NCLEX #751-800
NO.777 An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction? A. Boardlike, rigid abdomen B. Loss of the urge to defecate C. Liquid stool D. Abdominal pain
Answer: C Explanation: (A) A boardlike, rigid abdomen would point to a perforated bowel, not a fecal impaction. (B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so. (C) When an impaction is present, only liquid stool will be able to pass around the impacted site. (D) Abdominal pain without distention is not a sign of a fecal impaction.
NO.774 A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information: A. He should be on a high-fiber diet. B. He should eat a low-residue diet. C. He should drink minimal amounts of fluids. D. He does not need to make any modifications.
Answer: A Explanation: (A) Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with bran or bulk laxatives. (B) Lowresidue diets lead to constipation and are contraindicated in clients with diverticulosis. (C) Clients with diverticulosis should drink at least eight glasses of water each day to prevent constipation. (D) Clients with diverticulosis should modify their diet to include high-fiber foods and bulk laxatives.
NO.793 Which of the following nursing orders should be included in the plan of care for a client with hepatitis C? A. The nurse should use universal precautions when obtaining blood samples. B. Total bed rest should be maintained until the client is asymptomatic. C. The client should be instructed to maintain a low semi-Fowler position when eating meals. D. The nurse should administer an alcohol backrub at bedtime.
Answer: A Explanation: (A) The source of infection with hepatitis C is contaminated blood products. (B) Modified bed rest should be maintained while the client is symptomatic. Routine activities can be slowly resumed once the client is asymptomatic. (C) Nausea and vomiting occur frequently with hepatitis C. A high Fowler position may decrease the tendency to vomit. (D) The buildup of bilirubin in the client's skin may cause pruritus. Alcohol is a drying agent.
NO.753 A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to: A. Control the delivery by guiding expulsion of fetus B. Leave the room to call the physician C. Push against the perineum to stop delivery D. Cross client's legs tightly
Answer: A Explanation: (A) Controlling the rapid delivery will reduce the risk of fetal injury and perineal lacerations. (B) The nurse should always remain with a client experiencing a precipitous delivery. (C) Pushing against the perineum may cause fetal distress. (D) Crossing of legs may cause fetal distress and does not stop the delivery process.
NO.799 Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to: A. Reinforce attempts to eat B. Help the child gain weight C. Increase his appetite D. Make mealtimes pleasant
Answer: A Explanation: (A) Ignoring refusals to eat and rewarding eating attempts are the most successful means of increasing intake. (B) This goal is not specific enough or related to the loss of appetite. (C) This goal is not possible at this time based on his illness. (D) This goal is helpful, but alone will not address his loss of appetite.
NO.788 A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse's frequent monitoring of the child's temperature frightened her parents. Which response by the nurse would be most appropriate? A. Monitoring the temperature prevents undue chilling. B. Rapid temperature elevations can occur in children. C. Checking the temperature will prevent febrile seizures. D. Taking the child's temperature can prevent airway obstruction.
Answer: A Explanation: (A) The refrigerated cool mist tent creates a cool, moist environment. The child as well as bedding and clothing may become dampened. Monitoring the temperature of the child will ensure warmth and prevent chilling. (B) Only a low-grade fever is expected in laryngotracheobronchitis. (C) Febrile seizures are not expected with the low-grade fever. (D) Inflammation of the mucosal lining in the respiratory tract can cause airway obstruction. However, monitoring the child's temperature would not prevent airway obstruction.
NO.767 Which of the following statements relevant to a suicidal client is correct? A. The more specific a client's plan, the more likely he or she is to attempt suicide. B. A client who is unsuccessful at a first suicide attempt is not likely to make future attempts. C. A client who threatens suicide is just seeking attention and is not likely to attempt suicide. D. Nurses who care for a client who has attempted suicide should not make any reference to the word "suicide" in order to protect the client's ego.
Answer: A Explanation: (A) This is a high-risk factor for potential suicide. (B) A previous suicide attempt is a definite risk factor for subsequent attempts. (C) Every threat of suicide should be taken seriously. (D) The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions.
NO.787 A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must: A. Take a baseline set of vital signs B. Hang Ringer's lactate as the companion fluid C. Use microdrip tubing for the blood administration D. Have the registered nurse in charge assume responsibility for verifying the client and blood product information
Answer: A Explanation: (A) A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. (B) The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. (C) Only a blood administration set should be used. A microdrip tube would cause lysis of the red blood cells. (D) Proper identification of the recipient and the blood product must be validated by at least two people.
NO.789 A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful? A. Pork chop, baked acorn squash, brussel sprouts B. Chicken breast, rice, and green beans C. Roast beef, baked potato, and diced carrots D. Tuna casserole, noodles, and spinach
Answer: A Explanation: (A) Both acorn squash and brussels sprouts are potassium-rich foods. (B) None of these foods is considered potassium rich. (C) Only the baked potato is a potassium-rich food. (D) Spinach is the only potassium-rich food in this option.
NO.772 When teaching a sex education class, the nurse identifies the most common STDs in the United States as: A. Chlamydia B. Herpes genitalis C. Syphilis D. Gonorrhea
Answer: A Explanation: (A) Chlamydia trachomatis infection is the most common STD in the United States. The Centers for Disease Control and Prevention recommend screening of all high-risk women, such as adolescents and women with multiple sex partners. (B) Herpes simplex genitalia is estimated to be found in 5-20 million people in the United States and is rising in occurrence yearly. (C) Syphilis is a chronic infection caused by Treponema pallidum. Over the last several years the number of people infected has begun to increase. (D) Gonorrhea is a bacterial infection caused by the organism Neisseria gonorrhoeae. Although gonorrhea is common, chlamydia is still the most common STD.
NO.783 The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician's orders should the RN question? A. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery. B. Discontinue the oxytocin infusion. C. Insert an indwelling Foley catheter prior to delivery. D. Prepare abdominal area from below the nipples to below the symphysis pubis area.
Answer: A Explanation: (A) Meperidine is a narcotic analgesic medication that crosses the placental barrier and reaches the fetus, causing respiratory depression in the fetus. A narcotic medication should never be included in the preoperative order for a cesarean delivery. (B) Oxytocin infusion would be discontinued if client is being prepared for a cesarean delivery because the medication would not be needed. (C) The bladder is always emptied prior to and during the surgical intervention to prevent the urinary bladder from accidentally being incised while the uterine incision is made. (D) The abdominal area is always prepared to rid the area of hair before the abdominal incision is made. Abdominal hair cannot be sterilized and could become a source for postoperative incisional infection.
NO.756 As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, "I know I must come to the hospital, but what do I do next?" You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room? A. Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything. B. Inform the victim to bring insurance information with her to the hospital so she can be properly cared for. C. Phone a rape counselor to begin working with the victim as soon as she enters the hospital. D. Do not leave the victim alone to collect her thoughts.
Answer: A Explanation: (A) Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel "dirty" after rape, and their first instinct is to take care of personal hygiene before facing anyone. (B) This action is of lesser importance at this time. (C) Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. (D) Once the victim enters the emergency room, it is important not to leave her alone.
NO.751 To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration? A. Stinging, burning when placed under the tongue B. Temporary blurring of vision C. Generalized urticaria with prolonged use D. Urinary frequency
Answer: A Explanation: (A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not even side effects.
NO.760 On a mother's 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best position for the client to be placed in for this assessment is: A. Sims' B. Fowler's C. Prone D. Any position that the RN chooses
Answer: A Explanation: (A) The Sims' position is the best position for assessment of the perineum and anus. The top leg is placed over the bottom leg, and the RN raises the upper buttocks to fully expose the perineum and anus. (B) Fowler's position is a sitting position, and the perineum and anus would not be exposed. (C) The prone position would have the mother on her back, and her perineum and anus would not be exposed. (D) The position of choice should always be the Sims'.
NO.766 A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures? A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing. B. Advise the client to discontinue the drug at the first sign of dizziness. C. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause. D. Instruct the client in Valsalva's maneuver to equalize middle ear pressure and to prevent hearing loss.
Answer: A Explanation: (A) The first nursing measure is to instruct the client in which drug side effects to report. (B) Discontinuing the drug is not an independent nursing intervention and may compromise client care. (C) Audiometric testing will detect hearing loss, but it does not indicate a potential cause. (D) Equalizing middle ear pressure will not prevent hearing loss.
NO.765 A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level? A. 14 u g/mL B. 25 u g/mL C. 4 u g/mL D. 30 u g/mL
Answer: A Explanation: (A) The therapeutic blood level range of theophylline is 10-20 mg/mL. Therapeutic drug monitoring determines effective drug dosages and prevents toxicity. (B, D) This value is a toxic level of the drug. (C) This value is a nontherapeutic level of the drug.
NO.797 During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate? A. Tinnitus and nausea B. Dermatitis and blurred vision C. Unconsciousness and acetone odor of the breath D. Chills and an elevation of temperature
Answer: A Explanation: (A) These are toxic symptoms of sodium salicylate. (B, C, D) These are not symptoms associated with sodium salicylate.
NO.758 A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks' gestation. The nurse should be alert to which condition related to her age? A. Iron-deficiency anemia B. Sexually transmitted disease (STD) C. Intrauterine growth retardation D. Pregnancy-induced hypertension (PIH)
Answer: D Explanation: (A) Iron-deficiency anemia can occur throughout pregnancy and is not age related. (B) STDs can occur prior to or during pregnancy and are not age related. (C) Intrauterine growth retardation is an abnormal process where fetal development and maturation are delayed. It is not age related. (D) Physical risks for the pregnant client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy.
NO.798 The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching? A. "I'll be sure to rise slowly and sit for a few minutes after lying down." B. "I'll be sure to walk at least 2-3 blocks every day." C. "I'll be sure to restrict my fluid intake to four or five glasses a day." D. "I'll be sure not to take any more aspirin while I am on this drug."
Answer: A Explanation: (A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 2000-3000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide.
NO.773 A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first: A. Assist her with a sitz bath B. Administer the prescribed medication for pain C. Teach her Kegel exercises D. Apply an ice pack
Answer: A Explanation: (A) Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given. (B) Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective. (C) Kegel exercises facilitate sitting by decreasing tension on the episiotomy. They will not be effective for pain control or sustained comfort level. (D) Ice packs are appropriate to apply in the first 12 hours postdelivery to produce vasoconstriction and to reduce edema to the area.
NO.794 A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot of blood and required multiple blood transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss has occurred? A. Whole blood B. Platelets C. Fresh frozen plasma D. Packed red blood cells
Answer: A Explanation: (A) Whole blood is the transfusion component of choice when large volumes of blood need to be replaced. Whole blood contains all blood components that are lost during active bleeding. (B) Platelet therapy is indicated for thrombocytopenia if the client's platelet count is below 15,000/mm3. (C) Infusion of fresh frozen plasma is required when the prothrombin time and partial thromboplastic time are prolonged. (D) Packed red blood cells are transfused in instances of anemia with decreases in hematocrit and hemoglobin.
NO.784 A female client at 37 weeks' gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as: A. Reactive; needs follow-up contraction stress test B. Reactive; no contraction stress test required C. Non-reactive; needs follow-up contraction stress test D. Non-reactive; no contraction stress test required
Answer: B Explanation: (A) A contraction stress test is unnecessary following a reactive (normal) nonstress test. (B) The results are considered reactive, indicating that the fetus is not showing distress. Therefore, a contraction stress test, which is a more in-depth test for fetal distress, is unnecessary. (C) A nonreactive test would show fewer than two fetal movements or a failure of the FHR to increase at least 15 bpm with the movements in a 20-minute period. (D) A contraction stress test should follow a nonreactive nonstress test to validate fetal distress.
NO.779 A murmur has been discovered during the routine physical examination of a 1-year-old child. The parent is extremely concerned about this diagnosis. Which of the following explanations by the nurse indicates understanding of this dysfunction? A. The blood shifts from the right to the left atrium. B. Surgical closure by suture or patch is recommended before school age. C. Most atrial septal defects close spontaneously. D. The child can be treated medically with antibiotics to prevent bacterial endocarditis.
Answer: B Explanation: (A) Because the left atrial pressure is greater than right atrial pressure, oxygenated blood flows from the left to the right atria. (B) Because of the risk of pulmonary obstructive diseases and congestive heart failure later in life, surgery is usually performed between age 4 and 6 years, with essentially no operative mortality or postoperative complications. (C) Many ventricular septal defects close spontaneously (20-60%) as a result of growth and proliferation of the muscular septum or formation of a membrane across the opening. (D) This management is usually recommended with children with mild pulmonary stenosis.
NO.778 The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid "vena caval syndrome," a condition which: A. Occurs when blood pressure increases sharply with changes in position B. Results when blood flow from the extremities is blocked or slowed C. Is seen mainly in first pregnancies D. May require medication if positioning does not help
Answer: B Explanation: (A) Blood pressure changes are predominantly due to pressure of the gravid uterus. (B) Pressure of the gravid uterus on the inferior vena cava decreases blood return from lower extremities. (C) Inferior vena cava syndrome is experienced in the latter months of pregnancy regardless of parity. (D) There are no medications useful in the treatment of interior vena cava syndrome; alleviating pressure by position changes is effective.
NO.781 A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated? A. Encourage exercises in the unaffected extremities. B. Encourage her to cross and uncross her legs. C. Check neurological and circulatory status of the affected leg hourly. D. Place a trochanter roll along the upper thigh of the affected leg.
Answer: B Explanation: (A) Exercising the unaffected extremities will prevent contractures and emboli. (B) Crossing and uncrossing the affected leg after surgery can dislocate the joint. (C) Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. (D) A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.
NO.786 Before giving methergine postpartum, the nurse should assess the client for: A. Decreased amount of lochial flow B. Elevated blood pressure C. Flushing D. Afterpains
Answer: B Explanation: (A) Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. (B) Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. (C) Flushing is not a side effect of methergine. (D) Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
NO.776 The mother of a 7-year-old mental health center client reports that the client has refused to attend gymnastics for the past 2 weeks. Prior to that time, the child liked going to this class and was attending 3 times a week. In talking with the client, the nurse would: A. Ask her why she doesn't like gymnastics anymore B. Ask her to describe how things were at gymnastics before she started refusing to go C. Tell her that it is OK to be afraid of this activity D. Reassure her that things will get better once she begins the classes again
Answer: B Explanation: (A) The child has not said that she dislikes gymnastics. (B) The nurse will be able to obtain information on what events occurred at gymnastics prior to her refusal to attend. The nurse will also gain information about the child's perception of the problem. (C) The child has not said she is afraid to go to gymnastics. (D) False reassurance is inappropriate.
NO.763 A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is: A. In the acutely depressed state B. When the depression starts to lift C. In the denial phase D. During a manic episode
Answer: B Explanation: (A) The client may be too disorganized in the acute phase to make a workable plan. (B) When the depression starts to lift, the client is able to make a workable plan. (C) There usually is not a significant denial phase related to depression. Suicide occurs in a state of despair and hopelessness. (D) Suicide is uncommon in the manic state. In this state, clients do not feel hopeless, but euphoric and overly confident.
NO.796 A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion? A. Somatic B. Grandiose C. Persecutory D. Nihilistic
Answer: B Explanation: (A) These delusions are related to the belief that an individual has an incurable illness. (B) These delusions are related to feelings of self-importance and uniqueness. (C) These delusions are related to feelings of being conspired against. (D) These delusions are related to denial of self-existence.
NO.775 The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this program are: A. Month-old magazines that are provided by volunteers B. Large maps and posters depicting area of current residence C. A litter of kittens for the clients to pet D. A library of biographical books
Answer: B Explanation: (A) This answer is incorrect. Current magazines would be appropriate. (B) This answer is correct. Maps of the state and town and posters that depict current events in the area are appropriate props. (C) This answer is incorrect. Kittens would be appropriate for pet therapy, not reality therapy. (D) This answer is incorrect. Biographies depict a past, not a present, orientation.
NO.761 On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty. He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety? A. "You will not be allowed to remain in your room if you continue to bother things." B. "I can see how uncomfortable you are, but I would like you to walk with me so I can show you around the unit." C. "Tell me why your room needs to be so clean." D. "I've inspected this room and it is perfectly clean."
Answer: B Explanation: (A) This statement is punitive. (B) Acknowledging the anxiety and channeling it into some positive activity is therapeutic. (C) The client cannot say "why"; this statement puts the client on the defensive. (D) A rational approach, especially a judgmental one, is nontherapeutic.
NO.768 A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given? A. 0.06 mL B. 0.38 mL C. 2.7 mL D. Information given insufficient to determine the amount of atropine to be administered
Answer: B Explanation: (A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer. (B) The answer is correct. 0.4 mg = 1 mL:0.15 mg 5 = mL 0.4 x = 0.15 x = 0.15/0.4 x = 0.375 or 0.38 mL (D) Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.
NO.755 A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to: A. A left hemothorax B. A right hemothorax C. Intubation of the right mainstem bronchus D. An inadequate mechanical ventilator
Answer: C Explanation: (A) Although a left hemothorax could cause diminished and distant breath sounds, it is irrelevant to this situation. (B) A right hemothorax will not cause diminished and distant breath sounds on the left side of the chest. (C) The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left. (D) An inadequate mechanical ventilator has no relationship to this situation.
NO.782 The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay? A. Pulse rate of 50-70 bpm by her third postpartum day B. Diuresis by her second or third postpartum day C. Vaginal discharge or rubra, serosa, then rubra D. Diaphoresis by her third postpartum day
Answer: C Explanation: (A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.
NO.770 A client has been uncomfortable in crowds all her life. After the birth of her child, she has been housebound unless her husband can accompany her to the grocery store and for medical appointments. His schedule will not allow for this, and he has insisted that she must be more independent. Her anxiety has increased to the point of panic. The client has been diagnosed with agoraphobia. Which statement is true about this disorder? A. The behavior is not considered disabling. B. More men suffer from agoraphobia than women. C. The fears are persistent, and avoidance is used as the coping mechanism. D. Agoraphobia moves into remission when treated with chlorpromazine.
Answer: C Explanation: (A) Agoraphobia is the most pervasive and serious phobic disorder. (B) Women compose 70%-85% of agoraphobia sufferers. (C) Agoraphobia is an acute disorder that immobilizes the sufferer with extreme anxiety. (D) Chlorpromazine is not a drug used to treat phobias.
NO.780 A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital's psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies that the best approach to this problem is to: A. Allow him to eat late B. Suggest that he do the rituals after breakfast C. Get him up early so that he can complete the ritual before breakfast D. Ask him to get all the other clients up so that he will forget about his ritual
Answer: C Explanation: (A) Allowing him to eat late is not a solution to the problem because the ritual affects more than just this meal. (B) He is helpless to change this behavior because the rituals occur as a result of an irrational effort to control his anxiety. (C) To interfere with the ritual will increase anxiety. Until the basic problem is resolved, and in turn his need for the ritual relieved, arrange the schedule so that essential activities may be included (such as meals with the group). (D) This approach would be very disruptive to the other clients and would not serve to relieve the anxiety of the client.
NO.791 A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following? A. Antipsychotic medications B. Antidepressant medications C. Antianxiety medications D. Antimania medication
Answer: C Explanation: (A) Antipsychotic medications are also known as major tranquilizers. (B) Antidepressants fall into different categories, such as the tricyclics or the MAO inhibitors. (C) Antianxiety medications are also known as minor tranquilizers. (D) Antimania medications are those such as lithium and lithium carbonate (Lithobid).
NO.752 A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct? A. "It sounds as though you are coming down with a bad cold. I'll ask the doctor to prescribe a decongestant for relief of symptoms." B. "A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side." C. "These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them." D. "This is most unusual. I'm sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist."
Answer: C Explanation: (A) Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. (B) Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. (C) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. (D) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.
NO.769 A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, "Something is wrong. This is like my labor." Which reply by the nurse identifies the physiological response of the client? A. "Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract." B. "Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement." C. "The same hormone that is released in response to the baby's sucking, causing milk to flow, also causes the uterus to contract." D. "There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it."
Answer: C Explanation: (A) Mammary growth as well as milk production and maintenance in the breast occur in response to hormones produced primarily by the hypothalamus and the pituitary gland. (B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of breast-feeding. (C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of the myoepithelial cells surrounding the alveoli. In addition, it causes contractions of the uterus and uterine involution. (D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are other symptoms that occur in response to retained placental fragments.
NO.757 A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy: A. Prevents the development of ophthalmia neonatorum B. Assists the baby's clotting mechanism C. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine D. Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)
Answer: C Explanation: (A) The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. (B) The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. (C) Excessive bilirubin accumulates when the infant's liver cannothandle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. (D) Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
NO.762 The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, "My life is so bad no one can do anything to help me." The most helpful initial response by the nurse would be: A. "It concerns me that you feel so badly when you have so many positive things in your life." B. "It will take a few weeks for you to feel better, so you need to be patient." C. "You are telling me that you are feeling hopeless at this point?" D. "Let's play cards with some of the other clients to get your mind off your problems for now."
Answer: C Explanation: (A) This response does not acknowledge the client's feelings and may increase his feelings of guilt. (B) This response denotes false reassurance. (C) This response acknowledges the client's feelings and invites a response. (D) This response changes the subject and does not allow the client to talk about his feelings.
NO.754 A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity? A. 0.5 ng/mL B. 1.0 ng/mL C. 2.0 ng/mL D. 3.0 ng/mL
Answer: D Explanation: (A) 0.5 ng/mL of digoxin is a subtherapeutic level, not a toxic one. (B) 1.0 ng/mL is a therapeutic level. (C) 2.0 ng/mL is a therapeutic level. (D) Digoxin's therapeutic level is 0.8-2.0 ng/mL. Digoxin's toxic level is >2.0 ng/mL.
NO.800 A baby is circumcised. Immediate postoperative care should include: A. Applying a loose diaper B. Keeping the baby NPO for 4 hours to avoid vomiting C. Changing the dressing frequently using dry, sterile gauze D. Taking the baby to his mother for cuddling
Answer: D Explanation: (A) A pressure diaper should be applied to discourage hemorrhage. (B) The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable. (C) Dressing changes should not be dry. Dry dressing will stick. (D) Cuddling after the procedure will hopefully quiet the baby. Feeding is also important if his feeding was withheld prior to the procedure or it is time for a feeding.
NO.795 A 67-year-old postoperative TURP client has hematuria. The nurse caring for him reviews his postoperative orders and recognizes that which one of the following prescribed medications would best relieve this problem? A. Acetaminophen suppository 650 mg B. Meperidine 50 mg IM C. Promethazine 25 mg IM D. Aminocaproic acid (Amicar) 6 g/24 hr
Answer: D Explanation: (A) Acetaminophen (Tylenol) has analgesic and antipyretic actions approximately equivalent to those of aspirin. It produces analgesia possibly by action on the peripheral nervous system. It reduces fever by direct action on the hypothalamus heat-regulating center with consequent peripheral vasodilation. It is generally used for temporary relief of mild to moderate pain, such as a simple headache, minor joint and muscle pains, and control of fever. (B) Meperidine is a narcotic agonist analgesic with properties similar to morphine except that it has a shorter duration of action and produces less depression of urinary retention and smooth muscle spasm. It is used for moderate to severe pain, for a preoperative medication, for support of anesthesia, and for obstetrical analgesia. In a postoperative TURP client, it would be used in conjunction with other medications for relief of moderate to severe pain, but not specifically for bladder spasms associated with TURP surgery. (C) Promethazine hydrochloride is an antihistamine, antiemetic preparation. It exerts antiserotonin, anticholinergic, and local anesthetic actions. It is used for symptomatic relief of various allergic conditions, motion sickness, nausea, and vomiting. It is used for preoperative, postoperative, and obstetrical sedation and as an adjunct to analgesics for control of pain. (D) This answer is correct because aminocaproic acid is prescribed specifically for hematuria. Aminocaproic acid is excreted in the urine. The nurse should be alert for possible signs of thrombosis, particularly in the extremities.
NO.759 The nurse needs to be aware that the most common early complication of a myocardial infarction is: A. Diabetes mellitus B. Anaphylactic shock C. Cardiac hypertrophy D. Cardiac dysrhythmia
Answer: D Explanation: (A) Diabetes mellitus is not a common complication of myocardial infarction. (B) Anaphylactic shock is an allergic reaction. (C) Cardiac hypertrophy is a late potential complication. It is a common complication of congestive heart failure. (D) Myocardial infarction causes tissue damage, which may interrupt electrical impulses. Myocardial irritability results from lack of oxygenated tissue.
NO.792 A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn? A. Fluid volume deficit secondary to alteration in skin integrity B. Alteration in comfort secondary to alteration in skin integrity C. Alteration in sensation secondary to third-degree burn D. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
Answer: D Explanation: (A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48-72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
NO.790 A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages? A. Identity versus role confusion B. Integrity versus despair C. Intimacy versus isolation D. Generativity versus self-absorption
Answer: D Explanation: (A) Identity versus role confusion is experienced by adolescents making the transition from childhood to adulthood as they attempt to develop a sense of identity. (B) Integrity versus despair is experienced by the elderly as they reflect on their life in an attempt to find meaning. (C) Intimacy versus isolation is experienced by young adults as they establish intimate bonds of love and friendship. (D) Generativity versus self-absorption is experienced by middle-aged adults as they fulfill life goals that involve family, career, and society. The client is experiencing this crisis.
NO.785 When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash? A. Small round or oval reddish brown macules scattered over the entire body B. Scattered clusters of macules, papules, and vesicles over the body C. Bright red appearance of the palmar surface of the hands D. Reddened butterfly shaped rash over the cheeks and nose
Answer: D Explanation: (A) The appearance of small, round or oval reddish brown macules scattered over the entire body is characteristic of rubeola. (B) The appearance of scattered clusters of macules, papules, and vesicles throughout the body is characteristic of chickenpox. (C) Palmar redness is seen in clients with cirrhosis of the liver. (D) The characteristic butterfly rash over the cheek and nose and into the scalp is seen with systemic lupus erythematosus.
NO.764 A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to: A. Call the physician B. Assess her vital signs C. Give the prescribed oxytocic drug D. Massage her fundus
Answer: D Explanation: (A) The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. (B) Assessment of vital signs will not help to restore uterine atony, which is the priority need. (C) Giving a prescribed oxytocic drug would be necessary ifthe uterus did not maintain tone with massage. (D) Fundal massage generally restores uterine tone within a few moments and should be attempted first.
NO.771 A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will: A. Drink at least 8 oz of cranberry juice daily B. Maintain a fluid intake of at least 2000 mL daily C. Wash her hands before and after voiding D. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps
Answer: D Explanation: (A)Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.
