Adult Health Nclex questions Exam #4

A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective? a. "I can buy some aloe vera gel to use on the area." b. "I will expose the treatment area to a sun lamp daily." c. "I can use ice packs to relieve itching in the treatment area." d. "I will scrub the area with warm water to remove the scales."

ANS: A Aloe vera gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury. DIF: Cognitive Level: Apply (application) REF: 269 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate? a."The cancer involves only the cervix." b."The cancer cells look almost like normal cells." c."Further testing is needed to determine the spread of the cancer." d."It is difficult to determine the original site of the cervical cancer."

ANS: A Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread. DIF: Cognitive Level: Apply (application) REF: 254 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? a. The UAP assists the patient to use dental floss after eating. b. The UAP adds baking soda to the patient's saline oral rinses. c. The UAP puts fluoride toothpaste on the patient's toothbrush. d. The UAP has the patient rinse after meals with a saline solution.

ANS: A Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient. DIF: Cognitive Level: Apply (application) REF: 266 | 268 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

A patient is diagnosed with hypertension and nadolol (Corgard) is prescribed. The nurse should consult with the health care provider before giving this medication upon finding a history of a. asthma. b. peptic ulcer disease. c. alcohol dependency. d. myocardial infarction (MI).

ANS: A Nonselective β-blockers block β1- and β2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. β-blockers will have no effect on the patient's peptic ulcer disease or alcohol dependency. β-blocker therapy is recommended after MI.

The nurse is reviewing the laboratory tests for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? a. Serum creatinine of 2.6 mg/dL b. Serum potassium of 3.8 mEq/L c. Serum hemoglobin of 14.7 g/dL d. Blood glucose level of 98 mg/dL

ANS: A The elevated creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Have the patient record dietary intake for 3 days. b. Give the patient a detailed list of low-sodium foods. c. Teach the patient about foods that are high in sodium. d. Help the patient make an appointment with a dietitian.

ANS: A The initial nursing action should be assessment of the patient's baseline dietary intake through a 3-day food diary. The other actions may be appropriate, but assessment of the patient's baseline should occur first.

A maternity nurse should be aware of which fact about the amniotic fluid? a. It serves as a source of oral fluid and a repository for waste from the fetus. b. The volume remains about the same throughout the term of a healthy pregnancy. c. A volume of less than 300 mL is associated with gastrointestinal malformations. d. A volume of more than 2 L is associated with fetal renal abnormalities.

ANS: A - Amniotic fluid serves as a source of oral fluid, serves as a repository for waste from the fetus, cushions the fetus, and helps maintain a constant body temperature. The volume of amniotic fluid changes constantly. Too little amniotic fluid (oligohydramnios) is associated with renal abnormalities. Too much amniotic fluid (hydramnios) is associated with gastrointestinal and other abnormalities.

A key finding from the Human Genome Project is: a. Approximately 20,000 genes make up the genome. b. All human beings are 80.99% identical at the DNA level. c. Human genes produce only one protein per gene; other mammals produce three proteins per gene. d. Single gene testing will become a standardized test for all pregnant clients in the future.

ANS: A - Approximately 20,500 genes make up the human genome; this is only twice as many as make up the genomes of roundworms and flies. Human beings are 99.9% identical at the DNA level. Most human genes produce at least three proteins. Single gene testing (e.g., alpha-fetoprotein) is already standardized for prenatal care.

The nurse caring for the laboring woman should know that meconium is produced by: a. Fetal intestines. c. Amniotic fluid. b. Fetal kidneys. d. The placenta.

ANS: A - As the fetus nears term, fetal waste products accumulate in the intestines as dark green-to-black, tarry meconium.

The placenta allows exchange of oxygen, nutrients, and waste products between the mother and fetus by: a. Contact between maternal blood and fetal capillaries within the chorionic villi. b. Interaction of maternal and fetal pH levels within the endometrial vessels. c. A mixture of maternal and fetal blood within the intervillous spaces. d. Passive diffusion of maternal carbon dioxide and oxygen into the fetal capillaries.

ANS: A - Fetal capillaries within the chorionic villi are bathed with oxygen-rich and nutrient-rich maternal blood within the intervillous spaces. The endometrial vessels are part of the uterus. There is no interaction with the fetal blood at this point. Maternal and fetal blood do not normally mix. Maternal carbon dioxide does not enter into the fetal circulation.

Many parents-to-be have questions about multiple births. Maternity nurses should be able to tell them that: a. Twinning and other multiple births are increasing because of the use of fertility drugs and delayed childbearing. b. Dizygotic twins (two fertilized ova) have the potential to be conjoined twins. c. Identical twins are more common in white families. d. Fraternal twins are same gender, usually male.

ANS: A - If the parents-to-be are older and have taken fertility drugs, they would be very interested to know about twinning and other multiple births. Conjoined twins are monozygotic; they are from a single fertilized ovum in which division occurred very late. Identical twins show no racial or ethnic preference; fraternal twins are more common among African-American women. Fraternal twins can be different genders or the same gender. Identical twins are the same gender.

The nurse is assessing the knowledge of new parents with a child born with maple syrup urine disease (MSUD). This is an autosomal recessive inherited disorder, which means that: a. Both genes of a pair must be abnormal for the disorder to be expressed. b. Only one copy of the abnormal gene is required for the disorder to be expressed. c. The disorder occurs in males and heterozygous females. d. The disorder is carried on the X chromosome.

ANS: A - MSUD is a type of autosomal recessive inheritance disorder in which both genes of a pair must be abnormal for the disorder to be expressed. MSUD is not an X-linked dominant or recessive disorder or an autosomal dominant inheritance disorder.

With regard to prenatal genetic testing, nurses should be aware that: a. Maternal serum screening can determine whether a pregnant woman is at risk of carrying a fetus with Down syndrome. b. Carrier screening tests look for gene mutations of people already showing symptoms of a disease. c. Predisposition testing predicts with near certainty that symptoms will appear. d. Presymptomatic testing is used to predict the likelihood of breast cancer.

ANS: A - Maternal serum screening identifies the risk for the neural tube defect and the specific chromosome abnormality involved in Down syndrome. Carriers of some diseases, such as sickle cell disease, do not display symptoms. Predisposition testing determines susceptibility, such as for breast cancer. presymptomatic testing indicates that symptoms are certain to appear if the gene is present.

The nurse caring for a pregnant client knows that her health teaching regarding fetal circulation has been effective when the client reports that she has been sleeping: a. In a side-lying position. b. On her back with a pillow under her knees. c. With the head of the bed elevated. d. On her abdomen.

ANS: A - Optimal circulation is achieved when the woman is lying at rest on her side. Decreased uterine circulation may lead to intrauterine growth restriction. Previously it was believed that the left lateral position promoted maternal cardiac output, enhancing blood flow to the fetus. However, it is now known that the side-lying position enhances uteroplacental blood flow. If a woman lies on her back with the pressure of the uterus compressing the vena cava, blood return to the right atrium is diminished. Although having the head of the bed elevated is recommended and ideal for later in pregnancy, the woman still must maintain a lateral tilt to the pelvis to avoid compression of the vena cava. Many women find lying on her abdomen uncomfortable as pregnancy advances. Side-lying is the ideal position to promote blood flow to the fetus.

A new mother asks the nurse about the white substance covering her infant. The nurse explains that the purpose of vernix caseosa is to: a. Protect the fetal skin from amniotic fluid. b. Promote normal peripheral nervous system development. c. Allow transport of oxygen and nutrients across the amnion. d. Regulate fetal temperature.

ANS: A - Prolonged exposure to amniotic fluid during the fetal period could result in breakdown of the skin without the protection of the vernix caseosa. Normal development of the peripheral nervous system is dependent on nutritional intake of the mother. The amnion is the inner membrane that surrounds the fetus. It is not involved in the oxygen and nutrient exchange. The amniotic fluid aids in maintaining fetal temperature.

The nurse must be cognizant that an individuals genetic makeup is known as his or her: a. Genotype. c. Karyotype. b. Phenotype. d. Chromotype.

ANS: A - The genotype comprises all the genes the individual can pass on to a future generation. The phenotype is the observable expression of an individuals genotype. The karyotype is a pictorial analysis of the number, form, and size of an individuals chromosomes. Genotype refers to an individuals genetic makeup.

A woman asks the nurse, What protects my babys umbilical cord from being squashed while the babys inside of me? The nurses best response is: a. Your babys umbilical cord is surrounded by connective tissue called Wharton jelly, which prevents compression of the blood vessels and ensures continued nourishment of your baby. b. Your babys umbilical floats around in blood anyway. c. You dont need to worry about things like that. d. The umbilical cord is a group of blood vessels that are very well protected by the placenta.

ANS: A - Your babys umbilical cord is surrounded by connective tissue called Wharton jelly, which prevents compression of the blood vessels and ensures continued nourishment of your baby is the most appropriate response. Your babys umbilical floats around in blood anyway is inaccurate. You dont need to worry about things like that is an inappropriate response. It negates the clients need for teaching and discounts her feelings. The placenta does not protect the umbilical cord. The cord is protected by the surrounding Wharton jelly.

Congenital disorders refer to conditions that are present at birth. These disorders may be inherited and caused by environmental factors or maternal malnutrition. Toxic exposures have the greatest effect on development between 15 and 60 days of gestation. For the nurse to be able to conduct a complete assessment of the newly pregnant client, she should understand the significance of exposure to known human teratogens. These include(Select all that apply): a. Infections. b. Radiation. c. Maternal conditions. d. Drugs. e. Chemicals.

ANS: A, B, C, D, E - Exposure to radiation and numerous infections may result in profound congenital deformities. These include but are not limited to varicella, rubella, syphilis, parvovirus, cytomegalovirus, and toxoplasmosis. Certain maternal conditions such as diabetes and phenylketonuria may also affect organs and other parts of the embryo during this developmental period. Drugs such as antiseizure medication and some antibiotics as well as chemicals, including lead, mercury, tobacco, and alcohol, also may result in structural and functional abnormalities.

Which congenital malformations result from multifactorial inheritance (Select all that apply)? a. Cleft lip b. Congenital heart disease c. Cri du chat syndrome d. Anencephaly e. Pyloric stenosis

ANS: A, B, D, E - All these congenital malformations are associated with multifactorial inheritance. Cri du chat syndrome is related to a chromosome deletion.

Along with gas exchange and nutrient transfer, the placenta produces many hormones necessary for normal pregnancy. These include (select all that apply) a. Human chorionic gonadotropin (hCG) b. Insulin c. Estrogen d. Progesterone e. Testosterone

ANS: A, C, D - hCG causes the corpus luteum to persist and produce the necessary estrogens and progesterone for the first 6 to 8 weeks. Estrogens cause enlargement of the womans uterus and breasts; cause growth of the ductal system in the breasts; and, as term approaches, play a role in the initiation of labor. Progesterone causes the endometrium to change, providing early nourishment. Progesterone also protects against spontaneous abortion by suppressing maternal reactions to fetal antigens and reduces unnecessary uterine contractions. Other hormones produced by the placenta include hCT, hCA, and numerous growth factors. Human placental lactogen promotes normal nutrition and growth of the fetus and maternal breast development for lactation. This hormone decreases maternal insulin sensitivity and utilization of glucose, making more glucose available for fetal growth. If a Y chromosome is present in the male fetus, hCG causes the fetal testes to secrete testosterone necessary for the normal development of male reproductive structures.

The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)? a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e. Colorectal screening

ANS: A, C, D, E The patient's age, gender, and history indicate a need for screening and/or teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy. DIF: Cognitive Level: Analyze (analysis) REF: 255 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)? a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work done.

ANS: A, C, E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics. DIF: Cognitive Level: Apply (application) REF: 265 | eTable 16-16 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? a. The UAP flushes the toilet once after emptying the patient's bedpan. b. The UAP stands by the patient's bed for 30 minutes talking with the patient. c. The UAP places the patient's bedding in the laundry container in the hallway. d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.

ANS: B Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated. DIF: Cognitive Level: Apply (application) REF: 264 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates several times a day in the room. b. The patient's visitors bring in some fresh peaches from home. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection. DIF: Cognitive Level: Apply (application) REF: eTable 16-16 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available.

ANS: B Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapeutic drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred. DIF: Cognitive Level: Apply (application) REF: 259 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? a. Tell the patient to limit social contacts until regrowth of the hair occurs. b. Encourage the patient to purchase a wig or hat and wear it once hair loss begins. c. Teach the patient to gently wash hair with a mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once the chemotherapy is complete.

ANS: B The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicle and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem. DIF: Cognitive Level: Apply (application) REF: 266 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? a. Lime sherbet b. Blueberry yogurt c. Cream cheese bagel d. Fresh strawberries and bananas

ANS: B Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Lime sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein. DIF: Cognitive Level: Apply (application) REF: 276 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which assessment finding for a patient who is receiving furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Blood glucose level of 180 mg/dL b. Blood potassium level of 3.0 mEq/L c. Early morning BP reading of 164/96 mm Hg d. Orthostatic systolic BP decrease of 12 mm Hg

ANS: B Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg is common and will require intervention only if the patient is symptomatic.

Which BP finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of heart failure? a. 108/64 mm Hg b. 128/76 mm Hg c. 140/90 mm Hg d. 136/ 82 mm Hg

ANS: B The goal for antihypertensive therapy for a patient with hypertension and heart failure is a BP of <130/80 mm Hg. The BP of 108/64 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

The nurse in the emergency department received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 52-year-old with a BP of 212/90 who has intermittent claudication b. 43-year-old with a BP of 190/102 who is complaining of chest pain c. 50-year-old with a BP of 210/110 who has a creatinine of 1.5 mg/dL d. 48-year-old with a BP of 200/98 whose urine shows microalbuminuria

ANS: B The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention is needed. The symptoms of the other patients also show target organ damage, but are not indicative of acute processes.

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 200 mL less than the fluid intake. b. The patient is unable to move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient complains of a severe headache with pain at level 8/10 (0 to 10 scale).

ANS: B The patient's inability to move the left arm and leg indicates that a hemorrhagic stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations also likely are caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.

The nurse obtains this information from a patient with prehypertension. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular aerobic exercise c. Weight 5 pounds above ideal weight d. Drinks wine with dinner once a week

ANS: B The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake will not increase the hypertension risk.

A woman who is 16 weeks pregnant asks the nurse, Is it possible to tell by ultrasound if the baby is a boy or girl yet? The best answer is: a. A babys sex is determined as soon as conception occurs. b. The baby has developed enough that we can determine the sex by examining the genitals through ultrasound. c. Boys and girls look alike until about 20 weeks after conception, and then they begin to look different. d. It might be possible to determine your babys sex, but the external organs look very similar right now.

ANS: B - Although gender is determined at conception, the external genitalia of males and females look similar through the ninth week. By the twelfth week, the external genitalia are distinguishable as male or female.

With regard to chromosome abnormalities, nurses should be aware that: a. They occur in approximately 10% of newborns. b. Abnormalities of number are the leading cause of pregnancy loss. c. Down syndrome is a result of an abnormal chromosome structure. d. Unbalanced translocation results in a mild abnormality that the child will outgrow.

ANS: B - Aneuploidy is an abnormality of number that also is the leading genetic cause of mental retardation. Chromosome abnormalities occur in less than 1% of newborns. Down syndrome is the most common form of trisomal abnormality, an abnormality of chromosome number (47 chromosomes). Unbalanced translocation is an abnormality of chromosome structure that often has serious clinical effects.

In presenting to obstetric nurses interested in genetics, the genetic nurse identifies the primary risk(s) associated with genetic testing as: a. Anxiety and altered family relationships. b. Denial of insurance benefits. c. High false-positive results associated with genetic testing. d. Ethnic and socioeconomic disparity associated with genetic testing.

ANS: B - Decisions about genetic testing are shaped by socioeconomic status and the ability to pay for the testing. Some types of genetic testing are expensive and are not covered by insurance benefits. Anxiety and altered family relationships, high false-positive results, and ethnic and socioeconomic disparity are factors that may be difficulties associated with genetic testing, but they are not risks associated with testing.

A woman is 15 weeks pregnant with her first baby. She asks how long it will be before she feels the baby move. The best answer is: a. You should have felt the baby move by now. b. Within the next month, you should start to feel fluttering sensations. c. The baby is moving; however, you cant feel it yet. d. Some babies are quiet, and you dont feel them move.

ANS: B - Maternal perception of fetal movement usually begins 16 to 20 weeks after conception. Because this is her first pregnancy, movement is felt toward the later part of the 16- to 20-week time period. Stating that you should have felt the baby move by now is incorrect and may be alarming to the patient. Fetal movement should be felt by 16 to 20 weeks. If movement is not felt by the end of that time, further assessment will be necessary.

A mans wife is pregnant for the third time. One child was born with cystic fibrosis, and the other child is healthy. The man wonders what the chance is that this child will have cystic fibrosis. This type of testing is known as: a. Occurrence risk. c. Predictive testing. b. Recurrence risk. d. Predisposition testing.

ANS: B - The couple already has a child with a genetic disease so they will be given a recurrence risk test. If a couple has not yet had children but are known to be at risk for having children with a genetic disease, they are given an occurrence risk test. Predictive testing is used to clarify the genetic status of an asymptomatic family member. Predisposition testing differs from presymptomatic testing in that a positive result does not indicate 100% risk of a condition developing.

As relates to the structure and function of the placenta, the maternity nurse should be aware that: a. As the placenta widens, it gradually thins to allow easier passage of air and nutrients. b. As one of its early functions, the placenta acts as an endocrine gland. c. The placenta is able to keep out most potentially toxic substances such as cigarette smoke to which the mother is exposed. d. Optimal blood circulation is achieved through the placenta when the woman is lying on her back or standing.

ANS: B - The placenta produces four hormones necessary to maintain the pregnancy. The placenta widens until week 20 and continues to grow thicker. Toxic substances such as nicotine and carbon monoxide readily cross the placenta into the fetus. Optimal circulation occurs when the woman is lying on her side.

You are a maternal-newborn nurse caring for a mother who just delivered a baby born with Down syndrome. What nursing diagnosis would be the most essential in caring for the mother of this infant? a. Disturbed body image c. Anxiety b. Interrupted family processes d. Risk for injury

ANS: B - This mother likely will experience a disruption in the family process related to the birth of a baby with an inherited disorder. Women commonly experience body image disturbances in the postpartum period; however, this is unrelated to giving birth to a child with Down syndrome. The mother likely will have a mix of emotions that may include anxiety, guilt, and denial, but this is not the most essential nursing diagnosis for this family. Risk for injury is not an applicable nursing diagnosis.

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective? a. "The biopsy will remove the cancer in my prostate gland." b. "The biopsy will determine how much longer I have to live." c. "The biopsy will help decide the treatment for my enlarged prostate." d. "The biopsy will indicate whether the cancer has spread to other organs."

ANS: C A biopsy is used to determine whether the prostate enlargement is benign or malignant, and determines the type of treatment that will be needed. A biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life. DIF: Cognitive Level: Apply (application) REF: 256 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a. 35-year-old patient who has wet desquamation associated with abdominal radiation b. 42-year-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c. 24-year-old patient who received neck radiation and has blood oozing from the neck d. 56-year-old patient who developed a new pericardial friction rub after chest radiation

ANS: C Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening. DIF: Cognitive Level: Analyze (analysis) REF: 278-279 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information? a. "How long ago were you diagnosed with this cancer?" b. "Do you have any concerns about body image changes?" c. "Can you tell me what has been helpful to you in the past when coping with stressful events?" d. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"

ANS: C Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient's need for support. The patient's knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Because surgical interventions for stage I cancer of the colon may not cause any body image changes, this question is not appropriate at this time. DIF: Cognitive Level: Apply (application) REF: 280 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/µL after chemotherapy b. Patient who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) d. Patient who is worried about getting the prescribed long-acting opioid on time

ANS: C Temperature elevation is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions, but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/µL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patient does not appear to have breakthrough pain. DIF: Cognitive Level: Analyze (analysis) REF: 277 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."

ANS: C The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur. DIF: Cognitive Level: Understand (comprehension) REF: 253 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Teach the patient about the need for a colonoscopy at age 50. b. Teach the patient how to do home testing for fecal occult blood. c. Obtain more information from the patient about the family history. d. Schedule a sigmoidoscopy to provide baseline data about the patient.

ANS: C The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning. DIF: Cognitive Level: Apply (application) REF: 255-256 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate? a. Add strained baby meats to foods such as casseroles. b. Teach the patient about foods that are high in nutrition. c. Avoid giving the patient foods that are strongly disliked. d. Add extra spice to enhance the flavor of foods that are served.

ANS: C The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. The patient's poor intake is not caused by a lack of information about nutrition. DIF: Cognitive Level: Apply (application) REF: 277 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which action, if taken by the nurse, is most appropriate? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient two ounces of a citrus fruit beverage during treatments.

ANS: C Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach. DIF: Cognitive Level: Apply (application) REF: 266 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which action will be included in the plan of care when the nurse is caring for a patient who is receiving sodium nitroprusside (Nipride) to treat a hypertensive emergency? a. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night. b. Assist the patient up in the chair for meals to avoid complications associated with immobility. c. Use an automated noninvasive blood pressure machine to obtain frequent BP measurements. d. Place the patient on NPO status to prevent aspiration caused by nausea and the associated vomiting.

ANS: C Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 6 to 8 hours of undisturbed sleep is not appropriate. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.

A patient has been diagnosed with possible white coat hypertension. Which action will the nurse plan to take next? a. Schedule the patient for frequent BP checks in the clinic. b. Instruct the patient about the need to decrease stress levels. c. Tell the patient how to self-monitor and record BPs at home. d. Teach the patient about ambulatory blood pressure monitoring.

ANS: C Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Frequent BP checks in the clinic are likely to be high in a patient with white coat hypertension. Ambulatory blood pressure monitoring may be used if the data from self-monitoring is unclear. Although elevated stress levels may contribute to hypertension, instructing the patient about this is unlikely to reduce BP.

Which information should the nurse include when teaching a patient with newly diagnosed hypertension? a. Dietary sodium restriction will control BP for most patients. b. Most patients are able to control BP through lifestyle changes. c. Hypertension is usually asymptomatic until significant organ damage occurs. d. Annual BP checks are needed to monitor treatment effectiveness.

ANS: C Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes and sodium restriction are used to help manage blood pressure, but drugs are needed for most patients. BP should be checked by the health care provider every 3 to 6 months.

The RN is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside (Nipride). Which of the following nursing actions can the nurse delegate to an experienced LPN/LVN? a. Titrate nitroprusside to maintain BP at 160/100 mm Hg. b. Evaluate effectiveness of nitroprusside therapy on BP. c. Set up the automatic blood pressure machine to take BP every 15 minutes. d. Assess the patient's environment for adverse stimuli that might increase BP.

ANS: C LPN/LVN education and scope of practice include correct use of common equipment such as automatic blood pressure machines. The other actions require more nursing judgment and education and should be done by RNs.

After giving a patient the initial dose of oral labetalol (Normodyne) for treatment of hypertension, which action should the nurse take? a. Encourage oral fluids to prevent dry mouth or dehydration. b. Instruct the patient to ask for help if heart palpitations occur. c. Ask the patient to request assistance when getting out of bed. d. Teach the patient that headaches may occur with this medication.

ANS: C Labetalol decreases sympathetic nervous system activity by blocking both α- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dehydration, and headaches are possible side effects of other antihypertensives.

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and has a BP of 240/118 mm Hg. Which question should the nurse ask first? a. Did you take any acetaminophen (Tylenol) today? b. Do you have any recent stressful events in your life? c. Have you been consistently taking your medications? d. Have you recently taken any antihistamine medications?

ANS: C Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.

The charge nurse observes a new RN doing discharge teaching for a hypertensive patient who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to a. check the BP with a home BP monitor every day. b. move slowly when moving from lying to standing. c. increase the dietary intake of high-potassium foods. d. make an appointment with the dietitian for teaching.

ANS: C The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

During change-of-shift report, the nurse obtains this information about a hypertensive patient who received the first dose of propranolol (Inderal) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patient's most recent BP reading is 156/94 mm Hg. b. The patient's pulse has dropped from 64 to 58 beats/minute. c. The patient has developed wheezes throughout the lung fields. d. The patient complains that the fingers and toes feel quite cold.

ANS: C The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective β-blockers) is occurring. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with β-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated; however, this is not as urgently needed as addressing the bronchospasm.

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? a. Obtain a BP reading in each arm and average the results. b. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. c. Have the patient sit in a chair with the feet flat on the floor. d. Assist the patient to the supine position for BP measurements.

ANS: C The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, but the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

The measurement of lecithin in relation to sphingomyelin (L/S ratio) is used to determine fetal lung maturity. Which ratio reflects maturity of the lungs? a. 1.4:1 c. 2:1 b. 1.8:1 d. 1:1

ANS: C - A ratio of 2:1 indicates a two-to-one ratio of L/S, an indicator of lung maturity. Ratios of 1.4:1, 1.8:1, and 1:1 indicate immaturity of the fetal lungs.

With regard to the development of the respiratory system, maternity nurses should be understand that: a. The respiratory system does not begin developing until after the embryonic stage. b. The infants lungs are considered mature when the lecithin/sphingomyelin (L/S) ratio is 1:1, at about 32 weeks. c. Maternal hypertension can reduce maternal-placental blood flow, accelerating lung maturity. d. Fetal respiratory movements are not visible on ultrasound scans until at least 16 weeks.

ANS: C - A reduction in placental blood flow stresses the fetus, increases blood levels of corticosteroids, and accelerates lung maturity. Development of the respiratory system begins during the embryonic phase and continues into childhood. The infants lungs are mature when the L/S ratio is 2:1, at about 35 weeks. Lung movements have been seen on ultrasound scans at 11 weeks.

A pregnant woman at 25 weeks gestation tells the nurse that she dropped a pan last week and her baby jumped at the noise. Which response by the nurse is most accurate? a. That must have been a coincidence; babies cant respond like that. b. The fetus is demonstrating the aural reflex. c. Babies respond to sound starting at about 24 weeks of gestation. d. Let me know if it happens again; we need to report that to your midwife.

ANS: C - Babies respond to sound starting at about 24 weeks of gestation is an accurate statement. That must have been a coincidence; babies cant respond like that is inaccurate. Acoustic stimulations can evoke a fetal heart rate response. There is no such thing as an aural reflex. The statement, Let me know if it happens again; we need to report that to your midwife is not appropriate; it gives the impression that something is wrong.

The nurse is providing genetic counseling for an expectant couple who already have a child with trisomy 18. The nurse should: a. Tell the couple they need to have an abortion within 2 to 3 weeks. b. Explain that the fetus has a 50% chance of having the disorder. c. Discuss options with the couple, including amniocentesis to determine whether the fetus is affected. d. Refer the couple to a psychologist for emotional support.

ANS: C - Genetic testing, including amniocentesis, would need to be performed to determine whether the fetus is affected. The couple should be given information about the likelihood of having another baby with this disorder so that they can make an informed decision. A genetic counselor is the best source for determining genetic probability ratios. The couple eventually may need emotional support, but the status of the pregnancy must be determined first.

A couple has been counseled for genetic anomalies. They ask you, What is karyotyping? Your best response is: a. Karyotyping will reveal if the babys lungs are mature. b. Karyotyping will reveal if your baby will develop normally. c. Karyotyping will provide information about the gender of the baby and the number and structure of the chromosomes. d. Karyotyping will detect any physical deformities the baby has.

ANS: C - Karyotyping provides genetic information such as gender and chromosome structure. The L/S, not karyotyping, reveals lung maturity. Although karyotyping can detect genetic anomalies, the range of normal is nondescriptive. Although karyotyping can detect genetic anomalies, not all such anomalies display obvious physical deformities. The term deformities is a nondescriptive word. Physical anomalies may be present that are not detected by genetic studies (e.g., cardiac malformations).

In practical terms regarding genetic health care, nurses should be aware that: a. Genetic disorders affect people of all socioeconomic backgrounds, races, and ethnic groups equally. b. Genetic health care is more concerned with populations than individuals. c. The most important of all nursing functions is providing emotional support to the family during counseling. d. Taking genetic histories is the province of large universities and medical centers.

ANS: C - Nurses should be prepared to help with various stress reactions from a couple facing the possibility of a genetic disorder. Although anyone may have a genetic disorder, certain disorders appear more often in certain ethnic and racial groups. Genetic health care is highly individualized because treatments are based on the phenotypic responses of the individual. Individual nurses at any facility can take a genetic history, although larger facilities may have better support services.

A womans cousin gave birth to an infant with a congenital heart anomaly. The woman asks the nurse when such anomalies occur during development. Which response by the nurse is most accurate? a. We dont really know when such defects occur. b. It depends on what caused the defect. c. They occur between the third and fifth weeks of development. d. They usually occur in the first 2 weeks of development.

ANS: C - The cardiovascular system is the first organ system to function in the developing human. Blood vessel and blood formation begins in the third week, and the heart is developmentally complete in the fifth week. We dont really know when such defects occur is an inaccurate statement. Regardless of the cause, the heart is vulnerable during its period of development, the third to fifth weeks. They usually occur in the first 2 weeks of development is an inaccurate statement.

A father and mother are carriers of phenylketonuria (PKU). Their 2-year-old daughter has PKU. The couple tells the nurse that they are planning to have a second baby. Because their daughter has PKU, they are sure that their next baby wont be affected. What response by the nurse is most accurate? a. Good planning; you need to take advantage of the odds in your favor. b. I think youd better check with your doctor first. c. You are both carriers, so each baby has a 25% chance of being affected. d. The ultrasound indicates a boy, and boys are not affected by PKU.

ANS: C - The chance is one in four that each child produced by this couple will be affected by PKU disorder. This couple still has an increased likelihood of having a child with PKU. Having one child already with PKU does not guarantee that they will not have another. These parents need to discuss their options with their physician. However, an opportune time has presented itself for the couple to receive correct teaching about inherited genetic risks. No correlation exists between gender and inheritance of the disorder because PKU is an autosomal recessive disorder.

Sally comes in for her first prenatal examination. This is her first child. She asks you (the nurse), How does my baby get air inside my uterus? The correct response is: a. The babys lungs work in utero to exchange oxygen and carbon dioxide. b. The baby absorbs oxygen from your blood system. c. The placenta provides oxygen to the baby and excretes carbon dioxide into your bloodstream. d. The placenta delivers oxygen-rich blood through the umbilical artery to the babys abdomen.

ANS: C - The placenta functions by supplying oxygen and excreting carbon dioxide to the maternal bloodstream. The fetal lungs do not function for respiratory gas exchange in utero. The baby does not simply absorb oxygen from a womans blood system. Blood and gas transport occur through the placenta. The placenta delivers oxygen-rich blood through the umbilical vein and not the artery.

At approximately _____ weeks of gestation, lecithin is forming on the alveolar surfaces, the eyelids open, and the fetus measures approximately 27 cm crown to rump and weighs approximately 1110 g. a. 20 c. 28 b. 24 d. 30

ANS: C - These milestones human development occur at approximately 28 weeks.

The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in therapy with the health care provider? a. Poor oral intake b. Frequent loose stools c. Complaints of nausea and vomiting d. Increase in carcinoembryonic antigen (CEA)

ANS: D An increase in CEA indicates that the chemotherapy is not effective for the patient's cancer and may need to be modified. The other patient findings are common adverse effects of chemotherapy. The nurse may need to address these, but they would not necessarily indicate a need for a change in therapy. DIF: Cognitive Level: Apply (application) REF: 253 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Provide teaching about the importance of nutritional intake. d. Apply the ordered anesthetic gel to oral lesions before meals.

ANS: D Because the etiology of the patient's poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition, but would not be as helpful for this patient. DIF: Cognitive Level: Apply (application) REF: 268-269 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband indicates to the nurse that he never knows what to say to help his wife. Which nursing diagnosis is most appropriate for the nurse to add to the plan of care? a. Compromised family coping related to disruption in lifestyle b. Impaired home maintenance related to perceived role changes c. Risk for caregiver role strain related to burdens of caregiving responsibilities d. Dysfunctional family processes related to effect of illness on family members

ANS: D The data indicate that this diagnosis is most appropriate because poor communication among the family members is affecting family processes. No data suggest a change in lifestyle or its role as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities. DIF: Cognitive Level: Apply (application) REF: 279-280 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? a. Hematocrit of 30% b. Platelets of 95,000/µL c. Hemoglobin of 10 g/L d. White blood cell (WBC) count of 2700/µL

ANS: D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy. DIF: Cognitive Level: Apply (application) REF: 265 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution.

ANS: D The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended. DIF: Cognitive Level: Apply (application) REF: 266 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? a. "After cancer has not recurred for 5 years, it is considered cured." b. "The cancer will be cured if the entire tumor is surgically removed." c. "Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and radiation." d. "I will need to have follow-up examinations for many years after I have treatment before I can be considered cured."

ANS: D The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up. DIF: Cognitive Level: Apply (application) REF: 257 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration? a. Teach the patient to rest the brain by avoiding new activities. b. Teach that "chemo-brain" is a short-term effect of chemotherapy. c. Report patient symptoms immediately to the health care provider. d. Suggest use of a daily planner and encourage adequate rest and sleep.

ANS: D Use of tools to enhance memory and concentration such as a daily planner and adequate rest are helpful for patients who develop "chemo-brain" while receiving chemotherapy. Patients should be encouraged to exercise the brain through new activities. Chemo-brain may be short- or long-term. There is no urgent need to report common chemotherapy side effects to the provider. DIF: Cognitive Level: Apply (application) REF: 267 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 52-year-old patient who has no previous history of hypertension or other health problems suddenly develops a BP of 188/106 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that a. a BP recheck should be scheduled in a few weeks. b. the dietary sodium and fat content should be decreased. c. there is an immediate danger of a stroke and hospitalization will be required. d. more diagnostic testing may be needed to determine the cause of the hypertension.

ANS: D A sudden increase in BP in a patient over age 50 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need rapid treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

The nurse has just finished teaching a hypertensive patient about the newly prescribed quinapril (Accupril). Which patient statement indicates that more teaching is needed? a. "The medication may not work as well if I take any aspirin." b. "The doctor may order a blood potassium level occasionally." c. "I will call the doctor if I notice that I have a frequent cough." d. "I won't worry if I have a little swelling around my lips and face."

ANS: D Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.

When a patient with hypertension who has a new prescription for atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit, the BP is unchanged from the previous visit. Which action should the nurse take first? a. Provide information about the use of multiple drugs to treat hypertension. b. Teach the patient about the reasons for a possible change in drug therapy. c. Remind the patient that lifestyle changes also are important in BP control. d. Question the patient about whether the medication is actually being taken.

ANS: D Since noncompliance with antihypertensive therapy is common, the nurse's initial action should be to determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be done after assessing patient compliance with the prescribed therapy.

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of dietary protein. c. The patient has only one cup of coffee in the morning. d. The patient has a glass of low-fat milk with each meal.

ANS: D The Dietary Approaches to Stop Hypertension (DASH) recommendations for prevention of hypertension include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

A patient has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which information is important to include when teaching the patient? a. Check BP daily before taking the medication. b. Increase fluid intake if dryness of the mouth is a problem. c. Include high-potassium foods such as bananas in the diet. d. Change position slowly to help prevent dizziness and falls.

ANS: D The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the medication, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP does not need to be checked at home by the patient before taking the medication. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

The most basic information a maternity nurse should have concerning conception is that: a. Ova are considered fertile 48 to 72 hours after ovulation. b. Sperm remain viable in the womans reproductive system for an average of 12 to 24 hours. c. Conception is achieved when a sperm successfully penetrates the membrane surrounding the ovum. d. Implantation in the endometrium occurs 6 to 10 days after conception.

ANS: D - After implantation, the endometrium is called the decidua. Ova are considered fertile for about 24 hours after ovulation. Sperm remain viable in the womans reproductive system for an average of 2 to 3 days. Penetration of the ovum by the sperm is called fertilization. Conception occurs when the zygote, the first cell of the new individual, is formed.

The _____ is/are responsible for oxygen and carbon dioxide transport to and from the maternal bloodstream. a. Decidua basalis c. Germ layer b. Blastocyst d. Chorionic villi

ANS: D - Chorionic villi are fingerlike projections that develop out of the trophoblast and extend into the blood-filled spaces of the endometrium. The villi obtain oxygen and nutrients from the maternal bloodstream and dispose of carbon dioxide and waste products into the maternal blood. The decidua basalis is the portion of the decidua (endometrium) under the blastocyst where the villi attach. The blastocyst is the embryonic development stage after the morula. Implantation occurs at this stage. The germ layer is a layer of the blastocyst.

A woman who is 8 months pregnant asks the nurse, Does my baby have any antibodies to fight infection? The most appropriate response by the nurse is: a. Your baby has all the immune globulins necessary: IgG, IgM, and IgA. b. Your baby wont receive any antibodies until he is born and you breastfeed him. c. Your baby does not have any antibodies to fight infection. d. Your baby has IgG and IgM.

ANS: D - During the third trimester, the only immune globulins that crosses the placenta, IgG, provides passive acquired immunity to specific bacterial toxins. The fetus produces IgM by the end of the first trimester. IgA is not produced by the baby. By the third trimester, the fetus has IgG and IgM. Breastfeeding supplies the baby with IgA. Your baby does not have any antibodies to fight infection is an inaccurate statement.

With regard to the estimation and interpretation of the recurrence of risks for genetic disorders, nurses should be aware that: a. With a dominant disorder, the likelihood of the second child also having the condition is 100%. b. An autosomal recessive disease carries a one in eight risk of the second child also having the disorder. c. Disorders involving maternal ingestion of drugs carry a one in four chance of being repeated in the second child. d. The risk factor remains the same no matter how many affected children are already in the family.

ANS: D - Each pregnancy is an independent event. The risk factor (e.g., one in two, one in four) remains the same for each child, no matter how many children are born to the family. In a dominant disorder, the likelihood of recurrence in subsequent children is 50% (one in two). An autosomal recessive disease carries a one in four chance of recurrence. In disorders involving maternal ingestion of drugs, subsequent children would be at risk only if the mother continued to take drugs; the rate of risk would be difficult to calculate.

Some of the embryos intestines remain within the umbilical cord during the embryonic period because the: a. Umbilical cord is much larger at this time than it will be at the end of pregnancy. b. Intestines begin their development within the umbilical cord. c. Nutrient content of the blood is higher in this location. d. Abdomen is too small to contain all the organs while they are developing.

ANS: D - The abdominal contents grow more rapidly than the abdominal cavity, so part of their development takes place in the umbilical cord. By 10 weeks of gestation, the abdomen is large enough to contain them. Intestines begin their development within the umbilical cord, but only because the liver and kidneys occupy most of the abdominal cavity. Blood supply is adequate in all areas.

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. Patient complains of severe fatigue. b. Patient needs to void every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has audible crackles to the midline posterior chest.

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. Patient complains of severe fatigue. b. Patient needs to void every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has audible crackles to the midline posterior chest.