textams (1/24-28/22)

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 200 feet away that a person with normal vision sees b) sees an object from 20 feet away that a person with normal vision sees from 20 feet away. c) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. d) sees an object from 200 feet away that a person with normal vision sees from 200 feet away.

c) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

Which type of medication may be used in the treatment of a patient with incontinence to inhibit contraction of the bladder? a) Estrogen hormone b) Tricyclic antidepressants c) Over-the-counter decongestant d) Anticholinergic agent

d) Anticholinergic agent Anticholinergic agents are considered first-line medications for urge incontinence.

Nursing management of the patient with acute symptoms of benign paroxysmal positional vertigo includes which of the following? a) The Epley repositioning procedure b) Meclizine for 2-4 weeks c) The Dix-Hallpike procedure. d) Bed rest

d) Bed rest Bed rest is recommended for patients with acute symptoms. Canalith repositioning procedures (CRP) may be used to provide resolution of vertigo, and patients with acute vertigo may be medicated with meclizine for 1-2 weeks.

Through which of the following activities does the patient learn to consciously contract excretory sphincters and control voiding cues? a) Kegel exercises b) Habit training c) Bladder training d) Biofeedback

d) Biofeedback Cognitively intact patients who have stress or urge incontinence may gain bladder control through biofeedback. a) Kegel exercises are pelvic floor exercises that strengthen the pubococcygeus muscle. b) Habit training is used to try to keep the patient dry by strictly adhering to a toileting schedule and may be successful with stress, urge, or functional incontinence. c) Habit training is a type of bladder training.

When providing care to the patient with bilateral nephrostomy tubes, the nurse never does which of the following? a) Reports a dislodged nephrostomy tube immediately b) Measures urine output from each tube separately c) Irrigates each nephrostomy tube with 30 cc of normal saline q8h as ordered d) Clamps each nephrostomy tube when the patient is moved

d) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a nephrostomy tube because it could cause obstruction and resultant pyelonephritis.

A patient who has Parkinson's disease is admitted to the hospital for medication control. In addition to presenting with muscle rigidity, the nurse should expect that the patient will have: A. A mask - like facial expression B. Tremors of the knees when resting C. Bilateral nystagmus D. Long - term memory loss

A. A mask - like facial expression Patients with Parkinson's disease experience muscle rigidity and mask-like facial expression. B - the patient with Parkinson's disease has tremors that involve the hand, diaphragm, tongue, lips and jaw. They are more prominent at rest and are aggravated by emotional stress. C and D - nystagmus and long-term memory loss are not identified as manifestations Parkinson's disease.

During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should instruct the client to push the control button at which time? A. At the beginning of each fetal movement. B. At the beginning of each contraction. C. After every three fetal movements D. At the end of fetal movement.

A. At the beginning of each fetal movement. An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR.

Which of the following discharge instructions should be given to Gabriel after a prostatectomy? A. Avoid straining at stool B. Report clots in the urine right away C. Soak in warm tub daily for comfort D. Return to your usual activities in 3 weeks

A. Avoid straining at stool Rationale: Prostatectomy refers to the surgical removal of part of the prostate gland (transurethral resection, a procedure performed to relieve urinary symptoms caused by benign enlargement), or the entire prostate (radical prostatectomy, the curative surgery most often used to treat prostate cancer). (http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/prostatectomy.jsp) Provide teaching after discharge. Some activities are limited for prostatectomy. The surgeon's orders should be followed regarding heavy lifting, strenuous activity, prolonged sitting, sexual activity and driving or riding on an automobile. Because this increases intraabdominal pressure and may precipitate bleeding, the man should avoid sitting except during meals. Advise the client not to strain during defecation for at least 6 weeks after surgery because this can lead to bleeding from the operative site. Docusate sodium, prune juice, and milk of magnesia are usually satisfactory bowel stimulants during this time. Increasing the amount of fluids also helps prevent constipation (Black, MSN p.1025). B- blood clots are expected but if there's unusual bleeding this should be reported right away. Elevated temperature, manifestation of wound infection or UTI and obstructed urinary flow should be reported as well. C- this enhances vasodilation which may lead to bleeding D- 3 weeks is not enough, strenuous exercise are still contraindicated for 4-6 weeks

Which of the following vaccines has the shortest half-life? A. BCG B. Hep B C. OPV D. TT

A. BCG Among the vaccines, BCG has a half-life of 4 hours; DPT, OPV, TT, Hep B, AMV has a half-life of 8 hours.

A patient is in her last trimester of pregnancy. Nurse Vickie should instruct her to notify her primary health care provider immediately if she notices: A. Blurred vision B. Hemorrhoids C. Increased vaginal mucus D. Shortness of breath on exertion

A. Blurred vision Blurred vision or other visual disturbance, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for both the patient and fetus.

Normal lochial findings in the first 24 hours post-delivery include: A. Bright red blood B. Large clots or tissue fragments C. A foul odor D. The complete absence of lochia

A. Bright red blood Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia.

An 18 - year - old primigravida is admitted at 34 weeks' gestation with preeclampsia. The nurse should observe her carefully for manifestations of eclampsia, which include: A. Convulsions, seizures and coma B. A diastolic blood pressure of 90 mm Hg or more C. Proteinuria of 3+ g/day D. A rise in systolic blood pressure of 30 mm Hg or more

A. Convulsions, seizures and coma Severe preeclampsia becomes eclampsia when grand mal seizures or coma occurs. Warning signs of impending eclampsia are amnesia, epigastric pain and hyperreflexia. B, C and D - a diastolic blood pressure of 90 mmHg or more, proteinuria of 3+ and a rise in systolic blood pressure of 30 mmHg or more are characteristic of preeclampsia, rather than eclampsia.

A nurse would assess a patient who has undergone a lumbar laminectomy for which of the following post - surgical complications? A. Deep vein thrombosis B. Urinary frequency C. Intermittent claudication D. Flank pain

A. Deep vein thrombosis Following a lumbar laminectomy, the patient should wear anti-embolism stockings or another anti-embolism device to prevent deep vein thrombosis. B - pain and a flat position in bed make urination difficult. Urinary retention, not frequency, usually occurs. C - intermittent claudication occurs in peripheral vascular disease, rather than as a postoperative complication of surgery. D - flank pain is characteristic of renal disease.

A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the client's: A. Disturbed thought processes B. Imbalanced nutrition C. Self-care deficit D. Deficient knowledge

A. Disturbed thought processes Major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with the client's psychosis. Psychosis is defined as a state in which a person's mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the person's capacity to deal with the demands of life. Altered thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all of the nursing diagnoses may be appropriate because the client is experiencing psychosis, option A is correct.

Which of the following vaccines is most sensitive to heat? A. DPT B. HepB C. Measles D. Tetanus toxoid

C. Measles The most heat sensitive vaccine is OPV and Measles. It should be stored in the freezer with temperature of -25 to -15C. BCG, Hep B, DPT and TT are not so heat sensitive and can be stored on the body of the refrigerator with temp. of 2-8C (acc. To IMCI) or 2-18C (acc. To EPI).

For which of the following procedures would the nurse expect to prepare a patient who has adult respiratory distress syndrome (ARDS)? A. Endotracheal intubation B. Chest tube insertion C. Incentive spirometry D. Ventilation - perfusion scan

A. Endotracheal intubation Patients with adult respiratory distress syndrome (ARDS) usually require endotracheal intubation, and mechanical ventilation with positive end-expiratory pressure and continuous positive airway pressure. B And C - incentive spirometry and chest tube insertion are not indicated in the management of ARDS. D - a ventilation-perfusion scan visualizes the distribution of pulmonary blood flow and confirms the diagnoses of pulmonary emboli, pneumonia, tumor and fibrosis.

Republic Act 8976 is also known as: A. Food fortification law B. Fajardo Act C. Araw ng Sangkap Pinoy D. Philippine Nursing Act of 2002

A. Food fortification law Option A is the answer. Republic Act 8976 refers to the Philippine Food Fortification Act of 2000.Sangkap Pinoy Seal is a program under RA 8976. Sangkap Pinoy Seal Program (SPSP) - a strategy to encourage food manufacturers to fortify processed foods or food products with essential nutrients at levels approved by the DOH. "Fajardo Act" which authorized the consolidation of municipalities into sanitary division and established what is now known as the "Health Fund" refers to Act. No. 2156. The Philippine Nursing Act of 2002 is known as RA 9173. (Venzon, 165).

For which of the following substances should a nurse test to determine if nasal drainage contains cerebro - spinal fluid (CSF)? A. Glucose B. Blood C. Albumin D. Bicarbonate

A. Glucose A keto-diastix reagent strip with a positive sugar reaction is indicative of the presence of cerebrospinal fluid (CSF). A negative sugar reaction should occur in the sole presence of nasal mucus. B, C and D - blood, albumin and bicarbonate found in the nasal mucus are not absolute indicators of the presence of CSF.

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? A. Hemorrhagic skin rash B. Edema C. Cyanosis D. Dyspnea on exertion

A. Hemorrhagic skin rash DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition. Disseminated intravascular coagulation (DIC) can be defined as a widespread hypercoagulable state that can lead to both microvascular and macrovascular clotting and compromised blood flow, ultimately resulting in multiple organ dysfunction syndrome or MODS. As this process begins consuming clotting factors and platelets in a positive feedback loop, hemorrhage can ensue, which may be the presenting symptom of a patient with DIC.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for delirium tremens? A. Hypertension, changes in LOC, hallucinations B. Hypotension, ataxia, hunger C. Stupor, agitation, muscular rigidity D. Hypotension, coarse hand tremors, agitation

A. Hypertension, changes in LOC, hallucinations Some of the symptoms associated with delirium tremens typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, and changes in LOC, agitation, fever, and delusions. Delirium tremens was first recognized as a disorder attributed to excessive alcohol abuse in 1813. It is now commonly known to occur as early as 48 hours after abrupt cessation of alcohol in those with chronic abuse and can last up to 5 days. It has anticipated mortality of up to 37% without appropriate treatment. It is crucial to identify early signs of withdrawal because it can become fatal.

When a woman is 18 weeks pregnant, it is determine that she has a twin pregnancy. Which of the following additional findings would be consistent with the diagnosis? A. Rapid uterine growth B. Low hematocrit C. Decreased amniotic fluid D. Urinary frequency

A. Rapid uterine growth Rapid uterine growth is associated with a twin gestation. B - the mother should not experience a low hematocrit due to the twin gestation. The mother's diet may need iron supplements because of the difficulty in getting adequate amounts through dietary intake. C - decreased amniotic fluid is not associated with twin gestation. D - urinary frequent is a problem for the mother during the first and third trimester but is not caused by the twin gestation.

A woman comes into the ER in a severe state of anxiety following a car accident. The most appropriate nursing intervention is to: A. Remain with the client. B. Put the client in a quiet room. C. Teach the client deep breathing. D. Encourage the client to talk about their feelings and concerns.

A. Remain with the client. If a client with severe anxiety is left alone; the client may feel abandoned and become overwhelmed. Remain with the client at all times when levels of anxiety are high (severe or panic); reassure the client of his or her safety and security. The client's safety is an utmost priority. A highly anxious client should not be left alone as his anxiety will escalate.

Aseptic necrosis is a common complication after surgical repair of fracture of the neck of the femur because: A. The vascular supply may be damaged with the fracture B. The patient cannot bear any weight on the leg C. The patient is usually and elderly D. Surgical repair takes a long time

A. The vascular supply may be damaged with the fracture Possible complications following fracture repair include excessive bleeding, improper fit of joined bone ends, pressure on nearby nerves, delayed healing, and a permanent incomplete healing of the fracture. If there is a poor blood supply to the fractured site with one of the portions of broken bone not properly supplied by the blood, the bony portion will die and healing of the fracture will not take place. This is called aseptic necrosis. Aseptic necrosis is bone death. (http://www.lifesteps.com/gm/Atoz/ency/fracture_repair.jsp)

The manic client announces to everyone in the dayroom that a stripper is coming to perform this evening. When the nurse firmly states that this will not happen, the manic client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the most appropriate action would be to: A. With assistance, escort the manic client to her room and administer Haldol as prescribed if needed. B. Tell the client that smoking privileges are revoked for 24 hours. C. Orient the client to time, person, and place D. Tell the client that the behavior is not appropriate.

A. With assistance, escort the manic client to her room and administer Haldol as prescribed if needed. The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to Haldol. Alert staff if a potential for seclusion appears imminent. Usual priority of interventions would be: firmly setting limits; chemical restraints (tranquilizers); and seclusions.

When assessing a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breastfeeding success? A. "It's contraindicated for you to breastfeed following this type of surgery." B. "I support your commitment; however, you may have to supplement each feeding with formula." C. "You should check with your surgeon to determine whether breast-feeding would be possible." D. "You should be able to breastfeed without difficulty."

B. "I support your commitment; however, you may have to supplement each feeding with formula." Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breastfeeding after surgery is possible. Still, it's good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother's ability to meet all of her baby's nutritional needs, and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the client's psychological adaptation to mothering may be dependent on how successfully she breast-feeds.

When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse in charge that the client understands the information given to her? A. "I'll report increased frequency of urination." B. "If I have blurred or double vision, I should call the clinic immediately." C. "If I feel tired after resting, I should report it immediately." D. "Nausea should be reported immediately."

B. "If I have blurred or double vision, I should call the clinic immediately." Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. It can affect the visual pathways, from the anterior segment to the visual cortex.

A depressed client is ready for discharge. The nurse feels comfortable that the client has a good understanding of the disease process when the client states: A. "I'll never let this happen to me again. I won't let my boss or my job or my family get to me!" B. "It's important for me to eat well, exercise, and to take my medication. If I begin to lose my appetite or not sleep well, I've got to get in to see my doctor." C. "I've learned that I'm a good person and that I am worthy of giving and receiving love. I don't need anyone; I have myself to rely on!" D. "I don't know what happened to me. I've always been able to make decisions for myself and for my business. I don't ever want to feel so weak or vulnerable again!"

B. "It's important for me to eat well, exercise, and to take my medication. If I begin to lose my appetite or not sleep well, I've got to get in to see my doctor." The exact cause of depression is not known but is believed to be related to the biochemical disruption of neurotransmitters in the brain. Diet, exercise, and medication are recognized treatments for the disease process. Nursing care plan goals for patients with major depression include determining a degree of impairment, assessing the client's coping abilities, assisting the client to deal with the current situation, providing for meeting psychological needs, and promoting health and wellness.

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse "I should get out of this bad situation." The most helpful response by the nurse would be: A. "I agree with you. You should get out of this situation." B. "What do you find difficult about this situation?" C. "Why don't you tell your husband about this?" D. "This is not the best time to make that decision."

B. "What do you find difficult about this situation?" The most helpful response is one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can foster dependency. Develop a trusting relationship through frequent contact being honest and nonjudgmental. Project an accepting attitude about alcoholism. Provides the patient with a sense of humanness, helping to decrease paranoia and distrust. The patient will be able to detect biased or condescending attitudes of caregivers.

A registered nurse is assigned to the following patients. Which one's should the nurse see first after shift report? A. A 32 - year - old postoperative appendectomy patient of five hours who is complaining of pain B. A 44 - year - old myocardial infarction (MI) patient who is complaining of nausea C. A 24 - year - old patient admitted for dehydration whose intravenous (IV) has infiltrated D. A 62 - year - old postoperative abdominal hysterectomy patient of three days who's incisional dressing is saturated with serosanguinous fluid

B. A 44 - year - old myocardial infarction (MI) patient who is complaining of nausea Nausea is symptom of impending myocardial infraction (IM) and should be assessed immediately so that treatment can be instituted and further damage to the heart avoided. A - a patient who is five hours postoperative should be assessed for pain, but this would not take priority over assessing the patient with a possible myocardial infraction. C - the patient's intravenous (IV) should be assessed and restored, but this action would not be the priority. D- the patient whose dressing is saturated with serosanguinous drainage should be assessed after the patient with nausea is evaluated by the nurse.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A. A negative Kernig's sign. B. A positive Brudzinski's sign. C. Absence of nuchal rigidity. D. A Glascow Coma Scale score of 15.

B. A positive Brudzinski's sign. Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. Brudzinski's sign is characterized by reflexive flexion of the knees and hips following passive neck flexion. To elicit this sign, the examiner places one hand on the patient's chest and the other hand behind the patient's neck. The examiner then passively flexes the neck forward and assesses whether the knees and hips flex.

The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time? A. Between 10 and 12 weeks' gestation B. Between 16 and 20 weeks' gestation. C. Between 21 and 23 weeks' gestation. D. Between 24 and 26 weeks' gestation.

B. Between 16 and 20 weeks' gestation. A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks' gestation.

A 10 - year - old child is receiving therapeutic does of acetylsalicylic acid (aspirin) for treatment of Kawasaki disease. Which of the following findings indicates to the nurse that the drug therapy needs to be modified? A. Temperature of 97.8oF (36.6oC) B. Bilateral tinnitus C. Platelet count of 240,000 cells/cu mm D. Desquamation of the palms

B. Bilateral tinnitus Adverse reactions to aspirin include tinnitus, hearing loss, dyspepsia, heartburn, anemia and hemolysis. Aspirin has been the primary therapy for both its anti-inflammatory and anti-platelet effect. In the early phase of treatment, there is believed to be impaired absorption of aspirin. As the course of the disease progresses into the subacute phase, the aspirin does can be reduced because there is improved absorption, and therefore higher serum levels. Aspirin levels must be monitored to ensure that appropriate therapeutic levels are achieved to accomplish he anti-platelet purpose without producing toxicity. A - the patient's temperature returns to normal in the subacute phase of Kawasaki disease. C - in the subacute phase of Kawasaki disease, aspirin is continued for its anti-platelet activity. D - desquamation is a symptom of Kawasaki disease and does not indicate the need for modification of drug therapy.

Which of the following symptoms can be expected temporarily when Gabriel's Foley catheter is removed? A. Urgency B. Dribbling C. Urinary retention D. Decreased urinary output

B. Dribbling Retention catheters are removed after their purpose has been achieved usually on order of the primary care provider. Clients who had a catheter for a prolonged period may require retraining to regain muscle tone that is why there may be some dribbling after removal for the urinary sphincter control is affected and has not been used for a time. With an indwelling catheter, the bladder muscle does not stretch and contract regularly as it does when the bladder fills and empties by voiding. A few days before removal, the catheter may be clamped for specified periods of time (2-4 hours), then released to allows bladder to empty. This allows the bladder to distend and stimulate its musculature.(Kozier, Fundamentals in nursing. p.1279) After removal tell the patient it is important to have fluid intake of 1.5-2L/day (unless contraindicated); Instruct the client of the need to void within 8 hours and that each voiding will be measured to ensure the ability to empty the bladder adequately; explain that many clients experience mild burning or discomfort with the first voiding, which soon subsides; Inform the client to report any signs of UTI, which are most likely to develop in 2-3 days. (Potter, Nursing interventions and clinical skills. P.850) A- a feeling of the need to void urine C- a state in which an individual experiences incomplete emptying of the bladder (Mosby's pocket dictionary p.1320)

A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions? A. Every 5 minutes. B. Every 15 minutes. C. Every 30 minutes. D. Every 60 minutes.

B. Every 15 minutes. During the second stage of labor, the nurse should assess the strength, frequency, and duration of contraction every 15 minutes. If maternal or fetal problems are detected, more frequent monitoring is necessary.

A client makes a routine visit to the prenatal clinic. Although she is 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Charles diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: A. An empty gestational sac. B. Grapelike clusters. C. A severely malformed fetus. D. An extrauterine pregnancy.

B. Grapelike clusters. In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually, no embryo (and therefore no fetus) is present because it has been absorbed.

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. The most appropriate maintenance goal should focus on which of the following? A. Continued contact with a crisis counselor. B. Identifying anxiety-producing situations. C. Ignoring feelings of anxiety. D. Eliminating all anxiety from daily situations.

B. Identifying anxiety-producing situations. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Observe for increasing anxiety. Assume a calm manner, decrease environmental stimulation, and provide temporary isolation as indicated. Early detection and intervention facilitate modifying a client's behavior by changing the environment and the client's interaction with it, to minimize the spread of anxiety.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise. Cushing triad is a clinical syndrome consisting of hypertension, bradycardia and irregular respiration and is a sign of impending brain herniation. This occurs when the ICP is too high the elevation of blood pressure is a reflex mechanism to maintain CPP.

Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? A. Applying cold to limit edema during the first 12 to 24 hours. B. Instructing the client to use two or more peri pads to cushion the area. C. Instructing the client on the use of sitz baths if ordered. D. Instructing the client about the importance of perineal (Kegel) exercises.

B. Instructing the client to use two or more peri pads to cushion the area. Using two or more peripads would do little to reduce the pain or promote perineal healing. A fourth-degree perineal laceration is the injury to the perineum involving the anal sphincter complex and anorectal mucosa.

After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur? A. Decreased peristalsis. B. Increase heart rate. C. Dry mucous membranes. D. Nausea and Vomiting.

D. Nausea and Vomiting. Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Bethanechol directly stimulates cholinergic receptors in the parasympathetic nervous system while stimulating the ganglia to a lesser extent.

The physician wants to examine Gabriel's prostate gland. What equipment will be necessary for the exam: A. Foley catheter B. Lubricants and gloves C. Urethral dilators D. Rectal tube

B. Lubricants and gloves Benign prostatic hyperplasia is commonly known as an enlarged prostate gland. The prostate gland is about the size and shape of a walnut. Located just below the bladder, it surrounds the urethra, which carries urine out of the bladder. The prostate produces semen, the fluid that carries sperm. The prostate gland continues to grow throughout a man's life. This rarely causes problems until later in life. The layer of tissue around the prostate keeps it from growing outward. As a result, the prostate gland begins to press on the urethra like a clamp. It is a noncancerous condition. (http://www.csmc.edu/9561.html) Prostate gland is examined through Digital rectal examination (DRE). During the examination, The man is advised that a finger needs to be inserted into their rectum in order to examine the prostate gland. Usually the man is asked to stand, feet apart, face the examination couch and bend forward so that arms or elbows are on the couch. The health professional gently puts a lubricated, gloved finger will be inserted to the rectum in a downwards angle as if pointing to the umbilicus (belly button). He or she may use the other hand to press on the lower belly or pelvic area. The doctor moves their finger in a circular motion in order to identify the lobes and groove of the prostate gland. In a normal sized prostate gland they would expect to find the prostate around 2-4 cm long and triangular in shape. They would also expect the prostate to feel firm and rubbery.

After 3 days of breastfeeding, a postpartum patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: A. Apply warm compresses to her nipples just before feeding. B. Lubricate her nipples with expressed milk before feeding. C. Dry her nipples with a soft towel after feedings. D. Apply soap directly to her nipples, and then rinse.

B. Lubricate her nipples with expressed milk before feeding. Measures that help relieve nipple soreness in a breastfeeding patient include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples.

When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? A. Bladder infection B. Middle ear infection C. Fractured clavicle D. Septic arthritis

B. Middle ear infection Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. Meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumococcus. A chronically draining ear is frequently also found.

Situation: Eileen is brought to the emergency department by ambulance after falling at home. X-rays confirm the diagnosis of displaced fracture of the neck of the left femur. During her post operative period, which of the following should Eileen be encouraged to do? A. Decrease fluid intake to avoid the need to urinate B. Perform foot flexion exercises to prevent clot formation C. Stay in bed as much as possible to conserve energy D. Avoid using assistive devices for walking

B. Perform foot flexion exercises to prevent clot formation Only option B is correct A- client's diet should include ample fluids and fiber, this helps prevent constipation. Fluid also replaces the fluids lost in the body during surgery C- After surgery, the client's mobility limitation and pain increase the risk for skin impairment and constipation. Thus, staying in bed would not be good for the client. Assist and encourage independence in activities within the limitation of the traction. The client should be instructed on repositioning techniques, possibly using extended horizontal bars with roller traction to allow movement to a chair at the bedside. Unaffected joints should be exercised regularly. D-An assistive device is used such as walker or crutches may be needed for temporary support of weak muscles and stiff joints. (Black, MSN, p.637)

DPT is a combination of weakened toxin and killed bacteria. Which among the 3 combined vaccines is made up of killed bacteria? A. Diphtheria B. Pertussis C. Tetanus D. None of the above

B. Pertussis The DPT vaccine is given to children to prevent diphtheria, pertussis (whooping cough) and tetanus. The pertussis portion of the DPT shot is composed of killed B. pertussis bacteria, the same bacteria that cause whooping cough. In the bacteria are toxins which are responsible for the neurological complications of both the vaccine and the disease. The DTaP vaccine contains a purified acellular version of the pertussis vaccine and has fewer B. pertussis toxins in it. The DTaP vaccine is associated with fewer reactions but can still cause injuries and death.

A nurse should assess a postoperative patient for which of the following early manifestations of hypovolemic shock? A. Hypotension B. Restlessness C. Oliguria D. Dyspnea

B. Restlessness An early neuromuscular sign of shock is anxiety and restlessness. A - a decrease in blood pressure and postural hypotension and early manifestations of shock. C - an early manifestation of shock is decreased urinary output, rather than oliguria. D - early manifestations of shock include increased respiratory rate and shallow respirations.

Situation: Eileen is brought to the emergency department by ambulance after falling at home. X-rays confirm the diagnosis of displaced fracture of the neck of the left femur. Which of the following interventions should be done first to mobilize Ms. Eileen quickly and avoid medical complications? A. Placing sandbag or trochanter rolls on the outside of the leg B. Scheduling early surgical intervention C. Applying Buck's traction to her leg D. Teaching her how to walk

B. Scheduling early surgical intervention Fracture neck of femur is a common injury. It commonly requires surgery for good results. The surgery needs to be precise to avoid potential complications. Most, if not all fractures should be surgically treated such that the patient can be up and about on their fractured legs. In physiologically younger and active patients, displaced fractures of the neck of the femur should be treated by reduction and fixing. The patient needs to be explained that there is a risk of further surgery if the hip develops painful avascular necrosis, a complication that may not be avoided despite the best surgical treatment. In physiologically older patients, these displaced fractures are best treated by replacement for the head and neck of the femur so that potential further surgery can be avoided. (http://www.bhj.org/journal/2000_4201_jan00/uo_175.htm) Other options could not help the client mobilize its leg because the problem is not corrected, a surgery must first be done. A&C- could help after surgery in maintaining the alignment and immobilization of the part.

The nurse reviews the activity schedule for the day and plans which activity for the manic client? A. Brown-bag luncheon and book review B. Tetherball C. Paint-by-number activity D. Deep breathing and progressive relaxation group

B. Tetherball A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow the use of excess energy yet not endanger others during the process. Tetherball is an exercise that uses the large muscle groups of the body and is a great way to expand the increased energy that the client is experiencing.

The nurse in-charge is reviewing a patient's prenatal history. Which finding indicates a genetic risk factor? A. The patient is 25 years old. B. The patient has a child with cystic fibrosis. C. The patient was exposed to rubella at 36 weeks' gestation. D. The patient has a history of preterm labor at 32 weeks' gestation.

B. The patient has a child with cystic fibrosis. Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder.

The nurse is planning activities for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate for this client? A. Ping pong B. Writing C. Chess D. Basketball

B. Writing Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing, walks with a staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. Provide structured solitary activities with the assistance of a nurse or aide. Structure provides focus and security.

Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first? A. "Do you have any chronic illness?" B. "Do you have any allergies?" C. "What is your expected due date?" D. "Who will be with you during labor?"

C. "What is your expected due date?" When obtaining the history of a patient who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illness, allergies, and support persons.

After completing a second vaginal examination of a client in labor, the nurse-midwife determines that the fetus is in the right occiput anterior position and at (-1) station. Based on these findings, the nurse-midwife knows that the fetal presenting part is: A. 1 cm below the ischial spines. B. Directly in line with the ischial spines. C. 1 cm above the ischial spines. D. In no relationship to the ischial spines.

C. 1 cm above the ischial spines. Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as -1, -2, or -3.

An adult female patient is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by: A. Return preovulatory basal body temperature. B. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of cycle. C. 3 full days of elevated basal body temperature and clear, thin cervical mucus. D. Breast tenderness and mittelschmerz.

C. 3 full days of elevated basal body temperature and clear, thin cervical mucus. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus.

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: A. A cerebral lesion B. A temporal lesion C. An intact brainstem D. Brain death

C. An intact brainstem Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or disconjugate eye movements indicate brainstem damage.

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: A. Tolerate the pain. B. Decrease the perception of pain. C. Escape the source of pain. D. Divert attention from the source of pain.

C. Escape the source of pain. The client's innate responses to pain are directed initially toward escaping from the source of pain. For example, in sudden strong pain like that generated by pricking the finger, a reflex response occurs within the spinal cord. Motor neurons are activated and the muscles of the arm contract, moving the hand away from the sharp object. This occurs in a fraction of a second — before the signal has been relayed on to the brain — so the client will have pulled his arm away before even becoming conscious of the pain.

Situation: Eileen is brought to the emergency department by ambulance after falling at home. X-rays confirm the diagnosis of displaced fracture of the neck of the left femur. As a result of this injury, Eileen complains of severe pain in the hip region; concurrently, her left leg would be: A. Internally rotated and shortened B. Internally rotated and lengthened C. Externally rotated and shortened D. Externally rotated and lengthened

C. Externally rotated and shortened Hip fracture is often caused by fall at home that involves only a moderate amount of trauma. Immediately after fall, the client is unable to bear weight on the affected leg. Objective findings include a shortened leg and an externally rotated hip. (Black, MSN p. 639)

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? A. Limiting conversation with the child. B. Allowing the child to play in the bathtub. C. Keeping extraneous noise to a minimum. D. Performing treatments quickly.

C. Keeping extraneous noise to a minimum. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. Maintain a quiet environment and keep the lights dim. Prevents stimulation that can cause or precipitate an episode of convulsion.

What do you call hospitals that are practicing the rooming-in and breastfeeding act? A. Family-oriented hospitals B. Hospital advocate C. Mother-baby friendly hospital D. Family friendly hospital

C. Mother-baby friendly hospital The Mother and Baby Friendly Hospital Initiative (MBFHI) is the main strategy to transform all hospitals with maternity and newborn services into facilities which fully protect, promote and support breastfeeding and rooming-in practices. The legal mandate to this initiative are the RA 7600 (The Rooming-In and Breastfeeding Act of 1992) and the Executive Order 51 of 1986 (The Milk Code).

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. The symptom presented by the client that requires the nurse's immediate intervention is the client's: A. Outlandish behaviors and inappropriate dress. B. Grandiose delusions of being a royal descendant of King Arthur. C. Nonstop physical activity and poor nutritional intake. D. Constant, incessant talking that includes sexual innuendos and teasing the staff.

C. Nonstop physical activity and poor nutritional intake. Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominately elevated, expansive, or irritable. All options reflect a client's possible symptomatology. Option C, however, clearly presents a problem that compromises one's physiological integrity and needs to be addressed immediately.

A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? A. The fetus should be delivered within 24 hours. B. The client should repeat the test in 24 hours. C. The fetus isn't in distress at this time. D. The client should repeat the test in 1 week.

C. The fetus isn't in distress at this time. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn't within normal limits.

Which of the following statements is false about the prostate gland? A. It's found between the bladder and sigmoid colon B. It produces seminal plasma, which is a component of semen. C. The male ureters passes thru it. D. None of the above.

C. The male ureters passes thru it. It's the male URETHRA that passes thru it.

A hospitalized client is being considered for ECT. The client appears calm, but the family is anxious. The client's mother begins to cry and states "My son's brain will be destroyed. How can the doctor do this to him?" The nurse's best response is: A. "It sounds as though you need to speak with the psychiatrist" B. "Your son has decided to have this treatment. You should be supportive of him." C. "Perhaps you'd like to see the ECT room and speak to the staff." D. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have."

D. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have." The nurse encourages the client and the family to verbalize fears and concerns. Today ECT is now frequently used to treat a variety of mental health disorders besides depression. The procedure is relatively safe and does work. However, the delivery of ECT requires an interprofessional team that includes a nurse, anesthesiologist, psychiatrist, and neurologist. The benefits of ECT are seen after several sessions and the results are durable. The key is to educate the patient and family about ECT because the procedure has been associated with many false and illogical beliefs.

This refers to body resistance which pertains to the protein present in the serum of blood: A. Antitoxin B. Allergen C. Antigen D. Antibody

D. Antibody Antibody is an immunoglobulin produced by lymphocytes in response to bacteria, viruses, or other antigenic substances. Antibodies are proteins that are found in blood or other bodily fluids of vertebrates, and are used by the immune system to identify and neutralize foreign objects, such as bacteria and viruses. An antigen or immunogen is a molecule that stimulates an immune response. An allergen is a substance that causes the allergic reaction. The (detrimental) reaction may result after exposure via ingestion, inhalation, injection or contact with skin. An antitoxin is an antibody with the ability to neutralize a specific toxin.

What are the products covered by the Milk code or EO 51: A. Breastmilk only B. Formula milk only C. Cow's milk alone D. Breastmilk substitutes, other milk products, food and beverages

D. Breastmilk substitutes, other milk products, food and beverages "National Code of Marketing of Breastmilk Substitutes, Breastmilk Supplement and Other Related Products." SECTION 3. Scope of the Code - The Code applies to the marketing and practices related thereto, of the following products: breastmilk substitutes, including infant formula; other milk products, foods and beverages, including bottlefed complementary foods, when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breastmilk; feeding bottles and teats. It also applies to their quality and availability, and to information concerning their use. Option D is the answer, other choices are incorrect.

A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and identifies a nursing diagnosis of imbalanced nutrition related to poor nutritional intake. The most appropriate nursing intervention related to this diagnosis is: A. Explain to the client the importance of a good nutritional intake. B. Weight the client 3 times per week before breakfast. C. Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon as possible. D. Consult with the nutritionist, offer the client several small meals per day, and schedule brief nursing interactions with the client during these times.

D. Consult with the nutritionist, offer the client several small meals per day, and schedule brief nursing interactions with the client during these times. Change in appetite is one of the major symptoms of depression. Weight the client weekly and observe the eating patterns of the client. Give the information needed for revising the intervention. Encourage eating with others. This increases socialization, decreases focus on the food.

In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following plans is best? A. Provide an activity that is quiet and solitary to avoid increased fatigue, such as working on a puzzle or reading a book. B. Plan nothing until the client asks to participate in milieu. C. Offer the client a menu of daily activities and insist the client participate in all of them D. Provide a structured daily program of activities and encourage the client to participate.

D. Provide a structured daily program of activities and encourage the client to participate. A depressed person experiences a depressed mood and is often withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness, and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Involve the client in gross motor activities that call for very little concentration (e.g., walking). Such activities will aid in relieving tensions and might help in elevating the mood.

What are the foods that must be fortified mandatory according to the food fortification law: A. Rice B. Flour C. Sugar D. Staple foods

D. Staple foods According to the "Philippine Food Fortification Act of 2000". SEC. 6. Mandatory Food Fortification. (a) The fortification of staple foods based on standards set by the DOH through the BFAD is hereby made mandatory for the following: (1) Rice - with Iron; (2) Wheat flour - with vitamin A and Iron; (3) Refined sugar - with vitamin A; (4) Cooking oil - with vitamin A; and (5) Other staple foods with nutrients as may later be required by the NNC. All of the above Options are correct but Staple food is encompassing, therefore it is the answer.

Which of the following would be inappropriate to assess in a mother who's breastfeeding A. The attachment of the baby to the breast. B. The mother's comfort level with positioning the baby. C. Audible swallowing. D. The baby's lips smacking.

D. The baby's lips smacking. Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who's smacking his lips isn't well attached and can injure the mother's nipples.

Buck's traction is applied on Eileen's left leg. Which of the following is true about the buck's traction? A. The head of the bed should be elevated B. Her heel should be resting on the bed C. The use of an overhead trapeze should be discouraged D. The leg in traction must not be elevated on a pillow

D. The leg in traction must not be elevated on a pillow Buck's traction is commonly used in patients who have a hip fracture. Buck's traction is one of the most common orthopedic mechanism by which pull is exerted on the lower extremity with a system of ropes, pulleys, and weights. It is used to immobilize, position and align the lower extremity in treatment of contractures and diseases of hip and knee. (Mosby's pocket dictionary, p.192) It aligns the ends of a fracture by pulling the limb into a straight position. Using the pillow will lessen the effectiveness of the traction, alignment not maintained A- only during eating. Client must be flat in bed for the traction to work. B- heels should not rest on bed, it lessens the effectiveness of the traction C- overhead trapeze are used

This act requires both public and private health institutions to promote rooming in and to encourage, protect and support the practice of breastfeeding A. Milk code B. EO 51 C. The rooming-in and breastfeeding act of 1986 D. The rooming-in and breastfeeding act of 1992

D. The rooming-in and breastfeeding act of 1992 Options A and b are wrong. EO 51 is known as "National Code of Marketing of Breastmilk Substitutes, Breastmilk Supplement and Other Related Products" or Milk Code. Republic Act No. 7600 "The Rooming-In and Breastfeeding Act of 1992" is an act providing incentives to all government and private health institutions with rooming in and breastfeeding practices and for other purposes. Option C is a distractor, this law does not exist- Milk Code Act of 1986.

The nursing assistant reports to the nurse that Gabriel is confused. "He keeps saying he has to urinate, but he has a catheter in place". Which of the following responses would be most appropriate for the nurse to make? A. His catheter is probably plugged. I'll irrigate it shortly B. He may be confused. What else did he say or do? C. That may be sign of internal bleeding D. The urge to urinate is usually caused by the catheter. He may also have bladder spasm.

D. The urge to urinate is usually caused by the catheter. He may also have bladder spasm. Bladder spasms are common with indwelling catheters. (Black MSN, p.1019) The ability of the bladder to store urine requires a relaxed bladder muscle. The bladder normally fills gently and does not contract (squeeze) until a person urinates. With bladder instability (spasms), the bladder randomly contracts. As the bladder begins to squeeze, most people can sense the need to urinate.

The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure... I can't do anything right!" The best nursing response would be: A. To tell the client this is not true; that we all have a purpose in life. B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings. C. To reassure the client that you know how the client is feeling and that things will get better. D. To identify recent behaviors or accomplishments that demonstrate skill ability.

D. To identify recent behaviors or accomplishments that demonstrate skill ability. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging but will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distort the cognitive view of self. Silence may be interpreted as agreement.

The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? A. Active phase B. Complete phase C. Latent phase D. Transitional phase

D. Transitional phase The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds.

During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks gestation, which procedure is used to detect fetal anomalies? A. Amniocentesis. B. Chorionic villi sampling. C. Fetoscopy. D. Ultrasound.

D. Ultrasound. Ultrasound is used between 18 and 40 weeks' gestation to identify normal fetal growth and detect fetal anomalies and other problems.

A 15 - year - old boy has undergone a spinal instrumentation at the level of T4 to T5 for scoliosis. Because there is an order to maintain strict bed rest, a nurse should use which of the following techniques when repositioning the boy? A. Assist the patient in pulling himself up with the overhead trapeze bar B. Turn the patient's head to one side, then have him reach for the rail to turn C. Place the bed in Trendelenburg position, then have the boy roll to one side D. Use an assistant and logroll the patient to the desired side

D. Use an assistant and logroll the patient to the desired side Scoliosis is a complex spinal deformity that includes curvature of the spine. It can be congenital but proper more commonly develops during the growth spurt of early adolescence. To maintain proper by body alignment after surgery, the patient should avoid twisting movements that can indwelling instruments to twists the spine. Log-rolling is preferred when moving the child A and B - use of trapeze and reaching and twisting movements can cause the indwelling instruments to twist the spine. C - Trendelenburg position is not recommended and may increase swelling at the surgical site.

Ageism refers to a) Bias against older people based solely on chronological age b) fear of old age. c) loss of memory. d) benign senescent forgetfulness.

Individuals demonstrating ageism base their beliefs and attitudes about older people based upon chronological age without consideration of functional capacity. b) Fear of aging and the inability of many to confront their own aging process may trigger ageist beliefs. c) Age-related loss of memory occurs more with short-term and recent memory. d) Benign senescent forgetfulness refers to the age-related loss of memory in the absence of a pathologic process.

This vaccine is given to prevent liver cirrhosis and liver cancer: A. DPT B. OPV C. BCG D. HepB

Option D is the answer. Hepatitis B is a serious disease. It can also cause long-term (chronic) illness that leads to liver cirrhosis, liver cancer and death. Hepatitis B vaccine can prevent hepatitis B. It is the first anti-cancer vaccine because it can prevent a form of liver cancer. Other choices are inappropriate. BCG prevents TB; OPV prevents polio; DPT prevents diphtheria, pertussis and tetanus.

Which of the following clinical characteristics is associated with Type 2 diabetes (previously referred to as non-insulin-dependent diabetes mellitus [NIDDM])? a) Can control blood glucose through diet and exercise b) Usually thin at diagnosis c) Ketosis-prone d) Demonstrate islet cell antibodies

a) Can control blood glucose through diet and exercise Oral hypoglycemic agents may improve blood glucose levels if dietary modification and exercise are unsuccessful.

Of the following types of insulin, which is the most rapid acting? a) Humalog b) Regular c) NPH d) Ultralente

a) Humalog The onset of action of rapid-acting Humalog is within 10-15 minutes.

Which of the following statements describe refractive surgery? a) Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea. b) Refractive surgery will alter the normal aging of the eye. c) Refractive surgery may be performed on all patients, even if they have underlying health conditions. d) Refractive surgery may be performed on patients with an abnormal corneal structure as long as they have a stable refractive error.

a) Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea. Refractive surgery is an elective procedure and is considered a cosmetic procedure (to achieve clear vision without the aid of prosthetic devices). It is performed to reshape the cornea for the purpose of correction of all refractive errors.

In which phase of the trajectory model of chronic illness are the symptoms under control and managed? a) Stable b) Acute c) Comeback d) Downward

a) Stable The stable phase indicates that the symptoms and disability are under control or managed. b) The acute phase is characterized by sudden onset of severe or unrelieved symptoms or complications that may necessitate hospitalization for their management. c) The comeback phase is the period in the trajectory marked by recovery after an acute period. d) The downward phase occurs when symptoms worsen or the disability progresses despite attempts to control the course through proper management.

In order to help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be to use a) a trochanter roll extending from the crest of the ilium to the midthigh. b) pillows under the lower legs. c) a hip-abductor pillow. d) a footboard.

a) a trochanter roll extending from the crest of the ilium to the midthigh. A trochanter roll, properly placed, provides resistance to the external rotation of the hip. b) Pillows under the legs will not prevent the hips from rotating externally. c) A hip-abductor pillow is used for the patient after total hip replacement surgery. d) A footboard will not prevent the hips from rotating externally.

The nurse knows that a postoperative vision-threatening complication of LASIK refractive surgery, diffuse lamellar keratitis (DLK) occurs a) in the first week after surgery. b) 1 month after surgery. c) 2-3 months after surgery. d) 6 months after surgery.

a) in the first week after surgery. DLK is a peculiar, non-infectious, inflammatory reaction in the lamellar interface after LASIK. It is characterized by a white granular, diffuse culture-negative lamellar keratitis occurring in the first week after surgery. Studies suggest that since no single agent appears to be solely the cause of DLK, a multifactorial etiology is likely.

The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. b) the first 24 hours after the procedure. c) two weeks after the procedure. d) the first month after the procedure.

a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could become activated with exposure to strong light, such as sunlight or bright lights. Ordinary indoor light is not a problem. The patient should be counseled to wear protective clothing, such as long-sleeved shirts, sunglasses, and wide-brimmed hats, if the patient has to go outdoors during daylight hours in the first five days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

To facilitate entry of a catheter into the male urethra, the penis should be positioned at which of the following degree angles (in relation to the body)? a) 45 degrees b) 90 degrees c) 180 degrees d) 270 degrees

b) 90 degrees A right angle straightens the urethra and makes it easier to insert the catheter.

Which type of glaucoma presents an ocular emergency? a) Normal tension glaucoma b) Acute angle-closure glaucoma c) Ocular hypertension d) Chronic open-angle glaucoma

b) Acute angle-closure glaucoma Acute angle-closure glaucoma results in rapid progressive visual impairment.

Which of the following categories of medications increases aqueous fluid outflow in the patient with glaucoma? a) Beta-blockers b) Cholinergics c) Alpha-adrenergic agonists d) Carbonic anhydrase inhibitors

b) Cholinergics Cholinergics increase aqueous fluid outflow by contracting the ciliary muscle, causing miosis, and opening the trabecular meshwork.

Which of the following states is characterized by a decline in intellectual functioning? a) Depression b) Dementia c) Delirium d) Delusion

b) Dementia Dementia is an acquired syndrome in which progressive deterioration in global intellectual abilities is of such severity that it interferes with the person's customary occupational and social performance. a) Depression is a mood disorder that disrupts quality of life. c) Delirium is often called acute confusional state. d) Delusion is a symptom of psychoses.

The nurse teaches the patient about diabetes including which of the following statements? a) Sugar is found only in dessert foods. b) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. c) The only diet change needed in the treatment of diabetes is to stop eating sugar. d) Once insulin injections are started in the treatment of Type 2 diabetes, they can never be discontinued.

b) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

Which of the following terms refers to the decrease in lens flexibility that occurs with age, resulting in the near point of focus getting farther away? a) Presbycusis b) Presbyopia c) Cataract d) Glaucoma

b) Presbyopia Presbyopia usually begins in the fifth decade of life, when reading glasses are required to magnify objects. a) Presbycusis refers to age-related hearing loss. c) Cataract is the development of opacity of the lens of the eye. d) Glaucoma is a disease characterized by increased intraocular pressure.

Of the following categories of oral antidiabetic agents, which exert their primary action by directly stimulating the pancreas to secrete insulin? a) Thiazolidinediones b) Sulfonylureas c) Biguanides d) Alpha glucosidase inhibitors

b) Sulfonylureas Therefore, a functioning pancreas is necessary for sulfonylureas to be effective.

According to the classification of hypertension diagnosed in the older adult, hypertension that can be attributed to an underlying cause is termed a) primary. b) secondary. c) essential. d) isolated systolic.

b) secondary. Secondary hypertension may be caused by a tumor of the adrenal gland (e.g., pheochromacytoma). a) Primary hypertension has no known underlying cause. c) Essential hypertension has no known underlying cause. d) Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 30 cc b) 50 cc c) 100 cc d) 400 cc

c) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Retinoblastoma is the most common eye tumor of childhood; it is hereditary in a) 10-20% of cases. b) 25-50% of cases. c) 30-40% of cases. d) 50-75% of cases.

c) 30-40% of cases. Retinoblastoma can be hereditary or nonhereditary. It is hereditary in 30-40% of cases. All bilateral cases are hereditary.

The nurse teaches the patient about glargine (Lantus), a "peakless" basal insulin including which of the following statements? a) Administer the total daily dosage in two doses. b) Draw up the drug first, then add regular insulin. c) Do not mix the drug with other insulins d) The drug is rapidly absorbed and has a fast onset of action

c) Do not mix the drug with other insulins Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine (Lantus) insulin it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Vital capacity b) Gas exchange and diffusing capacity c) Residual lung volume d) Cough efficiency

c) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity. a) The nurse anticipates decreased vital capacity. b) The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. d) The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Which of the following types of incontinence refers to involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure? a) Overflow b) Urge c) Stress d) Reflex

c) Stress Stress incontinence may occur with sneezing and coughing.

Which type of incontinence is associated with weakened perineal muscles that permit leakage of urine when intra-abdominal pressure is increased? a) Urge incontinence b) Reflex (neurogenic) incontinence c) Stress incontinence d) Functional incontinence

c) Stress incontinence Stress incontinence may occur with coughing or sneezing. a) Urge incontinence is involuntary elimination of urine associated with a strong perceived need to void. b) Neurogenic incontinence is associated with a spinal cord lesion. d)Functional incontinence refers to incontinence in patients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems.

Which of the following terms refers to surgical repair of the tympanic membrane? a) Tympanotomy b) Myringotomy c) Tympanoplasty d) Ossiculoplasty

c) Tympanoplasty Tympanoplasty may be necessary to repair a scarred eardrum.

To prevent footdrop, the patient is positioned in: a) A semi-sitting position in bed b) A sitting position with legs hanging off the side of the bed c) A side-lying position d) Order to keep the feet at right angles to the leg

d) Order to keep the feet at right angles to the leg When the patient is supine in bed, padded splints or protective boots are used. a) Semi-fowlers positioning is used to decrease the pressure of abdominal contents on the diaphragm. b) In order to prevent footdrop, the feet must be supported. c) Side-lying positions do not provide support to prevent footdrop.

Which of the following statements describes benign paroxysmal positional vertigo (BPPV)? a) The onset of BPPV is gradual. b) BPPV is caused by tympanic membrane infection. c) BPPV is stimulated by the use of certain medication such as acetaminophen. d) The vertigo is usually accompanied by nausea and vomiting; however hearing impairment does not generally occur

d) The vertigo is usually accompanied by nausea and vomiting; however hearing impairment does not generally occur. BPPV is a brief period of incapacitating vertigo that occurs when the position of the patient's head is changed with respect to gravity. The vertigo is usually accompanied by nausea and vomiting; however hearing impairment does not generally occur.