 

QUESTION 482A 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. “I am allowed to exercise by walking for short periods.”

 

D. “Teach my husband about the diet. He’ll be doing all the cooking now.”

 

QUESTION 483A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His

 

blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on

 

antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:

 

A. A blood pressure reading of 130/70 with a 5-lb weight loss

 

B. No side effects from antihypertensive medication and an accurate pill count

 

C. No evidence of increased left ventricular hypertrophy on chest x-ray

 

D. Serum blood levels of the antihypertensive medication within therapeutic range

 

QUESTION 484A 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. Inability to tolerate assessment session with the admitting nurse

 

D. History of hypertension treated with pharmacological therapy

 

QUESTION 485A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and

 

talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the

 

nurse after contacting the physician?

 

A. Serum osmolality is elevated indicating hemoconcentration.The nurse should increase IV fluid rate.

 

B. Serum sodium is low. The nurse should change IV fluids to normal saline.

 

C. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client’s diet as soon as possible.

 

D. Serum potassium is low. The nurse should administer KCl as ordered.

 

QUESTION 486A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he

 

complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face

 

to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:

 

A. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids

 

B. Is available at discount pharmacies for a reduced price

 

C. Is usually not necessary after the first year following transplantation

 

D. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually resolve themselves

 

QUESTION 487A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea.

 

She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to

 

sign the biopsy consent and states, “Can’t you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go

 

to Florida.” At this time the nurse’s greatest concern is that:

 

A. The client may contract an infection as a result of being exposed to large crowds at spring break

 

B. The client does not grasp the full impact of her illness

 

C. The client may require transfusion before leaving for spring break

 

D. The causative agent be identified and treatment begun

 

QUESTION 488A 68-year-old man was recently diagnosed with endstage renal disease. He has not yet begun dialysis but is experiencing severe anemia with associated

 

symptoms of dyspnea on exertion and chest pain. Which statement best describes the management of anemia in renal failure?

 

A. Hematocrit levels usually remain slightly below normalin clients with renal failure.

 

B. Transfusion is often begun as early as possible to prevent complications of anemia such as dyspnea and angina.

 

C. Anemia in renal failure is frequently caused by low serum iron and ferritin and corrected by oral iron and ferritin replacement therapy.

 

D. The renal secretion of erythropoiesis is decreased. The bone marrow requires erythropoietin to mature red blood cells.

 

QUESTION 489A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprimsulfamethoxazole

 

(Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature

 

was 104_F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells in the urine. A preliminary diagnosis of pyelonephritis was made.

 

During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?

 

A. “I have not been drinking six to eight glasses of water each day as the nurse had instructed.”

 

B. “I’m afraid I may have something wrong with my bladder because I have been getting bladder infections frequently since I’ve been married.”

 

C. “I took the Bactrim for 6 or 7 days. The burning stopped, so I saved the rest of the medication for the next time.”

 

D. “I recently had the flu, which could be settling in my kidneys now.”

 

QUESTION 490A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain

 

his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become

 

severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:

 

A. Loss of ability to speak and communicate effectively

 

B. Aspiration and weight loss

 

C. Secondary infection resulting from poor oral hygiene

 

D. Drooling

 

QUESTION 491A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular

 

accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24

 

hours following a CVA, which nursing diagnosis should receive the highest priority?

 

A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness

 

B. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow

 

C. Potential for injury related to impaired mobility and seizures

 

D. Impaired verbal communication related to aphasia

 

QUESTION 492A 32-year-old female client is being treated for Guillain- Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She

 

has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate

 

further evaluation?

 

A. Complaints of a headache

 

B. Loss of superficial and deep tendon reflexes

 

C. Complaints of shortness of breath

 

D. Facial paralysis

 

QUESTION 493A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On

 

assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury

 

is:

 

A. Reclining to control bleeding

 

B. Any position in which the client is comfortable

 

C. Side-lying, either left or right

 

D. Sitting with head support

 

QUESTION 494A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large

 

abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is

 

ototoxic, the nurse would implement which of the following measures?

 

A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.

 

B. Advise the client to discontinue the drug at the first sign of dizziness.

 

C. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.

 

D. Instruct the client in Valsalva’s maneuver to equalize middle ear pressure and to prevent hearing loss.

 

QUESTION 495A male client has experienced low back pain for several years. He is the primary support of his wife and six children. Although he would qualify for disability, he

 

plans to continue his employment as long as possible. His back pain has increased recently, and he is unable to control it with non-steroidal anti-inflammatory

 

agents. He refuses surgery and cannot take narcotics and remain alert enough to concentrate at work. His physician has suggested application of a transcutaneous

 

electrical nerve stimulation (TENS) unit. Which of the following is an appropriate rationale for using a TENS unit for relief of pain?

 

A. TENS units have an ultrasonic effect that relaxes muscles, decreases joint stiffness, and increases range of motion.

 

B. TENS units produce endogenous opioids that affect the central nervous system with analgesic potency comparable to morphine.

 

C. TENS units work on the gate-control theory of pain; biostimulation therapy of large fibers block painful stimuli.

 

D. TENS units prevent muscle spasms, decrease the potential for further injury, and minimize pressure on joints.

 

QUESTION 496A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed.

 

Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough

 

understanding of phantom pain and its management?

 

A. Phantom pain is entirely in the client’s mind. The client should be instructed that the pain is psychological and should not be treated.

 

B. The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real,

 

intense, and should be treated.

 

C. The cause of phantom pain is unknown. The nurse should provide the client with support, promote sleep, and handle the injured limb smoothly and gently.

 

D. Phantom pain is caused by trauma, spasms, and edema at the incisional site. It will decrease when postoperative edema decreases. It should be treated with nonnarcotic medication whenever possible.

 

QUESTION 497A 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. A tracheostomy set, O2, and suction are available at the bedside.

 

D. The nurse should instruct the client as soon as possible on alternative means of communication.

 

QUESTION 498A 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 tetany

 

B. Detection of hypocalcemia to prevent seizures

 

C. Evidence of depression

 

D. Detection of premature cataract formation

 

QUESTION 499A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has

 

not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him

 

because dancing is one of his favorite pastimes. He decides to question his wife’s home health nurse about diabetic peripheral neuropathy. The nurse points out

 

his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, “It has been my experience that the diabetic diet is very difficult to follow.

 

As far as the insulin, isn’t a fellow allowed to forget now and then?” The client’s actions and response best demonstrate:

 

A. Depression

 

B. Anger

 

C. Denial

 

D. Bargaining

 

QUESTION 500A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative

 

recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent

 

pernicious anemia, the nurse stresses that the client must:

 

A. Receive monthly blood transfusions

 

B. Increase the amount of iron in her diet

 

C. Eat small quantities several times daily until she is able to tolerate food in moderate portions

 

D. Understand the need for Vitamin B12 replacement therapy

 

QUESTION 501A 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 1620

 

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. Isolation of the client from the remainder of the family

 

B. Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution

 

C. No necessary precautions because she is beyond the contagious phase

 

D. Laundering clothes separately in cold water with a chloride solution

 

QUESTION 502A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing

 

assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing

 

diagnosis would receive the highest priority?

 

A. Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract

 

B. Fluid volume deficit related to vomiting and nasogastric tube drainage

 

C. Knowledge deficit related to treatment regimen

 

D. Altered nutrition: less than body requirements, related to inadequate intake associated with current anorexia, nausea, vomiting, and digestive enzyme loss

 

QUESTION 503A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After

 

several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of

 

psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client’s selfesteem

 

by:

 

A. Adhering to a strict schedule of diet, exercise, and wound care

 

B. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy

 

C. Following a standardized plan of care for burn clients formulated by a world-renowned burn center

 

D. Allowing him to plan, assist in, and perform his own care whenever possible

 

QUESTION 504A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After

 

collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to

 

be approximately:

 

A. 10 weeks

 

B. 16 weeks

 

C. 20 weeks

 

D. 30 weeks

 

QUESTION 505A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December

 

10, 1993. Using Nägele’s rule, the nurse estimates her date of delivery to be:

 

A. September 17, 1994

 

B. September 10, 1994

 

C. September 3, 1994

 

D. August 17, 1994

 

QUESTION 506A female client comes for her second prenatal visit. The nurse-midwife tells her, “Your blood tests reveal that you do not show immunity to the German measles.”

 

Which notation will the nurse include in her plan of care for the client? “Will need . . .

 

A. Rh-immune globulin at the next visit”

 

B. Rh-immune globulin within 3 days of delivery”

 

C. Rubella vaccine at the next visit”

 

D. Rubella vaccine after delivery on the day of discharge”

 

QUESTION 507A female client at 37 weeks’ gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate

 

(FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:

 

A. Reactive; needs follow-up contraction stress test

 

B. Reactive; no contraction stress test required

 

C. Non-reactive; needs follow-up contraction stress test

 

D. Non-reactive; no contraction stress test required

 

QUESTION 508A female client at 36 weeks’ gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has

 

been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG).

 

These lab values indicate:

 

A. Placental maturity

 

B. Suspected chronic asphyxia

 

C. Cord compression

 

D. Fetal lung maturity

 

QUESTION 509A primigravida with a blood type A negative is at 28 weeks’ gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client

 

demonstrates that more teaching is needed related to this therapy?

 

A. “I’m getting this shot so that my baby won’t develop antibodies against my blood, right?”

 

B. “I understand that if my baby is Rh positive I’ll be getting another one of these injections.”

 

C. “This shot should help to protect me in future pregnancies if this baby is Rh positive, like my husband.”

 

D. “This shot will prevent me from becoming sensitized to Rh-positive blood.”

 

QUESTION 510At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?

 

A. Restrict fluid intake.

 

B. Use Alka-Seltzer as necessary.

 

C. Eat small, frequent bland meals.

 

D. Lie down after eating.

 

QUESTION 511A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:

 

A. Frustration, vague in communication

 

B. Seriousness, some difficulty following directions

 

C. Calmness, follows directions easily

 

D. Excitement, openness to instructions

 

QUESTION 512The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:

 

A. Notifying the physician

 

B. Changing the client to the left lateral position

 

C. Continuing to monitor the FHR closely

 

D. Administering O2 at 8 L/min via face mask

 

QUESTION 513A female client is admitted to the emergency department complaining of severe right-sided abdominal pain and vaginal spotting. She states that her last menstrual

 

period was about 2 months ago. A positive pregnancy test result and ultrasonography confirm an ectopic pregnancy. The nurse could best explain to the client that

 

her condition is caused by:

 

A. Abnormal development of the embryo

 

B. A distended or ruptured fallopian tube

 

C. A congenital abnormality of the tube

 

D. A malfunctioning of the placenta

 

QUESTION 514

 

A female client at 10 weeks’ gestation complains to her physician of slight vaginal bleeding and mild cramps. On examination, her physician determines that her

 

cervix is closed. The client is exhibiting signs of:

 

A. An inevitable abortion

 

B. A threatened abortion

 

C. An incomplete abortion

 

D. A missed abortion

 

QUESTION 515A female client at 36 weeks’ gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse

 

explains that she is receiving this drug to:

 

A. Treat fetal respiratory distress syndrome

 

B. Prevent uterine infection

 

C. Promote fetal lung maturation

 

D. Increase uteroplacental circulation

 

QUESTION 516A female client at 30 weeks’ gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid,

 

boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?

 

A. Abruptio placentae

 

B. Ectopic pregnancy

 

C. Massive uterine rupture

 

D. Placenta previa

 

QUESTION 517A 4 days postpartum client who is gravida 3, para 3, isexamined by the home health nurse during her first postpartum home visit. The nurse notes that she has a

 

pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client’s lochia as:

 

A. Rubra

 

B. Rosa

 

C. Serosa

 

D. Alba

 

QUESTION 518A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy.

 

The nurse’s first action should be to:

 

A. Call the physician

 

B. Assess her vital signs

 

C. Give the prescribed oxytocic drug

 

D. Massage her fundus

 

QUESTION 519A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about

 

bromocriptine should be given by the nurse?

 

A. Bromocriptine stimulates the production of prolactin.

 

B. Hypertension is a primary side effect.

 

C. Bromocriptine is generally taken for 5 days.

 

D. Her blood pressure must be stable before starting bromocriptine.

 

QUESTION 520The postpartum nurse should include which of the following instructions to breast-feeding mothers?

 

A. Limit feeding times for several days to avoid nipple soreness.

 

B. Wash the nipples with soap and water before and after each feeding.

 

C. Daily caloric intake should be increased by 500 cal.

 

D. Breast milk is totally digestible by the baby because it contains lactose.

 

QUESTION 521At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?

 

A. Apical pulse of 52 bpm

 

B. Uterine fundus palpable left of midline

 

C. No bowel movement since delivery

 

D. Oral temperature of 100.4F

 

QUESTION 522The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks’ gestation. An appropriate response by the nurse would

 

be:

 

A. “It must be God’s will and probably is for the best.”

 

B. “This must be a difficult time for you. Would you like to talk about it?”

 

C. “I’m sure your other children will be a comfort for you.”

 

D. “Don’t worry, you’re still young. If I were you I’d just try again.”

 

QUESTION 523A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:

 

A. Prevents the development of ophthalmia neonatorum

 

B. Assists the baby’s clotting mechanism

 

C. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine

 

D. Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)

 

QUESTION 524After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client

 

will properly care for her son’s circumcision?

 

A. “I’ll make sure I soak the gauze with warm water first, before I take it off each time.”

 

B. “I’ll make sure that I report any drainage around where they operated.”

 

C. “I’ll apply alcohol to the area daily to clean it and prevent any infection.”

 

D. “I’ll keep a close watch on it for a day or two.”

 

QUESTION 525A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother’s discharge teaching plan?

 

A. Keep the umbilical area moist with Vaseline until the stump falls off.

 

B. Keep the umbilical area covered at all times with the diaper.

 

C. Clean the umbilical cord with alcohol at each diaper change.

 

D. Clean the umbilical cord daily with soap and water during the bath.

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