Unit 6 Exam Review - Theory

A nurse is planning care for a group of hospitalized children. Which age group does the nurse anticipate will have the most problem with separation anxiety? 1. 5 to 11 years 2. 12 to 18 years 3. 6 to 30 months 4. 36 to 59 month

3. 6 to 30 months

A client is treated with lorazepam for status epilepticus. What effect of lorazepam does the nurse consider therapeutic? 1. Slows cardiac contractions 2. Dilates tracheobronchial structures 3. Depresses the central nervous system (CNS) 4. Provides amnesia for the convulsive episode

3. Depresses the central nervous system (CNS) Lorazepam, an anxiolytic and sedative, is used to treat status epilepticus because it depresses the CNS. Slower cardiac contractions are not an effect of lorazepa

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what? 1. Restore the client's health. 2. Promote the client's recovery. 3. Relieve the client's discomfort. 4. Support the client's significant others

3. Relieve the client's discomfort.

What are the important points to be considered when imparting practical knowledge to nursing students about preventing complications in the hospital? Select all that apply. 1. Nursing students are not accountable if a client is harmed. 2. Nursing students should never be assigned any tasks they are unprepared for. 3. Nursing students are employees of the hospital and may act as witnesses to consent forms. 4. Nursing students can work as nursing assistants or nurse's aides when not attending classes. 5. Nursing students should notify the nursing supervisor in case they are delegated tasks they are not prepared for.

2. Nursing students should never be assigned any tasks they are unprepared for. 4. Nursing students can work as nursing assistants or nurse's aides when not attending classes. 5. Nursing students should notify the nursing supervisor in case they are delegated tasks they are not prepared for.

A 30-year-old woman is scheduled for a total abdominal hysterectomy because of noninvasive endometrial cancer. The nurse anticipates the client may have difficulty adjusting emotionally to this type of surgery. What is the most common reason for this difficulty? 1. Loss of femininity 2. Body image changes 3. Diminished sexual desire 4. Slow postmenopausal recovery

1. Loss of femininity

A client who recently has had an abdominoperineal resection and colostomy accuses the nurse of being uncomfortable during a dressing change because the "wound looks terrible." The nurse identifies the client as using which defense mechanism? 1. Projection 2. Sublimation 3. Compensation 4. Intellectualization

1. Projection

A nurse is obtaining consent from an unemancipated minor to perform an abortion. When would the nurse consider the consent-giving process to be appropriately completed? Select all that apply. 1. When consent has been obtained from the spouse 2. When consent has been given specifically by a court 3. When self-consent has been granted by a court order 4. When consent has been given by a grandparent 5. When consent has been obtained from at least one parent of the minor

2. When consent has been given specifically by a court 3. When self-consent has been granted by a court order 5. When consent has been obtained from at least one parent of the minor

When do you teach postop exercises? 1. postop 2. preop

2. preop

A young pregnant adolescent is diagnosed as having bacterial vaginosis. What further complications related to bacterial vaginosis may occur during pregnancy? Select all that apply. 1. Neonatal sepsis 2. Cervical dysplasia 3. Preterm labor and birth 4. Intraamniotic infection 5. Postpartum endometritis

3. Preterm labor and birth 4. Intraamniotic infection 5. Postpartum endometritis Preterm birth and labor may occur because bacteria that enters the cervix irritates the uterus, which cause contractions. Bacterial vaginosis is associated with high risk of intraamniotic infection and postpartum endometritis.

A client who had previously signed a consent form for a liver biopsy reconsiders and decides not to have the procedure. What is the nurse's best initial response? 1. "Why did you sign the consent form originally?" 2. "I can understand why you changed your mind." 3. "Can you tell me your reasons for refusing the procedure?" 4. "You must be afraid about something concerning the procedure."

3. "Can you tell me your reasons for refusing the procedure?"

A nurse is discussing sexuality with a teenage female who has cystic fibrosis. Which statement best reflects the teenager's understanding of healthy sexuality? 1. "I can never get pregnant." 2. "Having sex is not possible for me." 3. "My best protection is a diaphragm." 4. "I won't have sex unless I use a condom."

4. "I won't have sex unless I use a condom."

How can we treat someone with shortness of breath?

Sit them up and do diaphragmatic breathing with them

A registered nurse is teaching a nursing student about the components of the magnet model. What information should the registered nurse provide about exemplary professional practice according to the revised magnet model? 1. "Strong professional practice is established, and accomplishments of the practice are demonstrated." 2. "A vision for the future and the systems and resources to achieve the vision are created by nursing leaders." 3. "Focus is on structure and processes and demonstration of positive clinical, work force, and client and organizational outcomes." 4. "Structures and processes provide an innovative environment in which staff are developed and empowered and professional practice flourishes."

1. "Strong professional practice is established, and accomplishments of the practice are demonstrated." Exemplary professional practice is evident when a strong professional practice is established, and accomplishments of the practice are demonstrated. The characteristic of transformational leadership is a vision for the future and the systems and resources to achieve the vision are created by nursing leaders. The characteristic of empirical quality outcomes is that the focus is on structure and processes and demonstration of positive clinical, work force, and client and organizational outcomes. The characteristic of structural empowerment includes structures and processes to provide an innovative environment in which staff are developed and empowered and professional practice flourishes.

An older widow with lung cancer is now in the terminal stage of her illness. Her family is puzzled by her mood changes and apparent anger at them. The nurse explains to the family that the client is doing what? 1. Trying to avoid her situation 2. Coping with her impending death 3. Attempting to reduce family dependence on her 4. Hurting because the family will not take her home to die

2. Coping with her impending death

When should a medical examiner decide whether a postmortem examination should be conducted? 1. When a client dies under normal circumstances 2. When a client dies after 48 hours of admission to the hospital 3. When a client dies within 24 hours of admission to the hospital 4. When the client gives a written consent to perform autopsy before death

3. When a client dies within 24 hours of admission to the hospital

The nurse is performing an assessment of a client's reproductive system. Which action should the nurse take? 1. Maintain friendly demeanor with the client during assessment 2. Ask about sexual practices at the beginning of assessment 3. Ask about menstrual history at the beginning of assessment 4. Maintain gender-specific terms while questioning during assessment

3. Ask about menstrual history at the beginning of assessment It is necessary to gather health information as part of an assessment of the reproductive system. The nurse should always start the questioning with minimally sensitive information such as menstrual history. This will help the client adjust gradually.

An 18-year-old adolescent who was diagnosed with new-onset type 1 diabetes mellitus has stress and reports not having a menstrual cycle for a long time. Which condition is the adolescent experiencing? 1. Amenorrhea 2. Primary amenorrhea 3. Female athlete triad 4. Hypogonadotropic amenorrhea

4. Hypogonadotropic amenorrhea Hypogonadotropic amenorrhea may occur in type 1 diabetic adolescents experiencing stress. This condition can also result from sudden and severe weight loss, eating disorders, strenuous exercise, and mental illness.

Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1. Anger 2. Denial 3. Depression 4. Acceptance

4. Acceptance

A client at 16 weeks' gestation is scheduled for a sonogram followed by amniocentesis. The nurse instructs the client to drink 8 oz (237 mL) of fluid and not void before the sonogram. What should the nurse explain as the purpose of this? 1. To improve visualization of the fetus 2. To hydrate the mother and increase circulation 3. To hydrate the fetus and decrease fetal movement 4. To replace fluid lost during the procedure

1. To improve visualization of the fetus A full bladder places the uterus in the optimal position for imaging because it raises the uterus out of the pelvis. Increased circulation is not required before a sonogram and amniocentesis.

During her first prenatal visit the client reports that her last menstrual period began on April 15. According to Nägele rule, what is the expected date of delivery (EDD)? 1. January 8 2. January 22 3. February 8 4. February 22

2. January 22 To determine EDD with the use of Nägele rule, subtract 3 months from the date of the last menstrual period and add 7 days. January 8 is 2 weeks too early according to this formula.

What is a clinical manifestation of hypernatremia in burns? 1. Fatigue 2. Seizures 3. Paresthesias 4. Cardiac dysrhythmias

2. Seizures Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.

A 1-week-old infant has been in the pediatric unit for 18 hours after placement of a spica cast. The nurse obtains a respiratory rate slower than 24 breaths/min; no other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later the infant experiences severe respiratory distress, and emergency care is necessary. What should be considered if legal action is taken? 1. Most infants' respirations are slow when they are uncomfortable. 2. The respirations of young infants are irregular, so a drop in rate is unimportant. 3. Vital signs that are outside the expected parameters are significant and should be documented. 4. The respiratory tracts of young infants are underdeveloped, and the respiratory rate is not significant.

3. Vital signs that are outside the expected parameters are significant and should be documented.

A client complains of pain in the ear. While examining the client, a nurse finds swelling in front of the left ear. Which lymph node does the nurse expect to be involved? 1. Mastoid 2. Occipital 3. Submental 4. Pre-auricular

4. Pre-auricular

A nurse is planning to administer albuterol to a 4-year-old child. How will the nurse evaluate the effectiveness of this medication? 1. Auscultate breath sounds 2. Collect a sputum sample 3. Conduct a brief neurologic examination 4. Palpate chest excursion to gauge promotion of intercostal contractility

1. Auscultate breath sounds Albuterol is an adrenergic drug that stimulates beta-receptors, leading to relaxation of the smooth muscles of the airway. The lungs should be auscultated to evaluate the effectiveness of this medication

The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections? 1. Immunologic differences between adults and young children 2. Structural differences between eustachian tubes of younger and older children 3. Functional differences between eustachian tubes of younger and older children 4. Circumference differences between middle ear cavity size of adults and young children

2. Structural differences between eustachian tubes of younger and older children The eustachian tube in young children is shorter and wider, allowing a reflux of nasopharyngeal secretions. Immunologic differences are not a factor in the development of otitis media.

An 8-year-old child with a terminal illness is demanding of the staff. The child asks for many privileges that other children on the unit do not have. The staff members know that the child does not have long to live. The nurse can best help the staff members cope with the child's demands by encouraging them to do what? 1. Provide as many extra treats as possible because the child is dying. 2. Set reasonable limits to help the child feel more secure and content. 3. Give the child some extra treats so they will feel less anxiety after the child dies. 4. Understand that the dying child has unique needs and that special privileges can provide the necessary security.

2. Set reasonable limits to help the child feel more secure and content.

Three days after a stressful incident a client can no longer remember why it was stressful. The nurse, in relating to this client, can be most therapeutic by identifying that the inability to recall the situation is an example of what defense mechanism? 1. Denial 2. Regression 3. Repression 4. Dissociation

3. Repression

Which vaccine is used to prevent a human papilloma virus infection? 1. Varivax 2. RotaTeq 3. Gardasil 4. Hepatitis A vaccine

3. Gardasil Gardasil is a quadrivalent vaccine used to prevent genital cancers and warts caused by human papilloma virus. Varivax is associated with protection from the varicella virus; this vaccine is sometimes given in combination with the MMR vaccine. The RotaTeq vaccine is used to vaccinate against a rotavirus infection. The hepatitis A vaccine is used to protect against the hepatitis A virus.

A nurse is measuring the blood pressure of toddlers during a community health camp. What blood pressure finding is the nurse most often to find in the toddlers? 1. 85/54 mm Hg 2. 95/65 mm Hg 3. 105/65 mm Hg 4. 110/65 mm Hg

2. 95/65 mm Hg The nurse is most likely to find 95/65 mm Hg as a toddler's blood pressure because this is the normal blood pressure of toddlers. The normal blood pressure in infants is 85/54 mm Hg. The optimal blood pressure for children above the age of 6 years is 105/65 mm Hg. Between the ages of 10 and 13 years, normal blood pressure is 110/65 mm Hg.

The nurse plans to provide a back massage to a client. What should the nurse do first in this situation? 1. Assist the client into an appropriate position. 2. Start massaging the client as soon as possible. 3. Assess the client's preference for touch and massage. 4. Provide information regarding the massage procedure.

3. Assess the client's preference for touch and massage.

A cognitively impaired client's family member requests that the nurse list the benefits of using a respite care service. What information should the nurse provide about respite care services? Select all that apply. 1. "They are offered at home, in a day care setting, or in a health care institution that provides overnight care." 2. "They include services like laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping." 3. "A group of residents live together, but each resident has his or her own room and shares dining and social activity areas." 4. "Medicare health care plans do not cover this service, and Medicaid has strict requirements for services and eligibility." 5. "It is a service that provides short-term relief or "time off" for people providing home care to an ill, disabled, or frail older adult."

1. "They are offered at home, in a day care setting, or in a health care institution that provides overnight care." 4. "Medicare health care plans do not cover this service, and Medicaid has strict requirements for services and eligibility." 5. "It is a service that provides short-term relief or "time off" for people providing home care to an ill, disabled, or frail older adult."

How does exercise help relieve menstrual discomfort in adolescents? Select all that apply. 1. By reducing ischemia 2. By decreasing vasodilation 3. By increasing prostaglandins 4. By reducing pelvic discomfort 5. By releasing endogenous opiates

1. By reducing ischemia 4. By reducing pelvic discomfort 5. By releasing endogenous opiates

An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply. 1. Decreased thirst 2. Weak pulse 3. Increased pulse rate 4. Difficulty swallowing 5. Loss of bladder control

1. Decreased thirst 2. Weak pulse 4. Difficulty swallowing 5. Loss of bladder control

What is gynecomastia? Select all that apply. 1. Inflammation of epididymis of testis 2. Suspended testis from its vascular structures 3. Bilateral or unilateral enlargement of breast in adolescent boys 4. Elongation and dilation of the veins of the spermatic cord superior to the testicle 5. An unusual physical change during the growth and development of sexual organs

3. Bilateral or unilateral enlargement of breast in adolescent boys 5. An unusual physical change during the growth and development of sexual organs

What statement by a male client during a yearly physical examination indicates to a nurse that the client may have a sexual arousal disorder? 1. "I have no interest in sex." 2. "I don't get hard during sex anymore." 3. "I climax almost before we even get started." 4. "It takes forever before I finally have an orgasm."

2. "I don't get hard during sex anymore."

A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult. How should the nurse respond? 1. "Your lower rib cage is more restricted." 2. "Your diaphragm has been displaced upward." 3. "Your lungs have increased in size since you got pregnant." 4. "The height of your rib cage has increased since you got pregnant."

2. "Your diaphragm has been displaced upward." The pressure of the enlarging fetus causes upward displacement of the diaphragm, which results in thoracic breathing; this limits the descent of the diaphragm on inspiration

A client who recently was told by her primary healthcare provider that she has extensive terminal metastatic carcinoma of the breast tells the nurse that she believes an error has been made. She states that she does not have breast cancer, and she is not going to die. The nurse determines that the client is experiencing which stage of death and dying? 1. Anger 2. Denial 3. Bargaining 4. Acceptance

2. Denial

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? 1. Anger 2. Denial 3. Bargaining 4. Depression

2. Denial

A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates? 1. Elevate the IV site. 2. Discontinue the infusion. 3. Attempt to flush the tubing. 4. Apply a warm, moist compress

2. Discontinue the infusion.

An adolescent reports scrotal pain, redness, dysuria, and fever. Which condition does this adolescent have? 1. Varicocele 2. Epididymitis 3. Testicular torsion 4. Testicular cancer

2. Epididymitis Epididymitis is a condition associated with scrotal pain, dysuria, redness, and fever. Varicocele can be palpated as a worm-like mass situated above the testicles. Manifestations of testicular torsion include nausea, vomiting, and abdominal pain. The presence of a heavy, hard mass that is palpable accompanied by back pain and shortness of breath is associated with testicular cancer.

A registered nurse assesses a client's electronic medical record (EMR) and observes increased blood pressure, severe myopia, and blood glucose levels. Which type of eye disorder will the nurse most likely observe written in the EMR? 1. Cataract 2. Glaucoma 3. Corneal abrasions 4. Keratoconjunctivitis sicca

2. Glaucoma The common causes for glaucoma are associated conditions such as diabetes mellitus, hypertension, and severe myopia. Therefore a client with these diseases is at higher risk for glaucoma.

A client who just has been diagnosed with primary open-angle glaucoma (POAG) refuses therapy. The nurse reinforces that it is important for the client to seek treatment. Which goal is the nurse trying to achieve? 1. Prevent cataracts 2. Prevent blindness 3. Prevent retinal detachment 4. Prevent blurred distance vision

2. Prevent blindness POAG progresses gradually without symptoms; if untreated, blindness occurs. Peripheral vision slowly disappears until tunnel vision occurs in which there is only a small center field. Without treatment, eventually all vision is lost.

After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis? 1. Nodules on the pinna 2. Redness of the eardrum 3. Lesions in the external canal 4. Excessive soft cerumen in the external canal

2. Redness of the eardrum Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination

What is the professional nurse's legal responsibility regarding child abuse? 1. Honor the request of the parents not to report the suspected abuse. 2. Report any suspected abuse to local law enforcement authorities. 3. Return the child to the legal parent even if he or she is suspected of abuse. 4. Provide the parents with a copy of the child's medical record.

2. Report any suspected abuse to local law enforcement authorities.

A client asks a nurse for contraceptive information regarding a number of different methods available. What information should the nurse include as part of the teaching plan? 1. Sperm cannot reach the ovum if the male uses coitus interruptus. 2. The rim of a condom must be held in place while the penis is withdrawn from the vagina. 3. Diaphragms are equally effective even if the partners choose not to use spermicidal creams. 4. Individuals who use periodic abstinence should have intercourse on days when the woman has an increase in temperature.

2. The rim of a condom must be held in place while the penis is withdrawn from the vagina. Unless the condom is held firmly, it can be displaced, allowing the sperm to enter the vagina. Sperm may be deposited at the beginning of intercourse, without the man's knowledge

What services do nurse-managed clinics provide in preventive and primary care services? Select all that apply. 1. Crisis intervention 2. Wellness counseling 3. Health risk appraisal 4. Employment readiness 5. Communicable disease control

2. Wellness counseling 3. Health risk appraisal 4. Employment readiness

Which nutrient deficiency in the pregnant adolescent may result in decreased birth weight as a consequence of low bone mineral density in the fetus? 1. Zinc 2. Iron 3. Calcium 4. Folic acid

3. Calcium Calcium and vitamin deficiency may result in decreased birth weight as a consequence of low bone mineral density. Zinc deficiency may not lead to a decrease in bone mineral density. Iron deficiency may lead to anemia. Folic acid deficiency may result in neural tube defects.

Before discharge, a breastfeeding postpartum client and the nurse discuss methods of birth control. The client asks the nurse, "When will I begin to ovulate again?" How should the nurse respond? 1. "You should discuss this at your first clinic visit." 2. "Ovulation will occur after you stop breastfeeding." 3. "Ovulation may occur before you begin to menstruate." 4. "I really can't tell you, because everyone is so different.

3. "Ovulation may occur before you begin to menstruate." If the client is breastfeeding, ovulation and fertility may occur before menstruation resumes. It is the nurse's responsibility to answer the client's questions rather than putting the client off. Ovulation may occur while a woman is breastfeeding because the process of follicular maturation begins when the prolactin level decreases.

While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16 breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? 1. Recording these expected findings 2. Obtaining an order for an oxytocic medication 3. Asking the client when she last changed the perineal pad 4. Notifying the primary healthcare provider that the client may be hemorrhaging

3. Asking the client when she last changed the perineal pad The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia. These findings cannot be supported or recorded without additional information. Oxytocics are administered for uterine atony; the need for this is not supported by the assessment of a firm fundus. The vital signs do not indicate hemorrhage; further assessment is needed before the nurse comes to this conclusion.

A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? 1. Add a placebo to the morphine to appease the spouse. 2. Discuss with the spouse the risk for morphine addiction. 3. Assess the client's pain before increasing the dose of morphine. 4. Check the client's heart rate before increasing the morphine to the next level.

3. Assess the client's pain before increasing the dose of morphine.

While caring for a client who was critically injured in an earthquake, the nurse expects that the client will not survive. Which interventions should the nurse follow while dealing with family members after the death of the client? Select all that apply. 1. Expressing intense grief 2. Avoiding concrete language 3. Coordinating with crisis staff 4. Avoiding words such as "death" or "died" 5. Offering the option of speaking to a clergy

3. Coordinating with crisis staff 5. Offering the option of speaking to a clergy

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? 1. Increase left ventricular filling and improve cardiac output 2. Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias 3. Decrease the workload on the heart and promote maximum coronary artery filling 4. Increase venous return to the right atrium and increase pulmonary arterial blood flow

3. Decrease the workload on the heart and promote maximum coronary artery filling

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1. Apathy 2. Euphoria 3. Detachment 4. Emotionalism

3. Detachment When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic, but still may be concerned and use time constructively. Although resigned to death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed.

A 16-year-old client has a steady boyfriend with whom she is having sexual relations. She asks the nurse how she can protect herself from contracting human immunodeficiency virus (HIV). Which guidance is most appropriate for the nurse to provide? 1. Ask her partner to withdraw before ejaculating. 2. Make certain their relationship is monogamous. 3. Insist that her partner use a condom when having sex. 4. Seek counseling about various contraceptive methods.

3. Insist that her partner use a condom when having sex. A condom covers the penis and contains the semen when it is ejaculated; semen contains a high percentage of HIV in infected individuals. Preejaculatory fluid carries HIV in an infected individual, so withdrawing before ejaculation is not effective. Although a monogamous relationship is less risky than having multiple sexual partners, if one partner is HIV positive, the other person is at risk for acquiring HIV. The client is not asking about various contraceptive methods. Most contraceptives do not provide protection from HIV.

A drug is administered to a client in her third trimester of pregnancy. Which statement regarding the drug administration is correct? 1. All drugs should not be given to the pregnant client. 2. The dose of a drug should not be altered for a pregnant client. 3. The dose of a drug should be increased for pregnant clients. 4. The dose of a drug should be decreased for pregnant clients.

3. The dose of a drug should be increased for pregnant clients. During pregnancy, a client's hepatic metabolism and glomerular filtration are increased. As a result, the excretion rate is faster. Therefore the dose of a drug should be increased for the drug action to be optimal.

A pregnant client tells the nurse that she thinks she has developed an allergy because her nose is often very congested and she has difficulty breathing. How should the nurse reply? 1. "Use a nasal decongestant at least twice a day." 2. "It is common for allergies to develop during pregnancy." 3. "That is not normal; you may have a chronic respiratory infection." 4. "That is an expected occurrence; the increased hormones are responsible for the congestion."

4. "That is an expected occurrence; the increased hormones are responsible for the congestion." Increased estrogen and progesterone levels during pregnancy cause increased vascularization and resultant congestion of mucous membranes. Nasal decongestants are not advised during pregnancy. The pregnant client should consult her healthcare provider before using any medication. It is not common for allergies to develop during pregnancy if the client did not experience allergy symptoms before conception.

A client experiencing a tremendously stressful situation says, "My baby was diagnosed with terminal cancer 2 months ago. I'm either crying or walking around like I'm in a dream. I can't believe this is happening. What did we do to deserve something so horrible? The doctors can transplant almost every human organ, but they can't stop my baby from dying. I'm so angry. Most days I just want to take my child and run away." The nurse determines that the client is mainly expressing what? 1. Anger 2. Denial 3. Avoidance 4. Anticipatory grief

4. Anticipatory grief Anticipatory grief is an intellectual and emotional response to a potential loss. Signs include a sense of disbelief and numbness. Emotions swing from sadness to anger. Individuals express the desire to avoid the situation by running away and an intense feeling of anger toward the medical community for failing to save their loved one.

Which statement is true for attachment in the newborn? 1. Attachment occurs for the first 28 days. 2. Attachment begins in the first week of birth. 3. Attachment is the overlapping of soft skull bones. 4. Attachment is the interaction between parent and child.

4. Attachment is the interaction between parent and child.

A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication does the nurse suspect? 1. Hydatidiform mole 2. Vena cava syndrome 3. Marginal placenta previa 4. Complete abruptio placentae

4. Complete abruptio placentae Severe pain accompanied by bleeding at term or close to it is symptomatic of complete premature detachment of the placenta (abruptio placentae). A hydatidiform mole is diagnosed before 36 weeks' gestation; it is not accompanied by severe pain. There is no bleeding with vena cava syndrome. Bleeding caused by placenta previa should not be painful.

A nurse in a hospice program cares for clients and family members who are coping with imminent loss. What is the most important factor in predicting a person's potential reaction to grief? 1. Family interactions 2. Social support system 3. Emotional relationships 4. Earlier experiences with grief

4. Earlier experiences with grief

A pregnant client in the first trimester is experiencing nausea and vomiting. What does the nurse determine about this discomfort? 1. It is always present during early pregnancy. 2. It will disappear when lightening occurs. 3. It is a common response to an unwanted pregnancy. 4. It may be related to an increased human chorionic gonadotropin level.

4. It may be related to an increased human chorionic gonadotropin level. An increased level of human chorionic gonadotropin, or hCG, may cause nausea and vomiting, but the exact reason is unknown

What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? 1. Scant alba 2. Scant rubra 3. Moderate rubra 4. Moderate serosa

4. Moderate serosa On the third to fourth day the uterine discharge becomes pink to brown; it continues until approximately the 10th day. After about 10 days the uterine discharge becomes yellow to white (alba); alba may continue until 2 to 6 weeks after the birth. It is unusual to have scant lochia rubra. Lochia rubra lasts from the first to about the third day; it is usually heavy but may be moderate after a few days.

A client is admitted to the birthing unit in active labor. Which physiologic changes should the nurse anticipate after an amniotomy is performed? 1. Diminished bloody show 2. Increased and more variable fetal heart rate 3. Less discomfort with contractions 4. Progressive dilation and effacement

4. Progressive dilation and effacement Artificial rupture of the membranes (amniotomy) allows more effective exertion of pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Amniotomy does not directly affect the fetal heart rate. Discomfort may become greater because contractions usually increase in intensity and frequency after the membranes are artificially ruptured.