Exam 1: Communication and Documentation Questions

A husband sits in the waiting room while his wife is getting her infertility prescription refilled by the clinic pharmacist. As the nurse sits down beside him, he blurts, "It's like there are three of us in bed—my wife, me, and the doctor." Which feeling is reflected by this statement? 1. guilt 2. anger 3. depression 4. unworthiness

2 rationale: Anger is a coping strategy that allows a person to gain a sense of control over life; the husband feels a loss of control over the spontaneity of his intimate relationship with his wife because intercourse is now based on administration of the fertility medications. There is no evidence that the client is feeling guilty. The client is not withdrawing or expressing sadness, dejection, or lethargy. There is no evidence that the client feels undeserving of an intimate relationship.

The nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features did the nurse observe? Select all that apply. 1. hypotonia 2. webbed neck 3. female sex organs 4. rocker-bottom feet 5. widely spaced nipples

2, 3, 5 rationale: The broad, webbed neck is an outstanding characteristic of the newborn with Turner syndrome. All infants with Turner syndrome are female because their one sex chromosome is the X chromosome; although they have female sex organs, the organs are underdeveloped, and affected individuals are infertile. Widely spaced nipples are also a characteristic of Turner syndrome. Hypotonia is typical of newborns with Down syndrome and trisomy 18. Rocker-bottom feet are found in infants with trisomy 18.

A nurse is interviewing a client. Which of these statements is an example of an open-ended question? 1. who helps you at home 2. are you having pain now 3. tell me how you are feeling 4. do you think the medication is helping you

3 rationale: Asking the client how he or she is feeling now is an example of an open-ended question. Open-ended questions prompt clients to describe a situation in more than one or two words. Asking a client about who is assisting him or her at home, asking if the client is having pain, and asking if the medication is helping are all examples of closed-ended questions. This approach limits answers to one or two words such as a yes, a no, a caretaker's name, or a number.

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 rationale: An increased level of human chorionic gonadotropin, or hCG, may cause nausea and vomiting, but the exact reason is unknown. Some pregnant women do not experience nausea and vomiting. Lightening occurs at the end of the third trimester; nausea and vomiting usually cease at the end of the first trimester. Nausea and vomiting are unrelated to whether a pregnancy is desired or unwanted.

A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. Which condition does the nurse suspect? 1. chlamydia trachomatis infection 2. human immunodeficiency virus (HIV) infection 3. retinopathy of prematurity (retrolental fibroplasia) 4. a reaction to the ophthalmic antibiotic instilled after birth

1 rationale: Chlamydia trachomatis infection occurs 3 to 4 days after birth; if it is not treated prophylactically with an antibiotic at birth or within 3 days, chronic follicular conjunctivitis with conjunctival scarring will occur. HIV infection in the newborn does not manifest with conjunctivitis. The high oxygen concentrations given to severely compromised preterm infants cause vasoconstriction of retinal capillaries, which can lead to blindness; there are no data to indicate that this infant was preterm, severely compromised, or received oxygen. A chemical conjunctivitis occurs within the first 48 hours and is not purulent.

A school nurse is asked to screen children in a third-grade class for head lice. In light of an 8-year-old's developmental level, how should the nurse first address the class? 1. describe what head lice are and how they look 2. teach the importance of daily hair washing and not to share combs 3. explain that every student must be checked because head lice are spread easily 4. tell them that if they have head lice the rest of the family will become infected

1 rationale: School-aged children have reached the cognitive level of concrete operations that enables them to understand relationships between things and ideas. They can conceptualize what head lice look like, and if they see them they will recognize them by the description. Teaching them how to help prevent head lice and how to prevent the spread of head lice should be presented after the students understand the basic information about head lice.

A client who was admitted to the hospital with metastatic cancer has a temperature of 100.4° F (38° C), a distended abdomen, and abdominal pain. The client asks the nurse, "Do you think that I'm going to have surgery?" How should the nurse respond? 1. you seem concerned about having surgery 2. some people with your problem do have surgery 3. ill find out for you. your record will show if surgery is scheduled. 4. i don't know about any surgery. you'll have to ask your healthcare provider

1 rationale: The correct statement is open-ended and encourages the client to verbalize concerns. Nothing in the situation indicates that surgery is planned; this response may increase anxiety. "I'll find out for you. Your record will show if surgery is scheduled" and "I don't know about any surgery. You'll have to ask your healthcare provider" cut off communication.

The primary healthcare provider determines that a fetus is in a breech presentation. Which complication should the nurse monitor this client for? 1. rapid dilation of the cervix, indicating precipitate labor 2. stronger contractions, indicating progression of the labor 3. non-reassuring fetal signs, indicating prolapse of the cord 4. cessation of contractions, indicating primary uterine inertia

3 rationale: The feet or buttocks are not effective in blocking the cervical opening, and the cord may slip through and become compressed. Rapid dilation and precipitate labor are more likely to occur if the fetus is in a cephalic presentation. Stronger contractions, indicating progression of labor, are an expected occurrence. Uterine inertia may result from fatigue or cephalopelvic disproportion and is not related directly to fetal presentation.

A client at 31 weeks' gestation is admitted in preterm labor. What class of drugs might the nurse anticipate being prescribed? 1. an oxytocic 2. an analgesic 3. a corticosteroid 4. a beta-adrenergic

4 rationale: Beta-adrenergic medications are tocolytic agents that may halt labor, although only temporarily. Other tocolytics that may be used are magnesium sulfate, prostaglandin inhibitors, and calcium channel blockers. Oxytocin is a hormone that is secreted by the posterior pituitary gland; it stimulates contractions and is released after birth to initiate the let-down reflex. Analgesics do not halt preterm labor. Corticosteroids do not halt labor; they are used during preterm labor to accelerate fetal lung maturity, when birth is likely to occur within 24 to 48 hours.

A nurse teaches a new mother about neonatal weight loss in the first 3 days of life. How does the nurse explain the cause of this weight loss? 1. an allergy to formula 2. a hypoglycemic response 3. ineffective feeding techniques 4. excretion of accumulated excess fluids

4 rationale: Early weight loss occurs because excess fluid is lost, not body mass. Weight loss is expected; there are no data to support an allergic response. Weight loss is not related to hypoglycemia. Neither breast nor formula feeding will prevent the 10% weight loss that is expected in the first few days of life.

During the first hour after a cesarean birth, a nurse notes that the client's lochia has saturated one perineal pad. In light of the knowledge of expected lochial flow, what should the nurse conclude that this may be an indication of? 1. scant lochial flow 2. postpartum hemorrhage 3. retained placental fragments 4. lochial flow within expected limits

4 rationale: It is expected that as many as two perineal pads will be saturated in the first hour. A scant flow probably would not saturate even one pad. Hemorrhage would saturate more than two pads in 1 hour. Retained placental fragments would be accompanied by heavy bleeding and require more than two pads during the first hour.

Six hours after a femoropopliteal bypass graft, the client's blood pressure becomes severely elevated. What is the primary reason the nurse notifies the surgeon? 1.the increased blood pressure can cause the graft to occlude 2. the hypervolemia needs to be corrected immediately 3. the client's cardiovascular status can precipitate a brain attack 4. the client's intra-arterial pressure may compromise the graft's viability

4 rationale: The client is hypertensive, and the intraarterial pressure is elevated; this increased pressure can cause the arterial suture line to rupture. Blood pressure causing the graft to occlude is unlikely because the blood pressure is elevated and the client is at risk for bleeding. Hypervolemia is an assumption; other causes, such as arterial constriction, can precipitate hypertension. Although cardiovascular status can precipitate a brain attack, the priority for this client is protecting the graft.

After a traumatic event, a client is extremely upset and exhibits pressured and rambling speech. What therapeutic technique can the nurse use when a client's communication rambles? 1. touch 2. silence 3. focusing 4. summarizing

3 rationale: Focusing is indicated when communication is vague; the nurse attempts to concentrate or focus the client's communication on one specific aspect. Touch invades the client's space and will not help focus the client's communication. Silence prolongs the rambling communication; the client needs to be focused. Until the concern is identified and explored, summarizing is impossible.

During the physical assessment of a recently born neonate, the nurse palpates the infant's femoral pulses. For which cardiac defect is the nurse looking? 1. atrial septal defect 2. coarctation of the aorta 3. patent ductus arteriosus 4. ventricular septal defect

2 rationale: Coarctation of the aorta results in diminished or absent femoral pulses. An atrial septal defect has no effect on the volume of peripheral circulation. (Minimal shunting occurs in the newborn period.) A patent ductus arteriosus has minimal effect on the volume of peripheral circulation (left-to-right shunt). A ventricular septal defect has minimal effect on the volume of peripheral circulation (left-to-right shunt).

A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. Which is the best response by the nurse? 1. may i take a look at it 2. it's time for another graft 3. is there any sign of redness 4. it is supposed to curl up at the edges

1 rationale: An autograft is a permanent graft that should not be rejected; the nurse should assess the site immediately. An autograft should not need to be replaced, and the edges should not curl. The nurse needs to assess the site; the responsibility of assessment should not be left to the client.

When assessing a newly admitted primigravida in active labor, the nurse hears the fetal heartbeat loudest in the upper left quadrant. The nurse concludes that the position of the fetus is where? 1. left sacral anterior 2. left mentum anterior 3. left occipital posterior 4. left occipital transverse

1 rationale: If the heart is heard in the upper left quadrant, the fetus is lying in a breech presentation with the head upright and the heart uppermost. Fetal heart tones are heard best in the lower quadrants of the abdomen in cephalic presentations. This fetus is not positioned in the mentum anterior, occipital posterior, or occipital transverse positions.

A newborn is being treated with phototherapy for hyperbilirubinemia. What is the nurse's role when providing phototherapy? 1. turning the infant every 2 hours 2. measuring the bilirubin level every 2 hours 3. maintaining the infant on daily 24-hour phototherapy 4. apply a sterile gauze pad to the infant's umbilical stump

1 rationale: The infant's position is changed every 2 hours to expose all skin surfaces to the phototherapy for maximum effect. Measuring the bilirubin level every 2 hours is not necessary. The infant may be removed from the lights for feeding and the eye patches removed to assess the eyes for irritation. The lights will dry the cord more quickly, which is a desirable effect.

A 10-year-old boy who is about to begin chemotherapy for acute myelogenous leukemia (AML) tells the nurse that he is old enough to refuse treatment. What is the nurse's most appropriate response? 1. you seem frightened. lets talk about it 2. your parents have given their consent. i have to begin 3. your age prevents you from refusing treatment. you need to be 18 years old 4. you are old enough. you're also old enough to know that you need the chemotherapy

1 rationale: The nurse is responding to the child's feelings. If the child starts to discuss feelings, there may not be a need to inform him that he is too young to refuse treatment. Abruptly telling the child that his parents have given their consent disregards the child's feelings. Although the child is too young to make a decision about treatment, this response is insensitive to the child's feelings. Scolding the child is demeaning, and the nurse is misinforming the child by stating that he is old enough to refuse treatment.

Which statement made by the nurse indicates that the client interview is coming to a close? 1. i have just one more question for you 2. i hope you are comfortable and not in pain 3. i would like to spend some time to understand your concerns 4. i assure you that information i gather now will be confidential

1 rationale: The nurse should give the client a clue that the interview is drawing to a close. The nurse can do this by letting the client know that after one more question the interview will be over. The nurse sets the stage for the interview by ensuring that the client is comfortable and not in pain. The nurse begins the interview by stating that he or she would like to spend some time to understand the client's health concerns. The nurse informs the client at the beginning of the interview that the information shared by the client is confidential.

A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse? 1. you shouldn't give up hope 2. being incapacitated is difficult for you 3. would you like to speak to a religious advisor 4. have you talked to your family about your feelings

2 rationale: The response "Being incapacitated is difficult for you" is an open-ended, accepting response that permits and encourages the client to continue to express feelings. The response "You shouldn't give up hope" rejects the client's feelings and implies that it is wrong to feel this way. The response "Would you like to speak to a religious advisor?" avoids the issue and attempts to refer discussion of the client's feelings to someone else. The response "Have you talked to your family about your feelings?" changes the focus from the client's feelings to the family's role.

At 32 weeks' gestation a client undergoes an ultrasound examination, which reveals a low-lying placenta. What complication should the nurse anticipate as the client's pregnancy approaches term? 1. sharp abdominal pain 2. painless vaginal bleeding 3. increased lower back pain 4. early rupture of membranes

2 rationale: Because the process of effacement occurs in the latter part of pregnancy, placental separation from the uterus may occur, causing painless bleeding. There is pain with premature separation of a normally implanted placenta (abruptio placentae). Lower back pain is not associated with placenta previa. Rupture of membranes usually does not occur before the placenta starts to separate.

A nurse performs Leopold's maneuvers on a pregnant client and documents the following data: soft, firm mass in the fundus; several small parts on the right side; hard, round, movable object in pubic area; and cephalic prominence on right side. Applying these findings, which fetal position does the nurse identify? 1. left sacroposterior (LSP) 2. right sacroposterior (RSP) 3. left occipitoanterior (LOA) 4. right occipitoanterior (ROA)

3 rationale: In the LOA position, the small parts are on the right, the smooth back is on the left, and the head is in the pelvis. The LSP position is a breech position, and therefore the fetal head will not be in the pelvic area; the data reveal a hard, round, movable object in the pubic area, which indicates that the fetus is in the vertex position. The RSP position is a breech position, and therefore the fetal head will not be in the pelvic area. In the ROA position, the small parts will be on the left and the smooth back on the right.

During the first meeting of a therapy group, the members become quite uncomfortable. The nurse notes frequent periods of silence, tense laughter, and nervous movement in the group. What does the nurse conclude about these responses? 1. they require active leader intervention to relieve signs of obvious stress 2. they indicate unhealthy group processes and an unwillingness to relate openly 3. they are expected group behaviors because relationships are not yet established 4. they should be addressed immediately so members will not become too uncomfortable

3 rationale: The members have not established trust and are hesitant to discuss problems; the behaviors observed reflect anxiety and insecurity. Requiring active leader intervention to relieve signs of obvious stress can add to the anxiety and insecurity of group members. These behaviors are expected in the early stage of group interaction and are not unhealthy. Immediately addressing them may add to the anxiety and insecurity of the group members.

A client with renal colic is scheduled for extracorporeal shock-wave lithotripsy. The night before the procedure, the client puts the call light on frequently and has many demands. Which will be an appropriate statement for the nurse to make? 1. i know how you feel; i had this same procedure last year 2. we'll take good care of you, so you have nothing to worry about 3. you are facing a new experience tomorrow; tell me what concerns you have 4. your behavior tells me that you are scared of what you are facing tomorrow

3 rationale: The response "You are facing a new experience tomorrow" acknowledges the client's situation and allows the client to discuss feelings and fears related to the surgery. The response "I know how you feel" is inaccurate; each client's experience is unique. The response "We'll take good care of you" minimizes the client's feelings and provides false reassurance. The phrase "Your behavior tells me" may not be an accurate interpretation of the client's behavior.

An abandoned infant has been brought to the hospital. Ophthalmia neonatorum is diagnosed. What is the nurse's estimate of the infant's age? 1. 2 days 2. 24 hours 3. about 3-4 days 4. less than 24 hours

3 rationale: Untreated ophthalmia neonatorum becomes apparent on the third or fourth postnatal day and provides evidence that the mother may have had gonorrhea or a chlamydial infection. The most common presentation of ophthalmia neonatorum occurs by day 3 after birth.

What instructions should the nurse give to an overweight adolescent to help him or her lose weight? Select all that apply. 1. skip breakfast 2. sleep for long hours to reduce stress 3. perform physical activities regularly 4. eat small frequent meals throughout the day 5. reduce the intake of sugar and sweetened beverages

3, 4, 5 rationale: Regular physical activities can reduce risk factors associated with obesity and help a client lose weight. Eating small frequent meals throughout the day can increase a client's metabolism and help with weight reduction. Excess intake of sugar and sweetened beverages increases obesity. Sleeping for long hours increases the risk of obesity. Breakfast should not be skipped.

A client is admitted to the critical care unit after receiving multiple injuries in a motorcycle accident. Twelve hours later the client reports increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed, and the client is scheduled for an emergency splenectomy. What should the nurse include when providing preoperative teaching? 1. probability of wound dehiscence 2. safety aspects of this type of surgery 3. expectation of post-operative bleeding 4. presence of abdominal drains for several days

4 rationale: Drains usually are inserted into the splenic bed to facilitate removal of fluid that can lead to abscess formation. The risk for wound dehiscence is no greater than for any other abdominal surgery. Safety aspects of this type of surgery are the role of the primary healthcare provider. Bleeding occurs more commonly with splenic repair than with removal.

A nurse is assessing a postpartum client for signs of hemorrhage by evaluating the degree of perineal pad saturation. What other parameter can the nurse use to estimate blood loss in a postpartum client? 1. odor of the lochia 2. color of the lochia 3. presence of small clots on the pad 4. time elapsed between pad changes

4 rationale: Hemorrhage may occur after the third stage of labor or during the first 24 postpartum hours; hemorrhage is defined as a blood loss in excess of 500 mL. The best estimation of blood loss takes into consideration a combination of factors, including degree of saturation of perineal pads and frequency of pad changes. The nurse must also assess whether there is pooling of blood under the buttocks. Odor will reflect the possible complication of infection, not hemorrhage. The color of vaginal discharge at this time will not indicate hemorrhage. The color of the lochia during the first postpartum day is expected to be red (rubra). The presence of clots is common and is not an indicator of the amount of blood loss.

A client who is at 38 weeks' gestation is admitted to the birthing unit because her membranes ruptured 24 hours ago and contractions have started. The fetus is in a breech presentation. The nurse observes that the amniotic fluid is green. What does the nurse conclude from these findings? 1. the fetus has a neural tube defect 2. fetal well-being is compromised 3. intrauterine infection has developed 4. meconium is being expelled with contractions

4 rationale: In a breech presentation, the pressure of the contractions on the fetus's lower abdomen causes meconium to be expelled into the amniotic fluid with each contraction. Meconium in the amniotic fluid is not a sign of a neural tube defect, regardless of presentation. Greenish amniotic fluid does not indicate a compromised fetus if there is a breech presentation. The data do not indicate signs of malodorous amniotic fluid or maternal pyrexia, each of which is indicative of infection.

A nurse is assessing a new client in active labor for fetal position. Where will fetal heart tones be heard if the fetus' position is left occiput anterior (LOA)? 1. a 2. b 3. c 4. d

4 rationale: In the most common position, left occiput anterior, the fetus's back is on the left side of the mother. Position a is correct when the fetus is in the right sacrum anterior position. Position b is correct when the fetus is in the right occiput posterior position. Position c is correct when the fetus is in the left sacrum anterior position.