Practice test 1

Which of the following statements made by a patient who is scheduled for a mammogram indicates a need for FURTHER teaching? "I will not use underarm antiperspirant before the procedure." "A dye will be injected into my vein prior to the procedure." 'I may experience discomfort during the procedure." "My breasts will be compressed while the x-ravs are taken."

"A dye will be injected into my vein prior to the procedure." Explanation: Client Need: Health Promotion and Maintenance Rationale: A contrast mammogram involves injection of a contrast dye into the breast duct. Dye is never injected into a vein prior to a mammogram. The patient's statement indicates the need for further teaching. A. Skin creams, antiperspirant, deodorants and powders should be removed prior to the test. C and D. The patient who is scheduled for a mammogram should be told that the test takes 15- 30 minutes, and that compression of the breast may produce a temporary discomfort.

Which of the following statements, if made by a patient who is taking atenolol (Tenormin), should indicate to a nurse that the patient is experiencing adverse effects of the drug? "I can feel my heart pounding". "| feel dizzy when I get out of bed". "I am urinating more frequently". "I have a severe headache".

I feel dizzy when i get out of bed Explanation: Client Need: Physiological Integrity Rationale: B. Adverse effects of atenolol include dizziness, vertigo and syncope. The nurse should caution the patient about rising to a standing position too quicklv. A. Atenolol causes bradycardia rather than tachycardia. C. Atenolol does not cause infertility or affect the reproductive system. D. Headache is expected in atenolol.

A woman reports all of the following data when giving her history to a nurse. Which one would indicate a risk factor for developing cancer of the cervix? Diet high in fat Exposure to pesticides Menses at age eleven Multiple sexual partners

Multiple sexual partners Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Risk for cancer of the cervix varies directly with an increase in the numbers of sexual partners and with early incidence of first intercourse. A, B and C. A high fat diet, exposure to pesticides and menses at age 11 are not identified as risk factors for cervical cancer.

Which of the following manifestations should the nurse recognize as an early sign of neuroleptic malignant syndrome? Difficulty swallowing Unstable blood pressure Muscle stiffness Respiratory depression

Muscle stiffness Explanation: Client Need: Physiological Integrity Rationale: C. Malignant neuroleptic syndrome is an emergency state caused by a reaction to antipsychotic medications. Early signs of neuroleptic malignant syndrome are stiffness, fever, sweating and tremors. A, B and D. Difficulty swallowing, unstable blood pressure and respiratory depression are late manifestations of neuroleptic malignant syndrome.

The teaching plan for a child who is taking long- term corticosteroid therapy would include which of the following instructions? Dental check- ups every three months to assess for gingival hyperplasia Regular physical therapy sessions to prevent muscular hypertrophy Eye examinations yearly to assess for cataract formation Regular appointments with a registered dietician to prevent malnutrition

Eye examinations yearly to assess for cataract formation Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Children who require frequent courses of steroid therapy are highly susceptible to complications of steroids, such as growth retardation, infections and hyperglycemia. Eye examinations should be carried out to determine if cataract formation is beginning. A, B and D. Gingival hyperplasia, muscle hypertrophy and malnutrition are not side effects caused by long- term corticosteroid use.

Which of the following findings would lead a nurse to suspect that the ventriculoperitoneal shunt of a seven- year-old child is obstructed? Your Answer: & Incorrect Frequent complaints of tinnitus Falling asleep daily in school for the past five days Occasional complaints of abnormal pain The presence of fever for fever for the past three days

Falling asleep daily in school for the past five days Explanation: Client Need: Physiological Integrity Rationale: B. The child with a shunt obstruction often presents as an emergency with clinical manifestation of increased intracranial pressure. In order children, who are usually admitted to the hospital for elective or emergency shunt revision, the most valuable indicators of increasing intracranial pressure is an alteration in the child's level of consciousness and interaction with the environment. Changes are identified by observing and comparing present behavior with customary behavior, sleep patterns, developmental capabilities and habits obtained through a detailed history and a baseline assessment. This baseline information serves as a guide for postoperative assessment and evaluation of shunt function. A. Tinnitus is not related to ventriculoperitoneal shunt obstruction. Tinnitus is a noise in the ears such as ringing, buzzing or roaring, which at times may be heard by others than the patient. Common causes include prolonged exposure to loud environmental noise, and such pathological conditions as inflammation and infection of the ear, otoscelerosis, Meniere's disease and labrinthitis. Systemic disorders associated with tinnitus include hypertension, neurologic disorders, hyperthyroidism and hypothyroidism. Tinnitus is often one of the first symptoms produced by an ototoxic drug. C. There is no documentation to support the complaint of abdominal pain in relation to venticuloperitoneal shunt obstruction. D. Signs of shunt infection, rather than blockage, include elevate temperature, poor feeding, vomiting, decreased responsiveness and seizure activity.

A nurse is giving change of shift report and the nurses from the next shift start talking about the birthday party for a co-worker. The BEST approach for the nurse giving the report is to: speak more loudly and continues the report. stop giving the report and wait for the others to finish their discussion. join in the discussion. state that she would like, to continue with the report.

state that she would like, to continue with the report. Explanation: Client Need: Safe Effective Care Environment Rationale: D. The nurse should be assertive and state that he/she would like to continue the report. This is the task at hand and needs to be completed so that the nurse can complete the work shift. A. Speaking more loudly will not ensure that the next shift is paying attention. The nurse may be continuing the report with no one listening. B. Stopping the report is a passive approach. The nurse needs to make his/her feelings known. C. The nurse needs to stay focused on the task at hand. It is important for the nurse to let the staff know that he/she intends to continue with the report.

The purpose for giving a woman dinoprostone (Prostaglandin E2) vaginal gel during labor induction is to: lengthens the duration of contraction. dilates the cervix. intensify the force of contractions. effaces the cervix.

effaces the cervix. Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Dinoprostone gel is approved as a cervical ripening agent. After application it promotes softening and thinning of the cervix. A, B and C. No other purpose is indicated for this drug other than to induce abortion.

Which of the following recommendations should a nurse make to a patient who has a diagnosis of chronic prostatitis? "Daily sitz baths will provide comfort." "Cold scrotal compresses will reduce inflammation" "A week of antibiotic therapy should be effective." "Sexual activity should be curtailed."

Daily sitz bath will provide comfort Explanation: Client Need: Physiological Integrity Rationale: A. Therapeutic management of chronic prostatitis may include long-term administration of antibiotics and anti- inflammatory agents, frequent prostatic massage and ejaculations, sit baths and stool softeners. B. Hot, rather than cold, compresses are indicated to reduce inflammation. C. Usually long- term administration of antibiotics is required, and not a seven to 10- day course of treatments. However, in non- bacterial prostates, antibiotic are not indicated. D. Activities that drain the prostate, such as intercourse, masturbation and prostatic massage, are often helpful in the long- term management of prostatitis.

Which of the following statements should a nurse include when preparing a female patient for a cone biopsy? "You may experience vaginal bleeding after the procedure". "Take nothing by mouth for eight hours prior to the procedure" 'There will be a catheter in your bladder after the procedure". "Douche with vinegar the evening before the procedure"

"You may experience vaginal bleeding after the procedure". Explanation: Client Need: Physiological Integrity Rationale: A. The Patient is instructed to report excessive bleeding and to leave the packing in place until the physician removes it, usually 24 hours later. B, C and D. A cone biopsy is done as an outpatient surgery, and involves the excision of a small portion of the cervix for identified for this procedure. The patient does not have to be fasting, a catheter is not inserted and douching prior to the procedure is not recommended.

An infant who weighs 11 lb (5 kg) is to receive 750 mg of antibiotic in a 24- hour period. The liquid antibiotic comes in a concentration of 125 mg per 5 ml. If the antibiotic is to be given three times each day, how many milliliters would the nurse administer with each dose? 2 5 6.25 10

10 Client Need: Physiological Integrity Rationale: D. First calculate how many milligrams of antibiotic should be given for each dose: 750 mg/ 24 hr = x mg/8hr 24x = 6000 = 250 mg/dose Now calculate the number of milliliters needed for each dose: Dose Desired/Dose on Hand X vehicle = number of milliliters per dose 250 mg/ 125 mg X 5ml = 1250/125 = 10 ml per dose

A nurse is planning a community education presentation about testicular cancer. The target group should be men, aged: 20 to 39 years. 40 to 49 years. 50 to 64 years. 65 years and older.

20 to 39 years Explanation: Client Need: Health Promotion and Maintenance Rationale: A. Testicular tumors have a peak incidence in men aged 20 to 39 vears. B, C and D. Community education should be targeted to men ages 20 39, since the majority of testicular tumors occur within that age group.

A patient is experiencing an acute dystonic reaction. All of the following p. r. n. medications are prescribed. Which medication should the nurse administer? Chlorpromazine hydrochloride (Thorazine) Lorazepam (Ativan) Diphenhydramine hydrochloride Alprazolam (Xanax)

Diphenhydramine hydrocloride Explanation: Client Need: Physiological Integrity Rationale: C. Diphenhydramine (Benadryl) will reverse a dystonic reaction, which is one of the side effects of antipsychotic therapy. A. Chlorpromazine is an antipsychotic medication that has dystonia as a side effect. B and D. Lorazepam and Xanax are anti-anxiety medications. While dystonic reactions often increase anxiety in patients, relief of the dystonia is accomplished through the use of diphenhydramine.

A 48-year-old woman, who does not have a family history of breast cancer, asks a nurse in the ambulatory care center whether she should have a mammogram. Which of the following responses by the nurse would be accurate? "At your age, a mammogram is recommended every one to two years." "You do not need to begin to get mammograms until you are 50 years old." O "A mammogram is not indicated unless you have a family history of breast cancer." "A mammogram would be necessary only if you feel a change in breast tissue."

"At your age, a mammogram is recommended every one to two years." Explanation: Client Need: Health Promotion and Maintenance Rationale: A. As screening mammography is recommended for asymptomatic women between the ages of 40 and 49 every one two year and an annual mammogram for women 50 years of age and older. B. Screening mammograms are recommended between the ages of 40 and 49. Women should not wait until age 50 or order. C. Mammograms should be obtained by all women, as indicated in the above guidelines, even if there is no family history of breast cancer D. Mammograms should be done routinely and not just when breast tissue changes are felt.

A pregnant woman has external hemorrhoids and varicosities of the vulva that are painful at times. To help relive the varicosities, which of the following suggestions should the nurse give to the woman? "Lie down with a pillow under your hips for a few minutes several times a day'. "Lie on our abdomen and expose the affected areas to the air for 10 minutes three to four times a day". "Apply pressure to the perineum with a perineal pad." "Massage the affected areas with lanolin - based cream after each voiding and stool."

"Lie down with a pillow under your hips for a few minutes several times a day'. Explanation: Client Need: Health Promotion & Maintenance Answer: A.

A nurse would assess a patient who experiences prolonged vomiting for signs of: hypovolemic shock. water intoxication. metabolic acidosis. potassium excess.

Hypovolemic shock Explanation: Client Need: Physiological Integrity Rationale: A. Causative factors leading to the development of hypovolemic shock include prolonged vomiting diarrhea. B. Hypotonic over hydration or water intoxication is the result of excess fluid that is hypotonic to normal body fluids, resulting in the excess fluid moving into the extra cellular spaces. C. Metabolic acidosis usually results from a lack of bicarbonate or an excess acid production in the body. Metabolic alkalosis occurs when body fluids are lost, as in prolonged vomiting or nasogastric suctioning. D. Patients with hyperkalemia may experience diarrhea and spastic colon activity. Hypokalemia is caused by excessive loss of potassium, as occurs with vomiting and diarrhea.

Which of the following statements, if made by the parent of an 18-month-old child who has experienced two episodes of febrile seizures, is accurate? "My child will have to take antiseizure medicine." "I made an appointment to see a genetic counselor." "My child will probably outgrow these seizures." "I made arrangements to have oxygen equipment at home."

"My child will probably outgrow these seizures" Explanation: Client Need: Physiological Integrity Rationale: C. Although most children never have febrile seizures after the first occurrence, a younger age at onset and a family history of febrile are associated with recurring episodes. Most children outgrow febrile seizures by five year of age. A. Phenobarbital is ineffective in preventing febrile seizures and its use can cause a drop in intelligent quotient (IQ) scores. B. Boys are affected by febrile seizures about twice as often as girls, and there appears to be an increased susceptibility in families, indicating a possible genetic predisposition. Given the benign nature of the illness, genetic counseling is not the best option. D. Most febrile seizures last for a very short period of time. If seizure activity persists, it is usually treated with rectal or intravenous Valium rather than oxygen.

The parent of a 12-year-old child, who is on acetylsalicylic acid (Aspirin) therapy for juvenile rheumatoid arthritis, tells a nurse, "I just read an article that said Aspirin should not be given to children." Which of the following responses by the nurse is MOST APPROPRIATE? "Stop the Aspirin only if your child is diagnosed with a viral illness." "Your child can take a different anti-inflammatory instead of aspirin." "Because the Aspirin dose your child receives is so small, the risk is minimal" "The benefits of Aspirin for your child outweigh the risks."

"The benefits of Aspirin for your child outweigh the risks." Explanation: Client Need: Physiological Integrity Rationale: D. Aspirin administration in children with juvenile arthritis has come under scrutiny because of its possible relationship to Reye's syndrome. Despite this concern. Aspirin remains the drug of choice for juvenile arthritis. It is more effective than any other single non- steroidal anti-inflammatory agent and cost considerably less. A. Epidemiologic data suggest a relationship between Reye's syndrome and use of Aspirin by children who have influenza or chicken pox. However, a direct causal link has not been established. Because of the possible relationship between Aspirin and the development of Reye's syndrome, it is recommended that Aspirin be avoided by children and teenagers suspected of having influenza or chicken pox. B. Aspirin is the drug of choice for treatment of juvenile rheumatoid arthritis. C. Aspirin is the initial drug of choice for treatment of juvenile rheumatoid arthritis. Dose employed to suppress inflammation are considerably larger than doses employed for analgesia or reduction of fever.

The nurse provides information to a depressed patient and his family about electroconvulsive therapy (ECT). Which of the following statements would the nurse include in the teaching? "The patient will have minimal muscle twitching during treatment." "The patient must be in restraints following the treatment." "The patient will remain awake and alert during treatment." "The patient must remain flat on his back for one hour after treatment"

"The patient will have minimal muscle twitching during treatment." Explanation: Client Need: Psychosocial Integrity Rationale: A. Electroconvulsive therapy is the use of electrically- induced seizures for the safe and effective treatment of depression. Because of the anesthesia and muscle relaxants administered, muscle movement is barely discernable. B. Following treatment the patient remains in the recovery room until consciousness returns. Side rails are in place, but the patient is not restrained. C. The patient is given a short- acting, general anesthetic prior to treatment D. The patient is positioned on his side until reactive.

Which of the following statements, if made by a patient who is scheduled for a lumpectomy, indicates understanding of the preoperative teaching? "A portion of the growth will be excised and examined." "A needle will be inserted into the tumor and cells will be withdrawn." "The suspicious area and some normal surrounding tissue will be removed." "The underarm lymph nodes will be surgically removed and sent for analvsis."

"The suspicious area and some normal surrounding tissue will be removed." Explanation: Client Need: Physiological Integrity Rationale: C. Breast conservation surgery (lumpectomy) involves the removal of the entire along with a margin of normal tissue. A. The entire area and normal surrounding tissue will be removed, not just a portion for examination. B. This option describes a needle biopsy rather than a lumpectomy D. Underarm lymph nodes are not removed in a lumpectomy.

The mother of a child who has recently had myringotomy tubes inserted bilaterally calls the ambulatory surgery center and tells a nurse, "My child has a large amount of clear yellow drainage coming from both ears." Which of the following responses by the nurse is MOST APPROPRIATE? "Your child may have developed an ear infection." "Water may have gotten into your child's ears during bath time." "The tubes may already be working their way out." "This indicates that the tubes are working normally."

"This indicates that the tubes are working normally." Explanation: Client Need: Physiological Integrity Rationale: D. Many children with recurrent ear infections will benefit from myringotomy and tympanostomy tube placement. The tubes facilitate continued drainage of fluid and allow ventilation of the middle ear. This therapy allows for mechanical drainage of the fluid, which will promote better healing of the membrane while preventing scar formation and loss of elasticity. A. Preventing recurrence of otitis media requires adequate parent education regarding antibiotic therapy. Because the symptoms of pain and fever usually subside within 24 to 48 hours, nurses must emphasize that although the child may appear well in a couple of days, the infection is not completely eradicated until all of the prescribed medication is taken. B. Tympanostomy tubes may allow water to enter the middle ear. Several studies show that small amounts of water pose little hazard and that even swimming without ear plugs or occlusive bathing caps carries no risk of infection. C. Parents should be aware of the appearance of the grommet (Usually a tiny, white plastic spool- shaped tube) so that they can recognize the tube if it falls out. This is normal and requires no immediate intervention.

Which of the following nursing actions would be MOST important when caring for a patient who has begun treatment with diltiazem hydrochloride (Cardezem)? Auscultating heart soundS. Assessing capillary refill. Palpating pedal pulses. Monitoring blood pressure.

Monitoring blood pressure. Explanation: Client Need: Physiological Integrity Rationale: D. Blood pressure and the electrocardiogram should be evaluated before initiation of Cardizem therapy and monitored during adjustment of dosage. A, B and C. Auscultating heart sounds, assessing capillary refill and palpating pedal pulses are not identified as nursing actions for the patient receiving Cardizem.

A male patient's yearly laboratory screening reveals an elevated serum prostate-specific antigen (PSA) level. To which of the following nursing diagnoses should a nurse give PRIORITY for this patient? Defensive Coping Hopelessness Anxiety Social isolation

Anxiety Explanation: Client Need: Safe Effective Care Environment Rationale: C. The nursing diagnosis of anxiety is related to an uncertain outcome and the possibility of malignancy. PSA is a screening measure for prostate cancer. Elevation of PA levels indicates prostatic pathology, although not necessarily cancer of the prostate. Mild elevations in PSA levels occur in benign prostatic hypertrophy, prostatitis and infarction of the prostate. A, B and D. These nursing diagnosis could be present if a diagnosis of prostatic cancer is confirmed.

Which of the following nursing actions would be MOST effective when encouraging a depressed patient to be less socially isolated? Move the patient to a room closer to the nurse's station. Ask a more stable patient to accompany the patient to activities. Assign a psychiatric technician to monitor the patient's activity. Explain to the patient that continued isolation may delay discharge.

Ask a more stable patient to accompany the patient to activities. Explanation: Client Need: Psychosocial Integrity Rationale: B. This action allows the patient to begin socializing with one other patient. As the depressed patient becomes more tolerant of social integration, additional patients can be included in interactions. A. This approach does not facilitate social interaction and can increase patient dependence on staff. C. This assignment will not decrease the social isolation of the patient. D. Getting the depressed patient involved in activities requires a more directive approach by the nurse.

A woman is eight hours postpartum after a vaginal delivery. The fundus is at the level of the umbilicus and displaced to the right. Which of the following actions would a nurse take FIRST? Assist the woman to the toilet. Encourage the woman to drink fluids. Massage the woman's uterus. Straight catheterize the woman.

Assist the woman to the toilet Explanation: Client Need: Health Promotion and Maintenance Rationale: A. A full bladder causes the uterus to be displaced above the umbilicus and well to one side of midline in the abdomen. It also prevents the uterus from contracting normally. Nursing interventions focus on helping the woman spontaneously empty her bladder as soon as possible and encourage her to void. B. Hands is always encouraged in the postpartum period. Intake of hand is not the cause of displacement of the uterus to the right. C. Massaging the uterus may not be necessary if the bladder is emptied spontaneously. D. Straight catheterization may not be necessary if the bladder is emptied spontaneously.

Before administering furosemide (Lasix) to a patient, the nurse should monitor the patient's serum level of: albumin acid phosphatase blood urea nitrogen (BUN) lactic dehydrogenase (LDH)

Blood urea nitrogen ( BUN ) Explanation: Client Need: Physiological Integrity Rationale: C. The nurse should monitor electrolytes, renal function and glucose and uric acid levels prior to, and periodically throughout, the course of therapy. Lasix may cause elevated levels of blood urea nitrogen (BUN), serum glucose and serum uric acid, and decreased levels of electrolytes, especially potassium. A. Albumin levels are not affected by Lasix administration. Albumin is the protein responsible for colloidal osmotic pressure. It pulls fluid into the vascular space and is decreased in liver failure. B. Acid phosphatese is elevated in advanced Paget's disease, cancer of the prostate and hyperparathyroidism. D. Lactic dehydrogenase indicates tissue damage and is higher in congestive heart failure. Hemolythic disorders, hepatitis, metastatic cancer of the liver, myocardial infarction, pernicious anemia and skeletal muscle damage.

Nursing care for a patient who has multiple myeloma should focus on preventing which of the following complications? Pulmonary edema Venous thrombophlebitis Peripheral neuropathy Bone fractures

Bone fractures Explanation: Client Need: Physiological Integrity Rationale: D. The nurse should assess the patient for pathologic fractures of the ribs and weight- bearing bones and compression fractures of the spine due to osteoporosis. A, B and C. These options are not identified as clinical manifestation of multiple myeloma

During labor, a woman is receiving magnesium sulfate intravenously. It is essential that a nurse has which of the following drugs available to counteract potential adverse effects? Oxytocin (Pitocin) Sodium bicarbonate Phenytoin sodium (Dilantin) Calcium gluconate

Calcium gluconate Explanation: Client Need: Physiological Integrity Rationale: D. Calcium is the specific antidote for magnesium toxicity. Calcium gluconate solution should be kept ready nearby for immediate intravenous administration. A. Pitocin will not counteract the effects of magnesium sulfate. B. Sodium bicarbonate is not an antidote for magnesium sulfate C. Dilantin is not the drug of choice for prevention of seizures during labor. Magnesium sulfate would be used first, then other anticonvulsants as ordered.

A six-vear-old child has a short arm cast placed on the right extremity. While assessing the fingers during the immediate period after casting, a nurse would report which of the following findings? Mild edema Pain on movement Slight coolness of the cast when touched Capillary refill greater than three seconds

Capillary refill greater than three seconds Explanation: Client Need: Physiological Integrity Rationale: D. Capillary refill greater than two seconds indicates vascular compromise or pressure from the immobilizing device. A. Edema is usually present after injury or surgery and is most evident in uncasted, dependent areas. Mild edema usually does not need to be reported. Excessive edema, however, may indicate constriction of vessels from an immobilizing device and should be reported. B. Some pain is normal after trauma or surgery but the pain should decrease when the bone is immobilized. C. Plaster casts set rapidly, but take several hours dry completelv and feel cool to the touch. Promoting the circulation of warm, dry air around a damp cast can enhance moisture evaporation and speed the drying process.

Prior to assisting with electroconvulsive therapy, the nurse notices the signature of the patient's significant other on the consent form. Which of the following actions should the nurse take FIRST? Check to verify the legal guardianship for this patient. Ask the patient to explain why the form doesn't have the patient's own signature. Proceed with the treatment. Call a third party to witness the signature.

Check to verify the legal guardianship for this patient Explanation: Client Need: Psychosocial Integrity Rationale: A. In the case of an incompetent patient, consent must be obtained from the guardian. The nurse should determine if the signature is that of the guardian and if the patient is incompetent. As a client advocate, the nurse monitors treatment planning and delivery of service for abuse of patient rights. B. If the patient is psychotic, this would not be an appropriate action. The patient may not have insight into why the guardian has signed the consent. The first action should be to verify the signature of the guardian. C. The treatment should not be carried out until the signature is verified and the patient if deemed incompetent to sign the consent. D. A third party cannot witness a signature after the fact. The signature would have to be witnessed at the time of signing.

Which of the following clinical manifestations should a nurse expect to identify when assessing a patient who has a diagnosis of acute prostatitis? Penile lesion Bowel incontinence Cloudy urine Abdominal pain

Cloudy urine Explanation: Client Need: Physiological Integrity Rationale: C. Manifestations of prostatitis include fever, chills, dysuria, urethral discharge, frequency, cloudy foul- smelling urine, back pain and swelling of the prostate. A, B and D. Penile lesions, bowel incontinence and abdominal pain are not clinical manifestations of acute prostatitis.

An 85-year-old patient who lives alone and has major depression is being prepared for discharge. Which of the following nursing actions would be MOST therapeutic initially? Contact the patient's religious group to obtain a visitor passes. Arrange for food delivery by a home delivered meals program. Enroll the patient in a day-care center. Refer the patient to social services.

Contact the patient's religious group to obtain a visitor passes. Explanation: Client Need: Psychosocial Integrity Rationale: A. Interventions for patients who are socially isolated include encouraging interactions with family, friends and other members of the community. B. Food delivery does not encourage social contact. C. If the patient is unable to care for him/ herself at home, enrollment in a daycare center would be considered. D. Referral to social services may be an option, but it would not be the first course of action.

Methimazole (Tapazole) is ordered for a patient with hyperthyroidism. The nurse should instruct the patient to: eat two to three servings of foods high in iodine each day. contact the doctor if a sore throat develops. drinks three liters of fluid daily. uses a hard-bristled tooth brush when brushing the teeth.

Contract the doctor if a sore throat develops Explanation: Client Need: Physiological Integrity Rationale: B. Methimazole (Tapazole) has relatively few side effects. However, a toxic side effect of the drug is agranulocytosis, a reduction in white blood cells. Since such a reduction puts the patient at risk of ran infection, the patient should contact the physician should a sore throat develop. A. Tapazole inhibits use of thyroid hormones by decreasing iodine use. Therefore, foods high in iodine should be avoided. C. There is no indication that fluid intake should be increased with Tapazole. D. Tapazole increases the prothrombin time, which may cause bleeding. The patient should be instructed to use a soft- bristled tooth brush.

Which of the following conditions, if reported in a patient's history, should a nurse recognize as a contributing factor to the development of metabolic alkalosis? Chronic obstructive pulmonary disease (COPD) Type 1 diabetes mellitus Cushing's svndrome Raynaud's disease

Cushing's syndrome Explanation: Client Need: Physiological Integrity Rationale: C. The presence of excessive adrenocorticoid hormones (as in hyperaldosteronism and Cushing's syndrome) predisposes to metabolic alkalosis. A. Chronic obstructive pulmonary disease is associated with respiratory acidosis due to the retaining of carbon dioxide. B. Metabolic acidosis can occur in diabetes mellitus as a result of fat breakdown and ketoacidosis. D. Raynaud's disease is caused by intermittent arterial spasms and does not result in metabolic alkalosis

A nurse should understand that a patient who has supraventricular tachycardia is receiving propranolol hydrochloride (Inderal) in order to: diminishe the stroke volume of the left ventricle. reduce peripheral vascular resistance. decrease cardiac electrical activity. inhibit venous return to the right activity.

Decrease cardiac electric activity Explanation: Client Need: Physiological Integrity Rationale: C. Propranolol blocks the effects of adrenergic fibers, thus slowing the heart and decreasing the dromotropic properties of electrical activity. A. Inderal reduces the stroke of the left ventricle. However, this is not the primary reason for giving Inderal to a patient with supraventricular tachycardia. B. Inderal is a beta adrenergic blocker, therefore, its effect is not on the peripheral vasculature. The main purpose for use of the drug is to decrease electrical activity in the heart. D. Inderal decreases cardiac output from the left ventricle but does not inhibit venous return to the right atrium.

Which of the following measures should a nurse include in the care plan of a patient who has a diagnosis of bipolar disorder, manic type? 1 / 1 point Your Answer: ‹ Correct Decrease environmental stimuli Involve the patient in competitive activities • Limit the verbalization of feelings • Foster independent decision- making

Decrease environmental stimuli Explanation: Client Need: Psychosocial Integrity Rationale: A. Manic patients need room to move around and furnishings that do not over stimulate them in order to decrease distractibility. Over stimulation can increase the intensity of symptoms and can lead to aggressive and intrusive behavior. B. Competitive games can stimulate aggression and increase psychomotor activity. C. Discouraging verbalization of feelings is rarely the correct intervention with a patient. D. Manic patients have impaired problems- solving abilities. They exhibit unwarranted optimism and poor judgment due to inaccurate interpretations of the environment.

Which of the following responses should a nurse expect in a patient who is receiving nifedipine (Procardia), if the medication is having the desired effect? Decreased blood pressure. Increased peripheral vascular resistance. Improved cardiac contractility. Diminished premature ventricular contractions.

Decreased blood pressure Explanation: Client Need: Physiological Integrity Rationale: A. Nifedipine is used in the treatment of mild to moderate hypertension. The nurse should anticipate a decrease in blood pressure. B. Nifedipine decrease rather than increases peripheral vascular resistance C. Nifedipine has minimal effect on cardiac contractility D. Nifedipine has little or no effect on sinoatiral (SA) and atrioventicular (AV) nodal conduction.

Which of the following findings in a 13-year-old girl who has Crohn's disease would indicate that corticosteroid therapy has been EFFECTIVE? Expansion of muscle mass Increase in the number of stools Moon-like appearance of the face Decreased complaints of abdominal pain

Decreased complaints of abdominal pain Explanation: Client Need: Physiological Integrity Rationale: D. The goals of therapy of Crohn's disease, also known as regional enteritis, are to control the inflammatory process in order to reduce or eliminate the symptoms; to obtain long term remission; to promote normal growth and development; and to allow as normal a lifestyle as possible. Corticosteroids are the most effective drugs for treating moderate to severe Crohn's disease. Decreased abdominal pain is the only answer that gives an example of a symptom that is reduced. A. Expansion of muscle mass is not a desired outcome of treatment for Crohn's disease B. The patient with Crohn's disease experiences diarrhea. An increase in the number of stools would not be a positive outcome. C. The major clinical applications of glucocorticoids stem from the ability of these drugs to suppress immune responses and inflammation. Severe adverse effects can result from long- term use of corticosteroids and include adrenal suppression. Myopathy, osteoporosis, increased susceptibility to infection and a Crushingoid syndrome (including moon face)

A nurse should be aware that morphine sulfate is administered to a patient who has pulmonary edema in order to: diminish venous return to the heart. decrease pain. decrease the respiratory rate. reduce the glomerular filtration rate.

Decreased pain Explanation: Client Need: Physiological Integrity Rationale: A. Morphine reduces preload (the amount of blood returning to the heart) and after load (systemic blood pressure) and relaxes bronchioles to enhance oxygenation. B and C. Morphine does control pain and decrease the respiratory, but these are not the desired outcomes for a patient with pulmonary edema. D. Morphine does not reduce the glomerular filtration rate

A patient who has atrial fibrillation and is prescribed warfarin sodium (Coumadin) asks a nurse why Coumadin is necessary. The nurse's response would be based on the knowledge that Coumadin prevents: plaque deposits in the arteries. irregular heart rhythm. deep vein thrombosis. clot development in the heart.

Deep vein thrombosis Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Warfarin sodium (Coumadin) is an anticoagulant that may prevent thrombus formation. A. Preventing plaque deposits in the arteries is the action of HMG COA inhibitors. B. Preventing irregular heart rhythm is the action of antiarrhytmic agents. C. Heparin is used to prevent clot development in the heart.

A nurse is observed taking all of the following actions when suctioning a patient who has a newly-placed tracheostomy tube. Which of the following actions require intervention? Applying suction for less than 15 seconds at one time Administering 100% oxygen prior to starting suctioning Utilizing negative pressure of 120 mm Hg during suctioning Deflating the tracheostomy cuff for three minutes before initiating suction

Deflating the tracheostomy cuff for three minutes before initiating suction Explanation: Client Need: Physiological Integrity Rationale: D. As a general rule the cuff on a tracheostomy tube should be kept inflated to prevent dislodgment of the tube. A. Applying suction for less than 15 seconds is appropriate, suctioning for longer than that amount of time may lead to hypoxia in the patient. B. Administering 100% oxygen is appropriate prior to suctioning C. This is an appropriate pressure setting for suctioning

Which of the following criteria would be a reliable indicator of improvement in a patient who has a diagnosis of anorexia nervosa? Electrolvte balance Energy level Fluid intake Desire to eat

Desire to eat Explanation: Client Need: Psychosocial Integrity Rationale: A. The most reliable indicator of improvement in the patient with anorexia nervosa is electrolyte balance. As the patient starved herself, the body entered a hypometabolic state. Decreased nutrients and the loss of electrolytes through vomiting and laxative use contribute to electrolytes begin returning to normal. B. The patient's energy level does increase as the patient begins eating but it is not the most reliable indicator or improvement C. An increase in fluid intake does not necessarily indicate improvement since the patient may substitute fluids for food. D. Actual intake of food, rather than a desire eat, would indicate improvement in the patient with anorexia nervosa.

Shortly after a transfusion is started the patient complains of lower back pain. Which of the following actions should the nurse take FIRST? Notify the physician. Check the patient's apical pulse. Discontinue the transfusion. Monitor the patient's temperature.

Discontinue the transfusion Explanation: Client Need: Safe Effective Care Environment Rationale: C. While administering blood to a patient, the nurse should carefully observe the patient for a reaction to the transfusion. A sign of a hemolytic reaction is low back pain. Should the patient complain of low back pain while receiving a transfusion, the blood should by stopped immediately, vital signs taken and the physician notified. A. The physician should be notified, but stopping the transfusion is the first priority B. Vital signs should be taken after the transfusion is stopped and reported to the physician. D. The patient's temperature is monitored for febrile reactions caused by leukocytic incompatibility. However, stopping the transfusion should be the nurse's first action

A nurse is taking the history from a patient who is suspected of having Hodgkin's disease. Which of the following questions should the nurse ask to support the diagnosis? "Do you wake up sweating during the night?" Do you urinate more frequently?" "Have vou noticed recent memory lapses?" "Have you experienced visual changes lately?"

Do you wake up sweating during the night? Explanation: Client Need: Physiological Integrity Rationale: A. Patients with Hodgkin's disease often experience fever, malaise and night sweats B, C and D. Urinary frequency, memory lapses and visual disturbances are not generally associated with Hodgkin's disease.

Immediately after delivery a newborn is given to the nurse. Which of the following interventions would the nurse perform FIRST with the newborn? Dry thoroughly. Obtain the weight. Apply an identification band. Check the number of umbilical vessels.

Dry thoroughly Explanation: Client Need: Health Promotion and Maintenance Rationale: A. In emergency birth, after draining the infant's airways of mucus, the nurse should dry the baby to prevent rapid heat loss. During all procedures heat loss must be avoided or minimized for the newborn since cold stress in detrimental to the newborn. It increases the need for oxygen and can upset the acid- based balance. B. In many situations, infants are not weighed until they are transported to the nursery. C. Identical identification bands should be placed on the mother and infant while thy both are still in the birthing room. D. The number of umbilical vessels is part of the delivery room assessment but not take precedence over drying the infant.

The patient with cirrhosis would have which of the following laboratory results? Increased serum albumin Elevated serum transaminase Normal prothrombin time Increased serum magnesium

Elevated serum transaminase Explanation: Client Need: Physiological Integrity Rationale: B. Because of the damage to liver tissue, laboratory results for the patient with cirrhosis will show elevated serum enzymes, which include serum glutamic oxyloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and serum lactic dehydrogenase (LDH). A. Serum albumin is normal ore decreases in liver damage. Since albumin helps to hold fluid in the vessels by maintaining colloidal osmotic pressure, the patient with decreased albumin levels will manifest signs of edema. C. Prothrombin time is increased when the liver is damaged. There is decreased production of prothrombin in the liver and the patient's blood does not clot as it normally would. D. Chronic alcoholism and prolonged malnutrition may cause a decrease, rather than an increase, in magnesium levels. Alcohol abuse has been implicated in development of cirrhosis. Prolonged malnutrition can occur when alcohol is consumed in place of food.

Following a left modified radical mastectomy, which of the following nursing measures should be implemented to prevent complications in the affected arm? Using sequential comprehension devices on the arm. Applying warm soaks to the arm. Immobilizing the arm soaks to the arm. Elevating the arm on two pillows.

Elevating the arm on two pillows. Explanation: Client Need: Physiological Integrity Rationale: D. Positioning will help to promote venous lymphatic drainage. The affected arm is elevated to promote fluid drainage via the lymphatic and venous pathways. A, B and C. Elevation of the arm so that it is level with or above the heart, diuretics and isometric exercises may be recommended to reduce fluid volume in the arm. The patient may need to wear an elastic pressure gradient sleeve during waking hours to maintain volume reduction, but the initial action by the nurse would be elevating the arm.

A boss telephones an employee who is intoxicated, and the employee's spouse reports that the employee is ill. The spouse's behavior is an example of: dependency. enabling. enmeshment. transference.

Enabling Explanation: Client Need: Psychosocial Integrity Rationale: B. An enabler is a person whose behavior contributes to the continuation of the drug use of another. A. Dependence is a pattern of relying excessively on others for emotional support. Advice and reassurance. C. Enmeshment is exaggerated connectedness among family members. It occurs in response to diffuse boundaries in which there is over- investment, over- involvement and lack to differentiation between individuals and subsystems in the family. Although this couple is probably enmeshed, the behavioral example is one of enabling. D. Transference is the unconscious assignment of feelings and attitudes that were originally associated with important figures to another. For example, if a woman harbored angry feelings toward her father, she might feel unexplainably angry toward her husband.

A nurse evaluates a three-month-old, developmentally-delayed infant for manifestations of cerebral palsy. Which of the following findings would a nurse report? Exaggerated arching of the back Absence of the extrusion reflex when fed from a spoon Head circumference measurement less than the 50th percentile Slight head lag when pulled to a sitting position

Exaggerated arching of the back Explanation: Client Need: Physiological Integrity Rationale: A. Increased or decreased resistance to passive movement is a sign of abnormal muscle tone. The child with cerebral palsy may exhibit opisthotonic postures (exaggerated arching of the back) and may feel stiff on handling or dressing. B. Other significant signs of motor dysfunction are poor sucking and feeding difficulties with persistent tongue thrust. C. Head circumference measurement less than the 50th percentile is a normal finding for a three month- old infant. The National Center for Health Statistics growth charts use the fifth and 95th percentiles as criteria for determining which children are outside the normal limits for growth. D. When pulled to a sitting position, the child with cerebral palsy may extend the entire body, rigid and unbending at the hip and knee joints. This is an early sign of spasticity. Slight head lag is expected in a three month- old infant.

Which of these groups should a nurse target when planning a community education presentation about testicular cancer? Daycare providers Senior citizens Middle-aged men High-school students

High-school students Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Every man between the ages of 20 to 40 should be taught and encouraged to perform a monthly testicular self- exam. High school students should be educated early on about the importance of testicular self- examination as a means of prevention. A. Providing daycare does not increase the risk for testicular cancer. B. Male senior citizens are not in the high risk category of 20 to 40 years of age. C. Middle aged man are not in the high risk category of 20 to 40 years age.

The post-prandial serum glucose level of a pregnant woman who is at 24 week's gestation is 160 mg/dL. A nurse would expect the woman to have which of the following test performed? Fasting blood glucose Glycosated hemoglobin Plasma glucagons level Qualitative urine glucose

Fasting blood glucose Explanation: Client Need: Health Promotion and Maintenance Rationale: A. The normal postprandial serum glucose level for a pregnant woman is 140 mg/dL or less. A fasting blood sugar evaluation is indicated next for this patient to rule out diabetes mellitus. B. In diabetes with hyperglycemia the increase in glycohemoglobin is usually caused by an increased in glycosated hemoglobin. The glucose concentration will increase when hyperglycemia caused by insulin deficiency develops. However, the fasting blood sugar would be performed before this test. C. Increase plasma glucagons levels are associated with diabetes. However, a fasting blood sugar D. Twenty-four hour glucose tests are not routinely ordered.

To which of the following nursing diagnoses would a nurse give priority when caring for a patient who has syndrome of inappropriate secretion of antidiuretic hormone (SIADH)? Decreased cardiac outout Altered nutrition Urinary incontinence Fluid volume excess

Fluid volume excess Explanation: Client Need: Safe Effective Care Environment Rationale: In syndrome of inappropriate diuretic hormone (SIADH) excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia and fluid retention. Fluid volume excess would be the priority nursing diagnosis for this patient

The outcome that would be MOST APPROPRIATE for a patient who has a diagnosis of agoraphobia would be that the patient will: go shopping in town. touch the neighbor's dog. handles money without wearing gloves. bathes only once a day.

Go shopping in town Explanation: Client Need: Psychosocial Integrity Rationale: A. Agoraphobia is the fear of being incapacitated by, forced into or trapped in a situation from which there would be no easy escape, and there is a possibility of experiencing a sense of helplessness or embarrassment should a panic attack occur. Examples of places that escalate such attacks are restaurants, theaters, shopping malls and crowded social gatherings. Going shopping in town would indicate effectiveness of treatment. B, C and D. Fear of touching the neighbor's dog, handling money and bathing are examples of specific phobias rather than agoraphobia.

Which of the following statements about arm protection measures, if made by a patient who has had a right lumpectomy and axillary node dissection, indicates a need for FURTHER teaching? "I plan to get a good tan so that I will look healthy." "I will wear rubber gloves whenever I wash dishes." "I will tell lab personnel to draw blood from my left arm." "I will watch for signs of redness in my right arm."

I plan to get a good tan so that i will look healthy Explanation: Client Need: Physiological Integrity Rationale: A. Patient education includes avoiding lymphedema and sunburn. This statement by the patient indicates the need for additional teaching. B. The patient should be instructed to wear protective gloves when gardening and when using strong detergents. C. The patient is correct in telling lab personnel not to draw blood from the right arm D. The patient should observe her right arm for signs of lymphedema.

A nurse is educating a patient prior to an intracavitary cesium insertion as therapy for cervical cancer. Which of the following statements, if made by the patient, would indicate the need for FURTHER instruction? "My husband will visit for short periods" "I will need to ambulate daily". " will have a catheter in my bladder". "My diet will consist of low-fiber foods"

I will need to ambulate daily Explanation: Client Need: Physiological Integrity Rationale: B. The patient remains on absolute bedrest during treatment with intracavitary cesium. The patient needs further instruction on ambulation restrictions. A. The patient's visitors are restricted. No visitors who are pregnant or under 18 years of age are allowed. C. A urinary catheter will be in place. D. The patient usually receives a low- residue to prevent frequent bowel movements.

Which of the following measures is important for a nurse to include in the care of a patient who has septic shock? Promoting ambulation. Restricting dietary protein. Limiting sensory stimulation. Increasing fluid intake.

Increasing fluid intake. Explanation: Client Need: Physiological Integrity Rationale: D. Interventions for the patient experiencing septic shock should focus on correcting the conditions contributing to shock and the prevention of complications. Fluid volume deficit is associated with septic shop and is controlled by increasing the rate of IV fluid delivery. A, B and C. These measures are generally not included in the care plan of a patient in septic shock. The patient is usually on bed rest, and sensory stimulation does not have to be limited dietary protein restricted.

Which of the following actions should a nurse take when making the first contact with a paranoid patient? Introduce self and avoid touching the patient. Avoid eye contact and shake hands with the patient. Close the door to the interview room and remain standing. Wait for the patient to initiate communication.

Introduce self and void touching the patient Explanation: Client Need: Psychosocial Integrity Rationale: A. The paranoid patient is highly suspicious and believes that people are out to get him or her. The best approach when meeting the paranoid patient is matter-of- fact manner introduce yourself and avoid touching the patient. B. The nurse should not attempt to shake hands with the paranoid patient since this may be interpreted as attempting to inflict harm. Avoiding eye contact may make the paranoid patient even more suspicious. C. The nurse should always keep the door open and should stand between the patient and the door when interacting in a room with a patient. D. The patient may never initiate communication. The nurse should attempt communication for short periods of time, as tolerated by the patient.

When planning care for a 14-year-old female who is pregnant, a nurse should recognize that the adolescent is at risk for: glucose intolerance. fetal chromosomal abnormalities. incompetent cervix. Iron deficiency anemia.

Iron deficiency anemia. Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Adolescents to have inadequate diets that are especially lacking in iron and folic acid. A. Pregnant adolescents are not at risk for glucose intolerance B. A diet deficient in folic acid has been linked to neural tube defects but not fetal chromosomal abnormalities. C. Pregnant adolescents are not at risk for incompetent cervix.

A patient who has a diagnosis of glaucoma should be instructed to avoid which of the following activities? Lifting heavy objects Watching movies Drinking beverages that contain caffeine Eating foods that are high in potassium

Lifting heavy objects Explanation: Client Need: Physiological Integrity Rationale: A. The goal of treatment in glaucoma is to decrease intraocular pressure. Lifting heavy objects and other activities that cause straining and increase intraocular pressure should be avoided. B, C and D. Watching movies, eating foods high in potassium and drinking beverages that contain caffeine do not cause an increase in intraocular pressure.

A patient who is undergoing detoxification from heroin complains to the nurse of severe muscle cramps and headache and demands additional Methadone. Which of the following actions should the nurse take FIRST? Measure vital signs. Administer prn medication. Provide support and reassurance Contact the physician.

Measure viral signs Explanation: Client Need: Safe Effective Care Environment Rationale: A. Initial actions by the nurse caring for a patient who is detoxifying is to provide supportive physical care, monitor vital signs, provide adequate nutrition and hydration and institute seizure precautions. B. The prn medication ultimately may be administered but it would not be the first action by the nurse. C. Providing support and reassuring the patient is necessary but the nurse first needs to determine if there is a physical cause of the cramps and headache. All physical complaints should be addressed during detoxification even if the nurse suspects that the patient is using the complaint as a means of obtaining medication. D. The physician may be contacted, but not until the nurse assesses the patient.

When providing anticipatory guidance, the nurse should recognize that the parent of a two-year-old child needs FURTHER instruction on safetv issues when the parent states: "My child understands not to go near the pool by himself". "I watch my child closely when he plays at the neighborhood playground". "My child's car seat is strapped into the back seat of the car." O"I do not keep cleaning supplies under my kitchen sink".

My child understands not to go near the pool by himself Explanation: Client Need: Health Promotion and Maintenance Rationale: A. To prevent drowning, a toddler should be closely supervised when near any source of water, including buckets. A two-year- old cannot be relied upon to remember instructions at all times. B. To prevent falls, children should be supervised at playgrounds. Parents should select play areas with soft ground cover and safe equipment. C. Federally- approved car restraints should be used to prevent motor - vehicle injury. The safest area in the car for children of any age is the middle of the back seat. D. To prevent poisoning, all potentially toxic agents should be kept in a locked cabinet.

Which of the following clinical manifestations would be MOST significant when assessing a patient who is suspected of having breast cancer? Nipple retraction Breast enlargement Breast tenderness Nipple discoloration

Nipple retraction Explanation: Client Need: Physiological Integrity Rationale: A. Clinical manifestations of breast cancer include a lump, usually felt in the upper, outer quadrant, unilateral nipple discharge, nipple retraction and an orange peel appearance of the skin of the breast. B, C and D. Breast enlargement, breast tenderness and nipple discoloration are not identified as clinical manifestations of breast cancer.

What is the best patient-advocate approach to a patient who wishes to discontinue chemotherapy because of complications of the treatment and recurrence of her cancer, but her husband wants to continue treatment? Encourage the patient to discuss her feelings with you. Offer to stay with the patient when she talks to her husband and doctor about her wishes. Tell the patient that she should continue with treatment for the sake of her husband and family. Talk to the physician about the conflict between the patient and her husband.

Offer to stay with the patient when she talks to her husband and doctor about her wishes. Explanation: Client Need: Safe Effective Care Environment Rationale: B. By staying with the patient, the nurse provides support and is able to intercede for the patient when she is unable to speak on her own behalf. A. The patient may discuss the issues with the nurse but he advocacy role of the nurse is one of interceding or speaking for the patient when necessary. C. This response negates patient choice. D. The nurse is making an assumption that there is conflict but that has not been documented. The best advocacy approach is to support the patient in her decision making.

A nurse is caring for a patient who is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). Which of the following blood test results would indicate to the nurse that the treatment is having its desired effect? Pa02, 88 mm Hg pC02, 50 mm Hg Oxygen saturation, 86% НС03 20 mEq/L

Pa02, 88 mm Hg Explanation: Client Need: Physiological Integrity Rationale: A. Monitoring a patient receiving PEEP ventilation for signs of improvement would include assessment of Pa02 levels within normal limits of 75-100 Hg. B. The normal pCO2 is 38-42 Hg. The patient's readings is high C. An Oxygen saturation of 86% indicates hypoxia. D. A bicarbonate reading of 20 mEq/L is decreased from the normal of 24-26 mEq/L.

A nurse should expect a six-month-old infant who has iron-deficiency anemia to have which of the following findings? Weight for length at the 25th percentile Pale, chubby appearance History of a fractured clavicle at birth Delaved eruption of primary teeth

Pale, chubby appearance Explanation: Client Need: Physiological Integrity Rationale: B. Although chubby in size, infants with iron deficiency anemia are pale, usually demonstrate poor muscle development and are prone to infection. A. To assess whether or not the infant's weight is average for his/ her height, compare the weight with a standardized graph. Height and weight should follow the same percentiles. The National Center of Health Statistic's growth charts use the fifth and 95th percentiles as criteria for determining which children are outside the normal limits for growth. C. A fractured clavicle at birth is the most common birth injury. It often is associated with difficult vertex or breech deliveries of infants of greater- than- average size. D. The age to tooth eruption shows considerable variation among children, but the order of their appearances is fairly regular and predictable. The first primary teeth to erupt are the lower central incisions, which appear at approximately six to eight months of age.

Which of the following behaviors is MOST indicative of impairment due to substance abuse in a nurse? Patients report that the nurse is always distracted and tired during the shift. Patients report experiencing pain despite document administration of pain medication. Patients report that valuables are missing. Patients report rude treatment by the nurse.

Patients report experiencing pain despite document administration of pain medication. Explanation: Client Need: Psychosocial Integrity Rationale: B. Warning signs of chemical dependency in a nurse include reports from the nurse's patients that they experience little or no relief from their pain medication. The nurse may be substituting other substances for the pain medication and taking the drug for his/ her own use. A, C and D Although these problems may result from chemical dependency in the nurse, they alone do not indicate that the nurse is a substance abuser.

When providing anticipatory guidance to the parents of a six-month-old infant, a nurse would give PRIORITY to which of the following issues? Engaging the infant in interactive play. Placing potted plants out of the infant's reach. Adding multivitamin supplements to the infant's diet. Providing the infant with a cool-water-filled teething ring.

Placing potted plants put of the infant's reach Explanation: Client Need: Health Promotion and Maintenance Rationale: B. It is important to stress injury prevention with the parents before a child reaches the susceptible age group. As the child increases in mobility, dangerous objects such as potted plants must be placed out of the child's reach. A, C and D. The nurse may discuss all of these measures with the family, but preventing poisoning is the highest priority in light of the increasing mobility of the infant.

When teaching the caregivers of a patient who has dementia of the Alzheimer type, a nurse should stress the importance of: increased stimuli. predictable environment. Restricted activities. Independent decision making.

Predictable environment Explanation: Client Need: Psychosocial Integrity Rationale: B. It is important to provide the Alzheimer's patient with a predictable, unhurried and safe environment. A. While sensory stimulation is important; a predictable environment will help the patient to feel secure and to be as independent as possible. Too much stimulation can contribute to irritability in the patient. C. Patients with dementia are encouraged to be as active as tolerated although their physical abilities may be affected by the disease. Safety should be a primary concern since these patients may be unaware of the risks involved with certain activities. D. A symptom of dementia is poor judgment. Patients need guidance in the decision-making process.

Which of the following observations should be MOST significant to a nurse when assessing the condition of a six-week-old infant who is suspected of having pyloric stenosis? Loose stools Hiccoughs Projectile vomiting Distended abdomen

Projectile vomiting Explanation: Client Need: Physiological Integrity Rationale: C. Vomiting usually starts in the second or third week of life and becomes forceful and projectile when pyloric stenosis is present. A. Loose stools are not an indication of pyloric stenosis B. Hiccoughs generally do not occur with pyloric stenosis D. The child's abdomen may or may not become distended, but the most significant sign of pyloric stenosis is projectile vomiting following feedings.

A nurse should recognize that the main purpose of inserting myringtomy tubes into the ears of a 10-month-old child is to: prevent ear infections. reduce the need for antibiotic therapy. promote drainage of the middle ear. enhances sound discrimination.

Promote drainage of middle ear Explanation: Client Need: Physiological Integrity Rationale: C. The primary objective of inserting myringotomy tubes into the ear is to allow the eustacian tube a period of recovery while the myringotomy tubes perform their function. The tubes facilitate continued drainage of fluid and also allow ventilation of the middle ear. A and B. Preventing recurrence of otitis media requires adequate parent education regarding antibiotic therapy. Because symptoms of pain and fever usually subside within 24 to 48 hours, nurses must emphasize the importance of completing the antibiotic as prescribed. D. It is important to stress the potential complications of otitis media, especially hearing loss that can be prevented with adeguate treatment.

If child abuse is suspected in a family which of the following approaches would a nurse take when beginning to interview the child? Speaking to the child by using specific, anatomically correct terminology. Expressing concern to the child that something like this could have happened. Assuring the child that any information given will be kept confidential. Providing a private place to talk with the child about the incident.

Providing a private place to talk with the child about the incident. Explanation: Client Need: Psychosocial Integrity Rationale: D. Provide a private time and place to talk if child abuse is suspected. Do not express shock or criticize the child's family. A. The nurse should use the child's vocabulary body parts. B. The nurse should not express shock that the abuse may have happened. This response by the nurse may discourage the child from talking. C. The nurse should not promise to keep information confidential but should tell the child that the law requires reporting of abuse.

An elderly postoperative patient is disoriented to time and place. During rounds, the night charge nurse finds him standing at the side of the bed. The patient says to the nurse, "I'm waiting for the bus." Which of the following interventions by the nurse would be MOST APPROPRIATE? Place the patient in a wheelchair and allow him to sit in front of the nurses' bed. Call the patient's family to come and sit with him. Assist the patient back to bed and put on a posey jacket. Re-orient the patient, assist him back to bed and observe him closely.

Re-orient the patient, assist him back to bed and observe him closely. Explanation: Client Need: Psychosocial Integrity Rationale: D. Diminished ability to adapt to changer, increased stress of hospitalization and surgery and alterations in tissue perfusion can lead to confusion in the elderly patient. Orientation of the patient to place, time and situation will minimize confusion. A. Reality orientation and assisting the patient back to bed should be instituted first. There is no need at this time to keep the patient at the desk. B. Patient behavior does not warrant calling the family or having a family member sit with the patient. C. A posey restraint may cause agitation and injury to the patient. The patient's behavior does not warrant the use of restraints.

A 10-year-old boy who is in the terminal stages of Duchenne muscular dystrophy is being cared for at home. When evaluating for a major complications of this disease, a nurse would give PRIORITY to assessing which of the following body systems? Integumentary Neurological Respiratory Gastrointestinal

Respiratory Explanation: Client Need: Physiological Integrity Rationale: C. Muscular dystrophy is characterized by progressive weakness and wasting of symmetric groups of skeletal muscles, with increasing disability and deformity. The major complications of muscular dystrophy include contractures, disuse atrophy, infections, obesity and cardiopulmonary problems. Ultimately, the disease process involves the diaphragm and auxiliary muscles of respiration. Cardiomegaly is common. Relentless progression continues until death from respiratory failure or cardiac failure results. A, B and D. These body systems are not involved in the maior complications of Duchene muscular dystrophy. Skin integrity may be impaired due to decreased mobility. The gastrointestinal system is not impaired, although the child is prone to obesity. The central nervous system is not affected.

Which of the following findings in a pregnant woman's history would identify a need for the woman to receive Rho (D) immune globulin (RhoGAM) at 28 weeks of pregnancy? Rh negative, Coombs positive Rh negative, Coombs negative Rh positive, Coombs negative Rh positive, Coombs positive

Rh negative, coombs negative Explanation: Client Need: Health Promotion and Maintenance Rationale: B. Rh immune globulin is administered prenatally at 28 weeks to 30 weeks gestation to all Rh negative, antibody (Coombs) negative women. It also is given earlier is gestation after invasive procedures. This immunization prevents the mother's sensitization to the Rh factor and prevents hemolytic disease of the women. A. The drug is not given to this mother, even though she is Rh negative, because the Coombs (antibody) test is positive. C and D. These mothers are not candidates for the drug due to an Rh positive status, regardless of the status of the Coombs test.

To which of the following nursing diagnoses should a nurse give PRIORITY in the care of a patient who is receiving chemotherapy for treatment of breast cancer? Risk for infection Stress incontinence Altered sexualitv patterns Impaired physical mobility

Risk for infection Explanation: Client Need: Safe Effective Care Environment Rationale: A. The nursing diagnosis that should take priority when caring for a patient undergoing chemotherapy is risk for infection. Use of chemotherapeutic agent's results in leucopenia and a depressed immune system. Exposure of the patient with a compromised immune system to microorganisms may cause infections. B. Stress incontinence is not generally a nursing diagnosis for the patient receiving chemotherapy C. Altered sexuality pattern may be a nursing diagnosis due to the breast cancer but it would not take priority over risk for infection. D. Impaired physical mobility is no usually associated with chemotherapy administration. Fatigue and lethargy may be seen and are related to the decrease in red blood cells caused by chemotherapeutic agents.

A two-month-old infant who was born with Down syndrome, has been recently diagnosed with a ventricular septal defect. Based on a diagnosis of congenital heart disease, the parent needs to report which of the following manifestations of the infant immediately? Mottling with environmental temperature changes. Nasal congestion when recumbent. Scalp-sweating during feedings. Tongue-thrusting during episodes of crying.

Scalp-sweating during feedings Explanation: Client Need: Physiological Integrity Rationale: C. The early signs of the heart failure are tachycardia (especially during rest and slight exertion), tachypnea, profuse scalp sweating (especially in infants), fatigue, irritability, sudden weight gain and respiratory distress. A. Mottling due to a decrease in environmental temperature or stress in common in the newborn. B. Nasal discharge/ congestion is commonly associated with respiratory infections in infants. D. Upon inspection, the infant's tongue is enlarged and may protrude. This is a normal finding. Protrusion of the tongue is often seen in children with mental retardation.

Which of the following findings, if identified in a newborn who is receiving phototherapy, would indicate that the treatment is effective? Urine output improves Serum bilirubin level decreases Stool frequency increases Direct Coombs test becomes negative

Serum bilirubin level decreases Explanation: Client Need: Health Promotion and Maintenance Rationale: B. The expected outcome of treatment for hyperbilirubinemia is to help the newborn's body reduce serum levels of unconjugated bilirubin. The two principal methods for reducing serum bilirubin levels are phototherapy and exchange blood transfusions. A. Urinary output is not improved by the use of phototherapy C. Phototherapy does not cause an increase in stools D. Phototherapy does not convert a direct Coomb's test to negative

A nurse should instruct a pre-menopausal woman to examine her breasts according to which of the following schedules? During the week prior to the onset of the monthly period During every shower Seven days after the menstrual period On the same day every month

Seven days after the menstrual period Explanation: Client Need: Health Promotion and Maintenance Rationale: C. In pre-menopausal women, the best time for breast self- examination is seven days after the start of menstruation when breasts are least congested. A. Breast congestion is greatest during the week prior to the monthly period. It is not the best time to perform breast self- examination B. Breast self- examination is performed monthly D. Postmenopausal women should perform breast self - examination on the same day of each month.

Disclosure of confidential information by the nurse about patient's condition is legal when the information is: given to law enforcement personnel. shared with other psychosocial team members. discussed in private with a family member. provided to insurance company representatives assigned to the patient's case.

Shared with other psychosocial team members Explanation: Client Need: Safe Effective Care Environment Rationale: B. The patient has a right to confidentiality. The duty of confidentiality prohibits a professional from disclosing information obtained as a result of the treatment relationship, except to fellow professionals involved in the patient's care A. Law enforcement officers are not usually part of the patient's treatment team. Exceptions may occur in emergency situation or when court ordered C. Confidential patient information should not be shared with family members unless the patient authorizes the disclosure in writing or there is a clear and present danger to family members. Courts also may order disclosure. D. Insurance company representatives are not considered professional members of the treatment team. Confidential patient information should not be shared unless court ordered or in an emergency situation.

While working on the adolescent psychiatric unit, the nurse overhears a patient mentioning the name of another resident while he is talking on the telephone. The BEST response by the nurse would be to: intervene immediately to remind the patient of confidentiality. ignore the incident but re-emphasize confidentiality at the next community meeting. talk with the patient after the phone call is finished. insist that the patient terminate the telephone call immediately.

Talk with the patient after the phone call is finished Explanation: Client Need: Safe Effective Care Environment Rationale: A. Confidentiality is a right of patient on a psychiatric unit that should be respected by patients and staff. Reinforcing this as soon as a break in confidentiality occurs will have more meaning rather than waiting until a later time. B. The incident should not be ignored but addressed when it occurs and directly with the patient. Correcting the behavior when it occurs is more effective than waiting for the community meeting C. The behavior should be stopped so that further disclosure of confidential information does not occur. D. This option does not provide the patient with an explanation of why confidentiality is essential. It also is confrontational.

The purpose of performing a sterile versus clean intermittent urinary catheterization for a hospitalized child who has spina bifida is: to reduce the risk of nosocomial infection. to lessen the probability of a latex allergy episode. to comply with hospital policy. to prevent the need for an indwelling drainage system.

To reduce the risk of nosocomial infection Explanation: Client Need: Physiological Integrity Rationale: A. Parents of children with spina bifida are taught to perform clean intermittent catheterization if their child has neurogenic bladder dysfunction. Intermittent catheterization, while done as a clean procedure in the home, is done as a sterile procedure in the hospital because of the risk of nosocomial, or hospital- induced, infection. B, C and D. None of these options accurately describes the reasons for the change in procedural technique when the child is hospitalized.

Which of the following criteria would indicate improvement in an outpatient who has anorexia nervosa? The patient identifies the relationship between emotions and eating behaviors. The patient develops a plan to control negative feelings. The patient reports putting "thin" clothes on display in her room as a reminder to maintain proper weight. The patient avoids contact with her dysfunctional family.

The patient identifies the relationship between emotions and eating behaviors. Explanation: Client Need: Psychosocial Integrity Rationale: A. Criteria that would indicate improvement in a patient with anorexia nervosa include identifying the relationship between emotions and eating behaviors, development of adaptive coping mechanisms and improved perception of body image. B. Developing understanding of the reasons behind the eating behaviors is preferable to developing a plan to control negative feelings. Negative feelings should be explored with the patient. C. Displaying "thin" clothes does not indicate that the patient understands the reason for her eating patterns. D. Avoidance does not indicate a sign of improvement in the patient.

A patient is being treated for incapacitating ritualistic behavior. Which of the following behaviors would indicate to a nurse that the patient is achieving a short-term goal? The patient gives up the rituals. The patient identifies control mechanisms. The patient resumes activities of daily living. The patient gains insight into childhood trauma.

The patient resumes activities of daily living Explanation: Client Need: Psychosocial integrity Rationale: C. Performance of activities of daily living is a basic function of life. The patient must be able to accomplish this before he/ she attempts more complex goals. A, B and D. These behaviors indicate attainment of long term, more complex goals for this patient.

A nurse is counseling other personnel working in the pediatric department about the nursing care of children who are receiving ribavirin (Virazole). Which of the following instructions is accurate? This drug may cause conjunctivitis of the eye The patient should be on strict isolation while receiving this drug The drug must be administered at the same time each day. Ambient light should be kept to a minimum during administration of this drug

This drug may cause conjunctivitis of the eye Explanation: Client Need: Physiological Integrity Rationale: A. Side effects or rebavarin therapy conjunctivitis and dermatitis. Ribavarin, an antiviral agent, may be used to treat respiratory synctial virus (RSV). B. Strict isolation is not required to administer the medication; however, RSV predominantly transmitted through direct contact with respiratory secretions. C. The drug is administered by hood, tent or mask through ventilator tubing for 12 to 20 hours/ day. D. No lighting requirements are specified for drug administration.

A preterm newborn would receive surfactant (Exosurf) for which of the following purposes? To stimulate digestive enzymes. To minimize the effects of jaundice. To prevent intracranial hemorrhage. To improve respiratory function.

To improve respiratory function. Explanation: Client Need: Physiological Integrity Rationale: D. Preterm infants are at risk for respiratory distress syndrome (RDS) due to the lack of surfactant. Exogenous surfactant (Exosurf) is used for the treatment of RDS in infants. A, B and C. Exogenous surfactant is not given to the preterm newborn to stimulate digestive enzymes, to minimize the effects of jaundice or to diminish the incidence of premature ventricular contractions. It is used for the treatment of respiratory distress syndrome.

Which of the following conditions, reported to a nurse by a 20-year-old male patient, would indicate a risk for development of testicular cancer? Genital herpes Undescended testicle Measles Hydrocele

Undescended testicle Explanation: Client Need: Health Promotion and Maintenance Rationale: B. Testicular tumors are much more common in males who have undescended testicles. Other predisposing factors include a history of mumps, orchitis, inguinal hernia in childhood and testicular cancer in the contralateral testis. A, C and D. Genital herpes, measles and a hydrocele are not considered contributory factors in the development of testicular cancer.

Which of the following finding, if identified in a patient who is being treated for hypovolemic shock, should indicate to a nurse that the treatment is having the desired effect? Central venous pressure of 10 mm Hg Pulse oximeter reading of 98% Urine output of 50 ml/ hr Temperature of 98.6° F (37° C)

Urine output of 50 ml/hr Explanation: Client Need: Physiological Integrity Rationale: C. Management of hypovelemic shock includes careful monitoring of fluid balance. A diminished urinary output is characteristic, thus fluid replacement therapy would adequately perfuse the kidneys and increase urine output. A. A central venous pressure reading of 10 mm Hg would indicate fluid overload. B and D. The desired outcome of replacement of fluid volume is increased blood pressure and increased renal perfusion.

A patient develops stomatitis secondary to radiation therapy for oral cancer. Which of the following nursing instructions would be MOST helpful? Gargle with mouthwash and rinse thoroughly after each meal. Use ice cold liquids such as tea or cola to relieve discomfort. Use a toothbrush soaked in saline to clean the mouth. Drink citrus juices and broth.

Use ice cold liquids such as tea or cola to relieve discomfort. Explanation: Client: Physiological Integrity Rationale: B. Iced liquids tend to have a soothing effect on the mucosal lining should be encouraged. A and D. Gargling with mouthwash and drinking citrus juices will further irritate stomatitis and should be avoided. C. Using a toothbrush with saline to cleanse the mouth also will cause further irritation of the oral mucosa.

A child is being discharged from the emergency department with a diagnosis of acute glomerulonephritis. Which of the following measures would a nurse include in the home care plan? Restrict fluid intake. Weigh daily. Maintain strict bed rest. Limit visitors.

Weigh daily Explanation: Client Need: Physiological Integrity Rationale: B. There is no specific treatment available for acute glomerulonephritis, but recovery is spontaneous and uneventful in most cases. Management consists of general supportive measures, and early recognition and treatment of complications. Children who have normal blood pressure readings and satisfactory urine output can generally be treated at home. A record of daily weight is the most useful means of assessing fluid balance. A. Water restriction is seldom necessary unless the output is significantly reduced. C. Bedrest may be recommended during the acute phase but ambulation does not appear to have an adverse effect. D. Acute glomerulonephritis is a post- streptococcal complication and therefore, the patient is no longer contagious. Visitors do not have to be limited.

A nurse is preparing a community education program about early detection of prostate cancer. The nurse should emphasize that: an elevated serum prostate- specific antigen level is the definitive diagnostic test for prostate cancer. a digital rectal exam is recommended annually screen for prostate cancer in men aged more than 40 years. changes in patterns of elimination can be an early indicator of prostate cancer. frequent urinary tract infections may indicate a high risk for prostate cancer developing.

a digital rectal exam is recommended annually screen for prostate cancer in men aged more than 40 years. Explanation: Client Need: Health Promotion and Maintenance Rationale: B. The American Cancer Study recommends yearly digital rectal exams for all men over age 40. A. Elevated prostate- specific antigen (PSA) level indicates prostatic pathology, although not necessarily cancer of the prostate. C. Prostate cancer is asymptomatic in the early stages. D. Frequent urinary tract infections are not identified as a manifestation or risk factor of prostate cancer.

A patient who is admitted for treatment of an eating disorder displays controlling behaviors, takes responsibility for others actions, and has difficulty identifying feelings. These manifestations suggest: learned helplessness. manipulation. dependency. codependency.

codependency. Explanation: Client Need: Psychosocial Integrity Rationale: D. Co-dependents are individuals who allow another's behavior to affect them while being obsessed with controlling the other person's behavior. Co-dependents try to control events and people around them because they feel that everything around them and inside them is out of control. A. Learned helplessness is feeling that one has no control over the outcome of a situation B. Manipulation is purposeful behavior directed at getting needs met while disregarding the needs of others. C. Dependency is passively allowing others to take responsibility for one's life or a major portion it.

When discussing diet with a newly diagnosed pregnant woman who is diabetic and taking insulin, the nurse should: emphasize the normalcy of pregnancy and the fat that her prescribed pre-pregnancy diet will be suitable. explain that pregnancy increases the need for protein and calcium but that will be the only needed diet adjustment. confirm that dietary and insulin needs may vary throughout the pregnancy thus requiring close follow- up. Instruct her to self- regulate her diet and insulin based on daily urine tests for glucose.

confirm that dietary and insulin needs may vary throughout the pregnancy thus requiring close follow- up. Explanation: Client Need: Physiological Integrity Rationale: C. The nurse should emphasize that the patient will require an increase in almost all nutrients during pregnancy and may have to have her insulin adjusted throughout the course of the pregnancy. A, B and D. The pre-pregnancy diet is not sufficient to meet the demands of pregnancy. An increase in calories, protein, vitamins and minerals is necessary.

A patient, who has prostate cancer that has metastasize to the bones, is scheduled for an orchiectomy. The patient asks a nurse to explain why an orchiectomy is necessary. The nurse's response should be based on an understanding that the surgery: prevents metastasis to the testicles. eliminates production of testosterone which stimulates tumor growth. causes interruption of nerve pathways associated with bone pain. increases the ability of the immune system to fight cancer cells.

eliminates production of testosterone which stimulates tumor growth. Explanation: Client Need: Physiological Integrity Rationale: B. An orchiectomy effectively lowers plasma testosterone levels because 93 percent of testosterone is of testicular origin. As a result, the testicular stimulus required for continued prostatic growth is removed. A, C and D. These options do not describe the purpose of an orchiectomy for a patient cancer that has metastasized to the bone.

A woman phones the psychiatric department nurse's station and tells a nurse that her husband was brought to the hospital yesterday after taking an overdose of Aspirin. The woman asks the nurse how her husband is doing. The MOST APPROPRIATE action by the nurse is to: explain to the woman that she cannot release information about psychiatric patients. tell the patient that a woman who says she is his wife is on the phone and asks him if he wants the nurse to talk to her. give the wife a brief accurate report on her husband's condition. report the woman to the patient's primary doctor.

explain to the woman that she cannot release information about Explanation: Client Need: Safe Effective Care Environment Rationale: A. The patient has the right to confidentiality. Information may be shared only with other professionals directly involved in the patient' B. and C. Family members who are not directly involved in care of the patient are excluded from the information unless explicit written permission from the patient authorized release of information. D. The nurse can let the treatment team know that the patient's wife called, but there is no need to repeat the woman to the physician.

An eight-year-old boy who has hemophilia A falls in the classroom injuring his ankle and is brought to the school nurse. Immediate first-aid action by the nurse should include: applying warm compresses. dispensing ibuprofen (Pediaprofen) administering Factor VIII. immobilizing the joint.

immobilizing the joint. Explanation: Client Need: Safe Effective Care Environment Rationale: D. The nurse should first control bleeding by immobilizing and elevating the area. A. Applying warm compresses will increase bleeding. Cold compresses promote vasoconstriction B. The first action by the nurse should be to control bleeding C. Factor VIlI replacement therapy should be instituted according to established medical protocol. The first aid priority for this patient is control of bleeding through immobilization and elevation.

A schizophrenic patient says to a nurse, "You are wearing a pretty 1/1 point red dress. Tomatoes are red. Vegetables make you healthy. I am not healthy," a nurse should recognize that these statements are example of echolalia. confabulation. neologisms. looseness of association.

looseness of association. Explanation: Client Need: Psychosocial Integrity Rationale: D. Looseness of association is characterized by thoughts that seem fragmented. One idea is not clearly connected to another. A. Echolalia is the repetition of words or phrases heard from another person. For example, after the nurse asks a patient to take the medication, the patient repeats. "Medication, medication, medication." B. Confabulation is the exaggeration or making up of stories in an attempt to compensate for forgotten memories. C. Neologisms are "new words" devised by the patient and have meaning only to the patient. For example, "sintity" may be a word used by a patient to mean someone that she loved.

A new born receives erythromycin (Ilotycin) to: boost the immune response. stimulates growth of gastrointestinal flora. prevent bleeding problems. prevents eye infections.

prevents eye infections. Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Erythromcin or tetracaine ophthalmic ointment is instilled into the lower conjunctiva of each eve within two hours after birth to prevent ophthalmia neonatorum, an infection caused by Neisseria gonorrhea, and inclusion conjunctivitis, and infection caused by Chlamydia trachomatis. A. Erythromycin does not boost the immune system. It prevents opthalmia neonatorum B. Erythromycin does not stimulate the growth of normal flora in the gastrointestinal tract. C. Erythromycin does not prevent bleeding disorders.

A patient who had an excision of an anal fistula, has a sitz baths ordered. The nurse should instruct the patient that the purpose of the sitz bath is to: prevent infection. relax the anal sphincter. localize the drainage. promote comfort.

promote comfort. Explanation: Client Need: Physiological Integrity Rationale: D. Following a hemorroidectomy, sitz baths are used to promote comfort and cleans the area. A. While the primary purpose of the sitz bath is comfort and cleansing of the area a secondary effect is that of preventing infection. B and C. The sitz bath is not used to relax the anal sphincter or to localize the drainage.

The nurse should expect a patient who has chronic renal failure to be given epoetin alfa (Epogen) to: elevate the white blood cell count enhances the maturation of thrombocytes. increases the production of platelets. stimulates the synthesis of red blood cells.

stimulates the synthesis of red blood cells. Rationle: Client Need: Physiological Integrity Rationale: D. Erythropoietin is a glycoprotein that stimulates red blood cell (RBC) production. It is produced in the kidneys and stimulates bone marrow production of RBC. Epogen, a form of erythropoietin, is used to elevate the hemoglobin of patients with anemia secondary to chronic renal failure.

A nurse is leading a community meeting at the partial-hospitalization program. One group member talks constantly and interrupts the other patients. The MOST APPROPRIATE action for the nurse to take is to: explain to the member, after the meeting, that group time should be shared. thank the group member for his contribution and asks the other members for their ideas. ask the other group members if they are satisfied with the way the group is working. remain silent and wait for another group member to speak up.

thank the group member for his contribution and asks the other members for their ideas. Explanation: Client Need: Psychosocial Integrity Rationale: B. The role of the nurse as a group leader is to facilitate group progress by eliciting responses from group members and by preventing domination of the group by one member. A. Guidelines for group conduct should be established at the initial group meeting and reinforced within the group setting rather than outside the group. C. This response does not directly deal with the issue of one person monopolizing the group. D. This action may result in one member dominating for the course of therapy.