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NEW QUESTION 347
The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?
- A. Serum electrolytes
- B. Complete blood count
- C. Arterial blood gases
- D. 12-Lead ECG
Answer: A
Explanation:
(A) Furosemide, a potassium-depleting diuretic, inhibits the reabsorption of sodium and chloride from the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-base imbalances influence the movement of potassium into and out of the cells, but arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassium-depleting diuretic. A complete blood count does not reflect potassium levels. (D) Abnormalities in potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do not occur until the abnormality is severe.
NEW QUESTION 348
A client experiencing delusions states, "I came here because there were people surrounding my house that wanted to take me away and use my body for science." The best response by the nurse would be:
- A. "There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science."
- B. "I know that must be frightening for you; let the staff know when you are having thoughts that trouble you."
- C. "Describe the people surrounding your house that want to take you away."
- D. "I need more information on why you think others want to use your body for science."
Answer: B
Explanation:
Explanation
(A) Focusing on the delusional content does not reinforce reality. (B) Pursuing details or more information on the delusion reinforces the false belief and further distances the client from reality. (C) Challenging the client's delusional system may force the client to defend it, and you cannot change the delusion through logic. (D) Focusing on the feeling can reinforce reality and discourage the false belief. Seeking out staff when thoughts are troublesome can help to decrease anxiety.
NEW QUESTION 349
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
- A. Use a Doppler to determine presence and strength of these pulses.
- B. Document the finding that the pulses are not palpable.
- C. Call the physician and notify the physician of this finding.
- D. Palpate these pulses again in 15 minutes.
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler.
NEW QUESTION 350
After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?
- A. One centimeter below the ischial spines
- B. Located in the pelvic outlet
- C. One centimeter above the ischial spines
- D. Has not entered the pelvic inlet yet
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) The ischial spines are located on both sides of the midpelvis. These spines mark the diameter of the narrowest part of the pelvis that the fetus will encounter. They are not sharp protrusions that will harm the fetus. Station refers to the relationship between the ischial spines in the pelvis and the fetus. The ischial spines are designated at 0 station. If the presenting part of the fetus is located above the ischial spines, a negative number is assigned, noting the number of centimeters above the ischial spines. Therefore, 1 centimeter below the ischial spines is designated as +1 station. (B) See explanation in A One centimeter above the ischial spines is designated as +1 station. (C) The pelvic inlet is the first part of the pelvis that the fetus enters in routine delivery. The midpelvis is the second part of the pelvis to be entered by the fetus. The ischial spines are located on both sides of the midpelvis. (D) The pelvic outlet is the last part of the pelvis that the fetus will enter. When the fetus reaches this part of the pelvis, birth is near.
NEW QUESTION 351
The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:
- A. Provide a nutritious diet
- B. Maintain her interest in school
- C. Provide for physical and psychological rest
- D. Maintain contact with her parents
Answer: C
Explanation:
Explanation
(A) This goal is helpful, but rest is essential during the acute phase. (B) Rest is essential for healing to occur and for pain to be relieved. (C) This goal is important, but rest is essential. (D) This goal should be part of the plan of care, but it is not the priority during the acute phase.
NEW QUESTION 352
The following medications were noted on review of the client's home medication profile. Which of the medications would most likely potentiate or elevate serum digoxin levels?
- A. Thyroid agents
- B. Quinidine
- C. Theophylline
- D. KCl
Answer: B
Explanation:
Section: Questions Set A
Explanation:
(A) Hypokalemia can cause digoxin toxicity. Administration of KCl would prevent this. (B) Thyroid agents decrease digoxin levels. (C) Quinidine increases digoxin levels dramatically. (D) Theophylline is not noted to have an effect on digoxin levels.
NEW QUESTION 353
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her
room 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. "Have you had any lesions of the affected leg that have been difficult to heal?"
- B. "Do you experience swelling at the end of the day in the affected and unaffected leg?"
- C. "Do your muscle spasms occur following rest, walking, or exercising?"
- D. "Would you describe the intensity, duration, and symptoms associated with your pain?"
Answer: C
Explanation:
(A)
Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. (B) Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication.
(C)
Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. (D) With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.
NEW QUESTION 354
A mother who is breast-feeding her newborn asks the RN, "How can I express milk from my breasts manually?" The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:
- A. Alternately compress and release each nipple
- B. Slide the thumb and index finger forward from the outer border of the areola toward the end of the nipple
- C. Compress and release each breast at the outer border of the areola
- D. Roll the nipple and gently pull the nipple forward
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Manipulation of nipples will cause soreness and trauma. (B) Pulling the nipples will cause discomfort and soreness. (C) Sliding the thumb and index finger forward over the nipple will cause soreness. (D) The best method to express milk from the breast is to position the thumb and index finger at the outer border of the areola and compress. This is the location of the milk sinuses.
NEW QUESTION 355
During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most effective in resolving the condition?
- A. Coating the inflamed areas with zinc oxide
- B. Using talcum powder on the inflamed areas to promote drying
- C. Cleaning the inflamed area thoroughly with disposable wet "wipes" at each diaper change
- D. Removing the diaper entirely for extended periods of time
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Zinc oxide is not usually applied to inflamed areas because it contributes to sweat retention. (B) Talcum powder is of questionable benefit and poses a hazard of accidental inhalation. (C) Removing the diaper and exposing the area to air and light facilitate drying and healing. (D) Infants may be sensitive to one or more agents in the wet "wipes." It is better to simply clean with a wet cloth.
NEW QUESTION 356
A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:
- A. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures
- B. Febrile seizures are associated with diseases of the central nervous system
- C. Febrile seizures do not usually recur
- D. Sustained temperature elevation over 103F is generally related to febrile seizures
Answer: A
Explanation:
(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system.
NEW QUESTION 357
A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?
- A. IM
- B. IV
- C. Aerosol
- D. Oral
Answer: C
Explanation:
Section: Questions Set B
Explanation:
(A) Ribavirin is not supplied in an oral form. (B) Ribavirin is administered by aerosol in order to decrease the duration of viral shedding within the infected tissue. (C) Ribavirin is not approved for IV use to treat respiratory syncytial virus. (D) Ribavirin is a synthetic antiviral agent supplied as a crystalline powder that is reconstituted with sterile water. A Small Aerosol Particle Generator unit aerosolizes the medication for delivery by oxygen hood, croup tent, or aerosol mask.
NEW QUESTION 358
During burn therapy, morphine is primarily administered IV for pain management because this route:
- A. Allows for discontinuance of the medication if respiratory depression develops
- B. Avoids causing additional pain from IM injections
- C. Delays absorption to provide continuous pain relief
- D. Facilitates absorption because absorption from muscles is not dependable
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Absorption would be increased, not decreased. (B) IM injections should not be used until the client is hemodynamically stable and has adequate tissue perfusion. Medications will remain in the subcutaneous tissue with the fluid that is present in the interstitial spaces in the acute phase of the thermal injury. The client will have a poor response to the medication administered, and a "dumping" of the medication can occur when the medication and fluid are shifted back into the intravascular spaces in the next phase of healing. (C) IV administration of the medication would hasten respiratory compromise, if present. (D) The desire to avoid causing the client additional pain is not a primary reason for this route of administration.
NEW QUESTION 359
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
- A. Referring a client who has been on a detoxification unit to a rehabilitation center
- B. Teaching fifth-grade children the harmful effects of substance abuse
- C. Crisis intervention with an intoxicated teenager whose mother just committed suicide
- D. Counseling a client with post-traumatic stress disorder
Answer: B
Explanation:
Explanation
(A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
NEW QUESTION 360
A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:
- A. Potential for violence directed at others
- B. Alteration in thought processes: paranoid delusions
- C. Impaired verbal communication: loose associations
- D. Sensory-perceptual alteration: auditory command hallucinations
Answer: A
Explanation:
(A) Although the client is having command hallucinations, this is second in priority to real or potential violence, which can be a threat to life itself. (B) Although the client is experiencing delusions, this is also a lower priority than his potential or actual loss of control. (C) Whether real or potential, violence directed at self or others is always high priority. (D) There is no evidence of loosening of associations.
NEW QUESTION 361
Priapism may be a sign of:
- A. Reproductive dysfunction
- B. Urinary incontinence
- C. Imminent death
- D. Altered neurological function
Answer: D
Explanation:
(A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem.
NEW QUESTION 362
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day.
During a recent clinic visit, she says to the nurse, "I can't stay still at night. I toss and turn and can't fall asleep." The nurse suspects that she may be experiencing:
- A. Dystonia
- B. Opisthotonos
- C. Akinesia
- D. Akathisia
Answer: D
Explanation:
Section: Questions Set G
Explanation:
(A) Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. (B) Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. (C) Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. (D) Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.
NEW QUESTION 363
Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?
- A. Surgically repaired herniated lumbar disk
- B. Brain tumor or other space-occupying lesion
- C. History of frequent urinary tract infections
- D. History of mitral valve prolapse
Answer: B
Explanation:
(A) A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases. Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated. (B) Any cardiac dysrhythmias or complications that arise during ECT are usually attributed to the IV anesthetics used, not to preexisting cardiac structural conditions. (C) Musculoskeletal injuries during ECT are extremely rare because of the IV use of centrally acting muscle relaxers. (D) A history of any kind of infection would not contraindicate the use of ECT. In fact, concurrent treatment of infections with ECT is not uncommon.
NEW QUESTION 364
Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:
- A. Patent ductus arteriosus
- B. Transposition of the great arteries
- C. Tetralogy of Fallot
- D. Ventricular septal defect
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood the reach the systemic circulation. (B) A VSD alone creates a left-to-right shunt.
The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the systemic circulation. (C) In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. (D) Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.
NEW QUESTION 365
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, "I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like." This defense mechanism is an example of:
- A. Rationalization
- B. Reaction formation
- C. Regression
- D. Repression
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Repression is blocking a desire from conscious expression. The client is conscious of his desires. (B) Regression is returning to an earlier form of expression, which is not demonstrated here. (C) Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. (D) Rationalization is unconsciously falsifying an experience by giving a "rational" explanation. The client is attempting to justify his behavior by giving an explanation.
NEW QUESTION 366
A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:
- A. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment."
- B. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment."
- C. "Visitors are not allowed. We will telephone you to inform you of her progress."
- D. "There's really no need to stay with her. She's going to sleep for several hours after the treatment."
Answer: A
Explanation:
(A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members. (C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off. (D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.
NEW QUESTION 367
A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child's mother for the home treatment of croup?
- A. Give him a dose of antihistamine.
- B. Give large amounts of clear liquids if drooling occurs.
- C. Place him near a cool mist vaporizer and encourage crying.
- D. Take him in the bathroom, turn on the hot water, and close the door.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Initial home treatment of croup includes placing the child in an environment of high humidity to liquefy and mobilize secretions. (B) Antihistamines should be avoided because they can cause thickening of secretions. (C) Drooling is a characteristic sign of airway obstruction and the child should be taken directly to the emergency room. (D) Crying increases respiratory distress and hypoxia in the child with croup. The nurse should promote methods that will calm the child.
NEW QUESTION 368
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. "If I have any side effects from my medicines, I will take an extra dose of Cogentin."
- B. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now."
- C. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."
- D. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway."
Answer: C
Explanation:
Section: Questions Set G
Explanation:
(A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance.
NEW QUESTION 369
A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?
- A. High calorie and high carbohydrate
- B. Low-fat 2-g sodium diet
- C. High protein and high fat
- D. High protein and high calorie
Answer: A
Explanation:
Explanation
(A) A high-protein diet is contraindicated in hepatic disease. (B) High carbohydrates provide high-caloric content to prevent tissue catabolism. (C) A low-fat 2-g sodium diet is a cardiac diet; however, a low-fat diet would be beneficial. (D) A high-protein and high-fat diet is contraindicated in hepatic disease.
NEW QUESTION 370
A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?
- A. Fried chicken
- B. Eggs
- C. Tapioca
- D. Cabbage
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) Fried, greasy food, such as fried chicken, will produce diarrhealike stools in individuals with all types of GI ostomies. (B) Eggs will cause odor-producing stools in individuals with all types of GI ostomies. (C) Tapioca and rice products will cause constipation in individuals with all types of GI ostomies. (D) Cabbage will cause odor-producing and flatus-producing stools in individuals with all types of GI ostomies.
NEW QUESTION 371
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