Practice test 9

A nurse is taking a history from a patient who has just been admitted to the hospital with an acute myocardial infarction. Which of the following questions would be MOST important for the nurse to ask? "At what time did the pain start?" "When did you eat your last meal?" "Have you experienced a pounding headache?" "Did you feel fluttering in your chest?"

"At what time did the pain start?" Explanation: Client Need: Physiological Integrity Rationale: A. Myocardial cells do not die instantly. It takes approximately four to six hours for the entire thickness of the muscle to become necrosed in the majority of patients. Treatment of the acute myocardial infarction is geared to quickly dissolving the thrombus in the coronary artery and re- perfusing the myocardium before cellular death occurs. To be of benefit, thrombolytics must be given as soon as possible, preferably within the first six hours after the onset of pain. B, C and D. Knowing when the pain started has the greatest significance in determining the prognosis for treatment.

The teaching plan for a child who is taking long-term corticosteroid therapy would include: "Dental check-ups every three months to assess for gingival hyperplasia." "Regular physical therapy sessions to prevent muscular hypertrophy." "Eye examination yearly to assess for cataract formation." "Regular appointment with a registered dietician to prevent malnutrition."

"Eye examination yearly to assess for cataract formation." Explanation: Client Need: Physiological Integrity Rationale: C. Children who require frequent courses of steroid therapy are highly susceptible to the complications of steroids, such as growth retardation, cataracts, obesity, hypertension, gastrointestinal bleeding, bone demineralization, infections and hyperglycemia. A, B and D. Gingival hyperplasia, muscle hypertrophy and malnutrition are not side effects caused by long-term corticosteroid use.

A nurse has given instructions to a patient who is on steroid therapy. Which of the following statements by the patient, indicates understanding of the instruction? "I will limit carbohydrates in my diet." "I will avoid individuals who have infections." "I will take the medication on an empty stomach." "I will stop the medication when my symptoms subside."

"I will avoid individuals who have infections." Explanation: Client Need: Physiological Integrity Rationale: B. The patient should avoid individuals with known contagious diseases due to Immunosuppression secondary to the use of steroids. A. Most patients receiving steroids should be on a high- potassium, low-sodium diet and may need increased protein intake to decrease the effects of protein catabolism C. Steroids irritate the gastric mucosa and should be taken with meals or milk. D. The patient should be cautioned that withdrawal of steroids must be carried out slowly and under supervision to avoid adrenal insufficiency.

A nurse teaches pursed-lip breathing to a patient who has chronic obstructive pulmonary disease (COPD). Which of the following statement indicates that the patient understand the instructions? "I will maintain a supine position during the exercise." "I will alternate positions during the exercises." "I will exhale for twice as long as I inhale." "I will inhale and exhale through my nose."

"I will exhale for twice as long as I inhale." Explanation: Client Need: Physiological Integrity Rationale: C. Pursed-lip breathing helps the patient with chronic obstructive pulmonary disease (COPD) to prolong expiration time and rid the lungs of some of the air trapped in the alveoli. A and B. The patient should sit in a comfortable position during exercises. D. The patient should be instructed to inhale through the nose and exhale through the mouth.

Which of the following statements made by an elderly patient, indicates understanding the MOST effective method for preventing influenza? "I will stay indoors in bad weather." "I will have an annual flu vaccine." "I will wear a mask when my grandchildren visit." "I will take a daily multivitamin supplement."

"I will have an annual flu vaccine." Explanation: Client Need: Safe Effective Care Environment Rationale: B. Influenza immunization is the most effective measure for preventing or minimizing influenza symptoms. Annual flu vaccines are recommended by the Public Health Service for adults with chronic cardiovascular and pulmonary disorders. A. Staying indoors in bad weather will not prevent influenza. C and D. Wearing a mask and taking a multivitamin are not recommended as methods for preventing influenza.

Which of the following statements made by a patient who is administered with propranolol hydrochloride (Inderal), indicates understanding of the medication? "I will take the Inderal when I feel dizzy." "I will take the Inderal with orange juice." "I will check my pulse before taking the Inderal." "I will stop using the Inderal when I feel better."

"I will take the Inderal with orange juice." Explanation: Client Need: Physiological Integrity Rationale: C. The nurse caring for a patient taking propranalol (Inderal) should assess the patient's pulse daily. If the pulse is slower than baseline or irregular, it should be reported. A. Dizziness is a side effect of Inderal, not an indication for use. Inderal is not a drug to be used p.r.n. It should be taken at the same times each day. B. The patient should take Inderal before meals and with eight ounces of water. There is no indication that Inderal should be taken with orange juice. D. The patient should take the Inderal daily and never abruptly stop taking the drug.

A nurse has given a patient instructions about taking warfarin sodium (Coumadin). Which of the following patient statements indicate understanding of the instructions? "I can expect to gain weight while taking this medication." "I will take my pulse prior to each dose." "I can take Aspirin when I have a headache." "I will take the medication at the same time every day."

"I will take the medication at the same time every day." Explanation: Client Need: Physiological Integrity Rationale: D. Coumadin should be taken at the same time each day to maintain the prothrombin time within therapeutic levels. A. Nausea, rather than weight gain, is often a side effect of Coumadin. B. The pulse rate does not have to be monitored while taking Coumadin. Prothrombin levels should be checked regularly. C. The patient should not take over-the-counter drugs, particularly those containing Aspirin. Aspirin interferes with platelet aggregation and enhances the effect of Coumadin.

A patient who has asthma is given instruction about the use of bronchial medications. Which of the following statements made by the patient indicates understanding of the instructions? "I will use the steroid inhaler one hour before I use the bronchodilator." "I will use the bronchodilator before I use the steroid inhaler." "I need to take these medications one hour after each meal." "I need to alternate the sequence of inhaler administrations."

"I will use the bronchodilator before I use the steroid inhaler." Explanation: Client Need: Physiological Integrity Rationale: B. Patients using bronchodilator inhalant medications along with other inhalants should be instructed to use the bronchodilator first, and wait five minutes before administering the other medications. Dilation of the bronchi allows for greater distribution and absorption of the other inhalants. A and D. The bronchodilator should be used before other medications to promote greater distribution of those medications. C. Patients should take inhalant medications as ordered. There is no indication that the medications should be taken one hour after each meal.

A patient who is administered with isoniazid (INH) and pyridoxine hydrochloride (Vitamin B 6) for treatment of tuberculosis asks a nurse why pyridoxine is necessary. The nurse would respond that: "Vitamin B6 is necessary for the absorption of INH." "Vitamin B6 activates the metabolism of INH." "INH leads to vitamin B 6 depletion, which causes neurotoxic effects." "INH can cause anorexia, which leads to vitamin B6 deficiency"

"INH leads to vitamin B 6 depletion, which causes neurotoxic effects." Explanation: Client Need: Physiological Integrity Rationale: C. Isoniazid is a drug use to treat tuberculosis. It is the only anti-tuberculosis agent used routinely for prophylaxis. Isoniazid can delete Vitamin B6 in the body and cause neurotoxic effects. Vitamin B6 supplementation (10 to 50 mg) usually accompanies Isoniazid use to decrease the incidence of neuropathy. A, B and D. Pyridoxine is used in combination with Isoniazid to decrease the incidence of peripheral neuropathy. Pyridoxine is not required for the absorption of B6 and does not activate the metabolism of Isoniazid. The action of Isoniazid, rather than anorexia, leads to B6 depletion.

A nurse is instructing a group at the wellness center about first-aid treatment for burns. Which of the following instructions would the nurse give to the group? "Cover the burned area with butter." "Apply an antibacterial ointment to the burned area." "Wrap the burned area with the patient's clothes." "Submerge the burned area in cool water."

"Submerge the burned area in cool water." Explanation: Client Need: Health Promotion and Maintenance Rationale: D. The first step in treating the victim is to stop the burning process and halt the penetration of heat to the deeper tissues. Flush the burns with low pressure, cool water or submerge the burned area in cool water. A and B. Oils, salves and ointments should never be used on burns because they hamper treatment at the medical facility. C. Carefully remove clothing and jewelry. If wounds are to be covered, dressing (preferably sterile) is used.

The nurse is preparing a teaching plan for a patient who has recently tested positive for the human immunodeficiency virus (HIV). The nurse would include which of the following statements? "You should encourage your current and past sexual partners to be tested." "You will not need to take special precautions at this time." "You do not have reveal your condition to anyone." "You should refrain from physical contact with everyone."

"You should encourage your current and past sexual partners to be tested." Explanation: Client Need: Health Promotion and Maintenance Rationale: A. Confidential HIV testing should be encouraged for patients with risk factors. Sexual transmission of HIV still remains the most common mode of transmission. B. Blood and body fluid precautions must be taken first contact with the patient. The nurse should evaluate if the patient avoids transmission to others and uses barrier precautions properly. C. In some cases significant others also may be infected and should be tested so that they do not transmit the disease. Disclosure to significant others should be encouraged. D. Patients with HIV may share living quarters with others as long as basic hygiene is followed.

Which of the following statements made by a patient who has undergone abdominal surgery, would indicate to that the patient-controlled analgesia (PCA) pump use for management is effective? "l am able to cough and deep breath without help." "I only use the pump when I really need it." "I am very sleepy most of the time." "I feel pain only when I move."

"l am able to cough and deep breath without help." Explanation: Client Need: Physiological Integrity Rationale: A. Patient-controlled analgesia (PCA) is delivered intravenously via a pump that has a predetermined amount of analgesic contained within the unit. PCA is used to achieve better pain control. The patient adjusts the dosage on the basis of his or her pain level. PCA permits greater use of muscles when deep breathing and coughing. B. The nurse should assess the patient for under-medication by questioning the patient for nonverbal of consciousness. C. The nurse should assess the patient for signs of over-medication, and check the patient's level of consciousness. D. The patient who has optimal pain control is better able to cooperate with therapies and exercises. Pain on movement is an indication that the PCA pump is not being used effectively.

Which of the following statements made by a patient who has gastroesophageal reflux disease (GERD), would support a nursing diagnosis of knowledge deficit? "l will lie down for 30 minutes after meals." "I will restrict spicy foods in my diet." "I should sleep with the head of the be elevated." "I should decrease my intake of caffeine."

"l will lie down for 30 minutes after meals." Explanation: Client Need: Physiological Integrity Rationale: A. The patient with gastroesophageal reflux disease should not lie down immediately after eating. This would encourage backflow of gastric contents. The patient needs further instruction. B and D. Dietary restrictions include avoiding spicy, acidic and fatty foods, as well as drinks containing caffeine, such as coffee, tea and colas. C. Sleeping with the chest elevated six to eight inches, placing a pillow under the chest or elevating head on two pillows helps to prevent nocturnal reflux.

Which of the following statements made by a patient who is addicted to alcohol, would indicate understanding of disulfiram (Antabuse) therapy? "l will read the labels of mouthwash before using it." "I need to take this medication on an empty stomach." "This medication will decrease my desire for alcohol." "I need to take precautions in the sun."

"l will read the labels of mouthwash before using it." Explanation: Client Need: Psychosocial Integrity Rationale: A. Antabuse can cause a severe reaction when alcohol or alcohol-containing substances are taken while on the drug. Alcohol products to avoid while taking Antabuse include cough medicines, mouthwashes and after-shave lotions. B. Antabuse does not need to be taken on an empty stomach. C. Antabuse produces a severe reaction that includes hypotension, nausea and vomiting when taken by a person drinking alcohol. D. Sun precautions are not indicated for the person taking Antabuse since photosensitivity is not a side effect of the drug.

A patient who has type 1 diabetes is taking isophane insulin (NPH insulin) injection. A nurse should advise the patient to be alert for symptoms of hypoglycemia at which of the following time after insulin administration? 2 hours 4 hours 8 hours 20 hours

8 hours Explanation: Client Need: Physiological Integrity Rationale: C. Hypoglycemia that occurs in the late afternoon is related to the peaking of the morning NPH injection. NPH onset is three to four hours after administration and its peak, eight to 16 hours after administration. A and B. This is less than time after administration of NPH insulin. D. This is more than peak time after administration of NPH insulin.

A six-week-old infant was born prematurely. Which of the following manifestations would lead the nurse to suspect that the infant may have apnea? Intermittent episodes of acrocyanosis for periods of 10 minutes Random episodes of breath-holding during periods of stress Transient episodes of mottling with environmental temperature changes A lapse of spontaneous breathing for 20 or more seconds

A lapse of spontaneous breathing for 20 or more seconds Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Preterm infants are periodic breathers. Apnea is primarily an extension of this periodic breathing and can be defined as a lapse of spontaneous for 20 or more seconds, which may or may not be followed by bradycardia and color change. A. Acrocyanosis is the presence of cyanosis in the hands and feet and is typically found in the newborn. B. Apnea is a lapse of spontaneous breathing for 20 or more seconds. C. Transient mottling when an infant is exposed to decreased temperature, stress or over stimulation is normally found in the newborn.

Who among the following patients is at greatest risk for suicide? A middle-aged divorced male who recently lost his job An elderly married male in chronic pain A young single female who had a miscarriage An adolescent female who just broke up with her boyfriend

A middle-aged divorced male who recently lost his job Explanation: Answer: A Client Need: Psychosocial Integrity Rationale: A. Risk factors for suicide include male gender, living alone and recent loss. B, C and D. These patients are not at as great a risk for suicide as the divorced male who lives along and recently lost his job.

Which of the following results would a nurse expect to find in a reactive non-stress test? Acceleration of the fetal rate with fetal movement Deceleration of the fetal heart rate without fetal movement No change in fetal heart rate with fetal movement No change in fetal heart rate without fetal movement

Acceleration of the fetal rate with fetal movement Explanation: Client Need: Health Promotion and Maintenance Rationale: A. Acceleration of the fetal heart rate in response to fetal movement is the desired outcome of the non- stress test (NST) B. Decelerations are not a reassuring sign for the fetus and the NST would not considered reactive C. The expectation is fetal movement and acceleration in fetal heart rate with a reactive NST. D. The expectations are fetal movement and fetal heart rate increases.

A patient who had an acute myocardial infarction complains of severe substernal pain. Which of the following nursing interventions would be MOST APPROPRIATE? Administering the prescribed morphine Obtaining an electrocardiogram Encourage slow, deep breathing Eliminating environment stressors

Administering the prescribed morphine Explanation: Client Need: Physiological Integrity Rationale: A. Morphine is administered to promote analgesia, reduce anxiety and decrease the work load of the heart. B, C and D. Medical management of myocardial infarction is focused on controlling pain and limiting infarct size. Management includes the use of oxygen, nitrates, morphine, beta blockers, ACE inhibitors and rest.

A patient who visit a wellness clinic has a blood pressure of 158/100 mm Hg. Which of the following nursing actions is MOST APPROPRIATE? Send the patient to the emergency department. Refer the patient for an electrocardiogram as soon as possible. Advise the patient to have the blood pressure re-checked in one week. Encourage the patient to keep a food diary for one month.

Advise the patient to have the blood pressure re-checked in one week. Explanation: Client Need: Physiological Integrity Rationale: C. The blood pressure reading is the sole determinant of hypertension. It should be measured three consecutive times before making a diagnosis of hypertension. A. The patient with a B/P of 158/100 does not require treatment in an emergency department. B. Blood pressure screening, rather than electrocardiogram evaluation, determines hypertension. D. The patient does not need to keep a food diary at this time.

A 45-year-old nullipara is at risk for having an infant born with Trisomy 21. Information regarding which of the following diagnostic studies would be included in the care plan? Non- stress test Amniocentesis Percutaneous umbilical blood sampling Serum estriol levels

Amniocentesis Explanation: Client Need: Health Promotion and Maintenance Rationale: B. Prenatal assessment of genetic disorders, such as amniocentesis, is indicated in women of advanced age. The incidence of Trisomy 21 or Down syndrome, a chromosomal disorder, increases with maternal or paternal age. A. A non-stress test assesses fetal heart rate patterns in relation to fetal movement. C. Percutaneous umbilical blood sampling, performed in the second or third trimester, is the most widely used method for fetal blood sampling and fetal transfusion. Indications for this test do not include genetic testing. D. Serum estriol levels are used to evaluate fetal and placental function.

Who among the following patients is at greatest risk for fracture? An adolescent who is entering puberty An elderly man who has vertigo A toddler who is learning to walk A woman who is postmenopausal

An elderly man who has vertigo Explanation: Client Need: Physiological Integrity Rationale: B. A patient with vertigo has high risk for injury secondary to dizziness that can lead to falls. Elderly patients are identified as especially susceptible to falls. A. An adolescent who is entering puberty has a low susceptibility to falls. C. A toddler learning to walk has an increased susceptibility to falls. However, due to increased cartilage and the protection of underlying tissues, the incidence of fractures in toddlers is low. D. A postmenopausal woman is prone to fractures secondary to osteoporosis, but the elderly are at greatest risk.

A pregnant woman reports that her last menstrual period was from July 1 to July 5. The nurse would expect her due date will be on: March 24. March 28. April 8. April 12.

April 8. Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Naegle's Rule: Last Menstrual Period minus three months, plus seven days, plus one year = Estimated Date of Delivery of April 8th. A. The first day of the woman's last menstrual period would have been June 17th. B. The first day of the last menstrual period would have been June 21st. D. The first day of the last menstrual period would have been July 4th.

A woman complains of morning sickness during the first trimester of her pregnancy. A nurse would suggest that she take which of the following measures to help her alleviate the dicomforts? Consume a clear liquid diet. Take prenatal vitamins with milk. Eat foods that are low in protein. Avoid exposure to noxious odors.

Avoid exposure to noxious odors. Explanation: Client Need: Health Promotion and Maintenance Rationale: D. The nurse should instruct the patient to avoid odorous food if morning sickness occurs. A, B and C. Morning sickness is due to fluctuating hormone levels. Dry foods such as crackers before arising seem to alleviate some of the nausea.

A patient is administered diltiazem hydrochloride (Cardizem). Which of the following responses would a nurse expect from a patient if the medication is effective? Increased bone density Decreased seizure activity Blood pressure within normal limits Serum cholesterol level within normal limits

Blood pressure within normal limits Explanation: Client Need: Physiological Integrity Rationale: C. Diltiazem (Cardizem) is a calcium channel blocker that causes vasodilation and a decrease in peripheral vascular resistance, thus reducing arterial blood pressure. A, B and D. Cardizem is used in the treatment of angina and hypertension. It is not indicated for control of seizures, reduction of cholesterol or the increasing of bone density.

A six-year-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. Excessive edema may indicate construction of vessels from the immobilizing device. B. Some pain is normal after trauma or surgery. The pain should decrease when the bone is immobilized. C. Plaster casts set rapidly, but the several hours to dry completely and feel cool to touch. Promoting the circulation of warm, dry air around a damp cast can enhance moisture evaporation and speed the drying process.

A 12-year-old child has a diagnosis of appendicitis. Which of the following manifestations would be MOST important for the nurse to FOLLOW-UP? Tympanic temperature of 101.2 °F (38.4 °C) Absence of stool for 24 hours Nausea when exposed to food odors Cessation of abdominal pain

Cessation of abdominal pain Explanation: Client Need: Physiological Integrity Rationale: D. Signs of peritonitis usually include fever and sudden relief from pain after perforation. There may be a subsequent increase in pain, which is usually diffuse and accompanied by rigid guarding of the abdomen and progressive abdominal distention. Tachycardia, rapid, shallow breathing as the child refrains from using abdominal muscles, pallor, chills, irritability and restlessness also are manifestations of peritonitis. A. There is usually a low-grade lever in appendicitis without perforation. A temperature greater than 102.20 F indicates perforation or viral illness. B. A child with appendicitis may experience nausea, vomiting and anorexia after the onset of abdominal pain. Diarrhea, as well as other common signs of childhood illness (such as upper respiratory tract congestion, poor feeding lethargy or irritability), may accompany appendicitis. C. Nausea is a symptom of appendicitis, but the possibility of rupture would take priority for follow-up.

A nurse has taught a family about the prevention of Lyme disease. Which of the following actions by the family members indicate that the family understands the nurse's instructions? Applying an insect repellent to pets. Wearing clothing that exposes the maximum amount of skin. Checking for the presence of ticks after outdoor activities. Leaving a tick attached to the skin until examined by a health care provider.

Checking for the presence of ticks after outdoor activities Explanation: Client Need: Physiological Integrity Rationale: C. Lyme disease is transmitted by the deer tick and is most prevalent in the summer and early fall. Symptoms involve the skin, nervous system and joints. Families should be instructed to check often for ticks following outdoor activities, and to thoroughly inspect and wash clothes. A. Pest should wear tick collars. Pets should be inspected often, and not allowed on beds or furniture B. Families should be instructed to wear light- colored clothing in order to better see ticks if they are on the clothing. They should wear long pants tucked into boots or long socks, shirts tucked into pants, and closed shoes when engaging in outdoor activities. D. Attached ticks should be removed. The area should be washed with soap and water and an antiseptic applied.

A patient who has type 1 diabetes, experiences weakness and tremors. Which of the following actions would a nurse take FIRST? Obtaining a urine specimen from the patient Giving the patient a concentrated source of glucose Checking the patient's most recent blood glucose level Administering the patient's p.r.n. dose or insulin

Checking the patient's most recent blood glucose level Explanation: Client Need: Safe Effective Care Environment Rationale: C. The nurse should first check the patient's glucose level by the finger stick method. A. If the patient is hypoglycemic, no sugar will be found in the urine. B. If the patient's glucose is low, a longer-acting carbohydrate, such as skim milk, is recommended. Over treatment with large quantities of quick-acting carbohydrates should be avoided. D. If the patient is hypoglycemic, as indicated by weakness and tremors, the patient will not require insulin.

Which of the following clinical manifestations would support a nursing diagnosis of decreased cardiac output? Cool, moist skin Bounding peripheral pulses Increased urinary output Diminished breath sounds

Cool, moist skin Explanation: Client Need: Physiological Integrity Rationale: A. To compensate for decreased cardiac output the sympathetic nervous system is activated, resulting in constriction of peripheral blood vessels. The decreased blood perfusion causes the skin to feel cool and clammy and to appear pale. B and C. Bounding pulses and increased urinary output are not manifestations of decreased cardiac output, if the low cardiac output is secondary to poor left ventricular function, there may be a low BP and decreased urine output D. Rapid respirations typically occur during shock (decreased cardiac output) due to decreased tissue perfusion.

A nurse is assessing a patient who has just had an acute myocardial infarction. The patient will MOST likely have which of the following values in the laboratory report? White blood cell count of 7000 cu mm Creatine kinase of 1250 U/L Blood urea nitrogen of 6 mg/dL Potassium of 4.0 mEq/dL

Creatine kinase of 1250 U/L Explanation: Client Need: Physiological Integrity Rationale: B. The enzymes most commonly used to detect myocardial infarction (MI) are creatine kinase (CK) and lactic acid dehydrogenase (LDH). CK is an enzyme found in high concentrations as a specific index of injury to the myocardium. Thus, it is important in the diagnosis of MI. A normal CK range for men older than 19 year of age is 38- 174 U/L; for women older than 19 years of age CK range is 96- 140 U/L. A. This cell count represents a normal blood value and is not associated with damage to the myocardium. Leukocytosis of 10,000 to 20,000 cells/mm appears on the second day after myocardial infarction and disappears in one week. C. Normal blood urea nitrogen (BUN) is 50-25 mg/dl in an adult. D. This is normal serum potassium level.

A patient is in the postoperative period following renal transplant. Which of the following blood chemistry reports indicate that the transplant was successful? Bilirubin, 0.7 mg/dl Creatinine, 1.0 mg/dl Glucose, 85mg/dl Calcium, 6.5 mg/dl

Creatinine, 1.0 mg/dl Explanation: Client Need: Physiological Integrity Rationale: B. Signs of transplant rejection include decreasing creatinine clearance, increasing serum creatinine, elevated blood urea nitrogen (BUN) levels, fever, and weight gain, decreased urine output and increased blood pressure. Normal serum creatinine is 0.2-1.0 mg/dl. A, C and D. Bilirubin, glucose and calcium levels are not indicative of transplant success or rejection.

A nurse would expect a patient who has a cataract to report which of the following symptoms? Decreased color perception Loss of peripheral vision Halos around light Headache

Decreased color perception Explanation: Client Need: Physiological Integrity Rationale: A. A person with cataracts has opacity of the ocular lens and may complain of decreased vision, abnormal color perception and glare in bright lights. The pupils develop a milky-white appearance. B. Impaired peripheral vision occurs in glaucoma, a disease characterized by an increase in intraocular pressure and resulting in progressive loss of vision. C. Seeing halos around light is symptom glaucoma. D. Headaches are associated with neurologic disorders. They are not associated with cataracts.

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 bulk of the stool 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 for Crohn's disease 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 indicates a reduction of symptoms. A, B and C. The major clinical applications of the glucocorticoids stem from the ability of these drugs to suppress immune responses and inflammation. Sever adverse effects can result from long-term use of corticosteroids and include adrenal suppression, myopathy, osteoporosis, increased susceptibility to infection and Cushingoid syndrome (including moon face). Expansion of muscle mass and an increase in the bulk of the stool do not indicate the effectiveness of steroid therapy.

Which of the following manifestations MOST likely indicate the presence of complication in a patient who has chronic diabetes mellitus? Diminished olfactory sensation Increased deep tendon reflexes Decreased peripheral sensation Enhanced calcium excretion

Decreased peripheral sensation Explanation: Client Need: Physiological Integrity Rationale: C. The nurse must carefully assess the patient with chronic diabetes mellitus to determine the presence of pain, paresthesias, numbness, orthostatic changes and gastrointestinal symptoms. A, B and D. The most frequently occurring complications of diabetes mellitus include retinopathy, neuropathy and nephropathy.

A 10-year-old boy is admitted to the hospital with a history of fever and right, lower quadrant abdominal pain. Which of the following comport measures should the nurse implement until a diagnosis is made? Place the child in a recumbent position. Apply warm compresses to the affected area. Obtain an order for an age-appropriate analgesic. Distract the child with an age-appropriate video.

Distract the child with an age-appropriate video. Explanation: Client Need: Physiological Integrity Rationale: D. Appendicitis is inflammation of the vermiform appendix (blind sac at the end of the cecum). The most common symptoms of appendicitis are colicky, abdominal pain and tenderness with guarding of the abdomen. Initially, pain is generalized or periumbilical; however, it usually descends to the lower, right quadrant. There is often a low-grade fever in appendicitis without perforation. A number of nonpharmacologic techniques can be used with children to relieve pain. By definition, any pain intervention that is not a drug falls into this category. Using an age-appropriate video is a good distraction. This will allow the child to focus on the program and not his pain. A. The child should maintain a position of comfort. Children may complain of increased pain upon ambulation. For some children, maintaining a side-lying position with knees flexed may provide the most comfort. B. Applying warm compresses increases the possibility of rupture of the appendix and should not be done. C. Pain medication may mask the symptoms of appendicitis and delay the initial diagnosis.

A nurse would advise a patient to take a diuretic: early in the morning morning after lunch with the evening meal at bedtime

Early in the morning Explanation: Client Need: Physiological Integrity Rationale: A. Diuretics should be administered in early morning, if ordered daily because diuretic administration later in the day may cause nocturia. B, C and D. The only time diuretics should be taken at a time other than in the early morning is if the patient has a job that requires him/her to sleep during the day.

Which of the following serum laboratory results would a nurse expect to identify in a patient who has pancreatitis? Decreased cholesterol Decreased glucose Elevated amylase Elevated creatinine

Elevated amylase Explanation: Client Need: Physiological Integrity Rationale: C. Serum amylase is the most important aid in diagnosis acute pancreatitis. Peak levels are reached in 24 hours. A and D. Cholesterol and creatinine levels are not included in the diagnostic evaluation for pancreatitis. B. Transient hyperglycemia occurs in some patients with pancreatitis.

A nurse is teaching a community group about the prevention of osteoporosis. Which of the following should the nurse emphasize? Lap swimming Eliminating smoking Restricting sodium intake Minimizing sun exposure

Eliminating smoking Explanation: Client Need: Physiological Integrity Rationale: B. Osteoporosis is a disorder that results in reduction in bone mass. The cause has been attributed to estrogen deficiency, immobilization, use of steroids and high intake of caffeine. Contributing factors are cigarette smoking, diets low in calcium, too much protein in the diet and a sedentary life style. Chronic smoking appears to both lower body estrogen levels and block calcium absorption, thereby. increasing the risk of osteoporosis.

When teaching a patient who has a diagnosis of schizophrenia about successful independent living in the community, a nurse should encourage the patient to: establish a structured daily routine. spend time alone. plan a program of self-fulfillment. discontinue medication when symptoms disappear.

Establish a structured daily routine Explanation: Client Need: Psychosocial Integrity Rationale: A. A structured daily routine provides the patient with a sense of independence and control over the environment. B, C, and D. Social withdrawal is a common behavior of patients with schizophrenia. These patients usually need encouragement to interact with others. Setting unrealistic goals leads to frustration and failure. The nurse should provide feedback regarding how realistic the patient's goals are, so that the patient does not set him/herself up for failure.Studies show that without medication schizophrenics have a relapse rate 60 percent.

A nurse evaluates a three-month-old infant who is developmentally delayed for 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: Health Promotion and Maintenance Rationale: A. Increased or decreased resistance to passive movement is a sign of abnormal muscle tone. The child 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 normal three- month- old infant.

To reduce the risk of fetal neural tube defects, a nurse would evaluate the childbearing woman's need for which of the following nutrients? Ferrous sulfate (Feosol) Calcium carbonate (Tums) Folic acid (Folvite) Ascorbic acid (Vitamin C)

Folic acid (Folvite) Explanation: Client Need: Physiological Integrity Rationale: C. Diets deficient in folate have been implicated as a risk factor in the development of neural tube defects in the fetus. A, B and D. Ferrous sulfate, calcium carbonate and ascorbic acid deficiencies have not been implicated in development of neural tube defects.

A woman who is 12 weeks pregnant comes to the prenatal clinic for her second visit and tells the nurse, "I thought I wanted to be pregnant, but now I'm not sure." The nurse's response would be based on the understanding that the woman is: considering pregnancy termination. in need of a social service referral. experiencing a normal reaction to pregnancy. exhibiting predictors of child maltreatment syndrome.

Experience a normal reaction to pregnancy Explanation: Client Need: Psychosocial Integrity Rationale: C. The patient is experiencing a normal reaction to pregnancy. Often, new mothers are ambivalent about the pregnancy in the beginning. A, B and D. These patient statements do not indicate that the woman is considering termination of the pregnancy, is in need of a social service referral or that she is at risk for abusing the child.

A patient who has first stage dementia, Alzheimer type is admitted to the hospital. Which of the following symptoms should a nurse expect to observe? Fluctuating level of consciousness Forgetfulness Disorientation Long-term memory loss

Forgetfulness Explanation: Client Need: Psychosocial Integrity Rationale: B. In the early stage of Alzheimer's dementia the client complains of forgetfulness and has difficulty remembering appointments and addresses. A. Disturbance of consciousness is a symptom of delirium. C. Disorientation is a manifestation of the middle stage of Alzheimer's dementia. D. Memory problems become more pronounced in the middle to late stages of Alzheimer's dementia.

A nurse is instructing a patient to limit the intake of potassium rich food. Which of the following food has the lowest potassium content? Raisins Grapes Spinach Potato

Grapes Explanation: Client Need: Physiological Integrity Rationale: B. The potassium content of one serving of grapes is 105 mg. of the choices given, it is the lowest potassium. A. The potassium content of one serving of raisins is 1089 mg. C. The potassium content of one serving of spinach is 307 mg D. The potassium content of one serving of potatoes is 844 mg

A nurse assesses a patient who has schizophrenia, paranoid type. Which of the following behaviors should the nurse expect to observe? Elated affect and hyperactivity Obsessive thoughts and rituals Hallucinations and delusions Manipulation and narcissism

Hallucinations and delusions Explanation: Client Need: Psychosocial Integrity Rationale: C. Delusions and hallucinations are the dominant symptoms in paranoid schizophrenia. A. Elated affect and hyperactivity are behaviors in mania. B. Obsessive thoughts and rituals are behaviors typical of obsessive-compulsive disorders. D. Manipulation and narcissism are behaviors seen in narcissistic personality disorders.

A patient who is taking lithium carbonate (Eskalith) for the treatment of bipolar disorder, manic type comes to the outpatient clinic reporting insomnia, hyperactivity and pressured speech. Which of the following questions should a nurse ask the patient FIRST? "Have you been taking your medication?" "How much caffeine have you had today?" "How much sleep did you have last night?" "Is there something that has been upsetting you?"

Have you been taking your medication? Explanation: Client Need: Psychosocial Integrity Rationale: A. Insomnia, hyperactivity and pressured speech are signs of mania. A recurrence of signs and symptoms is indicative of a decrease in the lithium level, often caused by the discontinuation or erratic taking of medication by the patient. B, C and D. While the information gathered from these questions might be useful in planning care, asking the patient if he/she has been taking the medication helps to determine the cause of the relapse. Once the cause is determined and successfully treated by the healthcare team, the signs and symptoms of mania will subside.

A patient has an episode of epistaxis. Which of the following actions would a nurse take FIRST? Applying ice to the back of the patient's neck Tipping the patient backward and encourage swallowing Determining if the patient has a history of hypertension Having the patient lean forward and pinch the nose

Having the patient lean forward and pinch the nose Explanation: Client Need: Safe and Effective Care Environment Rationale: D. Immediate intervention for the patient experiencing epistaxis, or nosebleed, includes applying pressure to the nose to stop the bleeding and positioning the patient upright with the head tilted forward. A. Ice packs may be applied to the nasal area. B. Upright positioning will provide less blood flow to the head than the supine position. Forward tilting of the head will avoid drainage of blood into the nasopharynx. C. Immediate intervention for the patient experiencing a nosebleed includes applying pressure to the nose in an attempt to stop the bleeding. Assessing for hypertension would be secondary.

A patient who has schizophrenia, paranoid type says to a nurse,"That guy over there is staring at me and putting a spell on me." Which of the following nursing diagnoses should be the PRIORITY for this patient? High risk for violence related to delusional thinking Alteration in thought processes related to mistrust Anxiety related to misinterpretation of external stimuli Defensive coping related to fear of other patients

High risk for violence related to delusional thinking Explanation: Client Need: Psychosocial Integrity Rationale: A. Risk for violence related to altered perception and a cognitive distortion is the priority diagnosis. Hostility is projected onto the environment and then acted upon. Psychiatric healthcare workers are injured most often by patients with paranoid schizophrenia. B, C and D. Each of these nursing diagnoses is reasonable for the patient with paranoid schizophrenia, but the priority diagnosis is high risk for violence because it deals with the safety of patients and staff.

A patient who has undergone a thyroidectomy would be predisposed to: hypocalcemia. hyponatremia. hyperkalemia. hypermagnesemia.

Hypocalcemia Explanation: Client Need: Physiological Integrity Rationale: A. The parathyroid glands are located on the posterior surface of the thyroid gland. During thyroid surgery, parathyroid tissue may be removed inadvertently or damaged. The postoperative thyroidectomy patient is at risk for hypocalcemia due surgical loss or damage since the parathyroids play a role in calcium regulation. B, C and D. Hyponatremia (decreased serum sodium), hyperkalemia (excess serum potassium) and hypermagnesemia (excess serum magnesium) are not complications of thyroid surgery.

A patient has a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which the following clinical findings would a nurse monitor this patient? Hyperglycemia Hyponatremia Polyuria Dysphagia

Hyponatremia Explanation: Client Need: Physiological Integrity Rationale: B. The nurse caring for a patient with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) should be alert for low urinary output with a high specific gravity, a sudden weight gain or a serum sodium decline. A and D. Hyperglycemia and dysphagia are not manifestations of SIADH. C. The patient with SIADH has a low urinary output and may need diuretics to remove excess fluid volume.

A patient was diagnosed with schizophrenia. Which of the following patient statements indicate a need for ADDITIONAL instruction regarding haloperidol (Haldol)? "l can stop my medicine when I don't hear the voices anymore." "I'll take my Cogentin if my neck feels stiff." "I'm going to eat bran cereal every morning." "I have to wear a hat when I go to the beach."

I can stop my medicine when i don't hear the voices anymore Explanation: Client Need: Physiological Integrity Rationale: A. Studies show that without medications schizophrenics have a relapse rate of 60 percent. The patient should be instructed to not stop the medication. B. Antiparkinsonian medication is prescribed for the patient taking Haldol to counteract extrapyramidal side effects. Congentin relieves the stiff neck that can accompany Haldol administration. C. Constipation is a side effect of treatment with Haldol. The patient should increase the amount of bulk in his/her diet. D. Photosensitivity is a side effect of Haldol. The patient should use sunscreen and not expose the skin.

A nurse identifies a 2 mm superficial open blister over a patient's sacrum. The nurse would document pressure ulcer as stage: I. II. III. IV.

II. Explanation: Client Need: Physiological Integrity Rationale: B. Stage Il pressure ulcers are identified by skin that is not intact. There is partial-thickness loss of the epidermis, as evidenced by a blister or shallow crater. A. Stage I pressure ulcers are identified by skin that is intact, with a red are that does not Blanche with external pressure. C. Stage III pressure ulcers are identified by full-thickness skin loss. Subcutaneous tissues may be damaged, with a crate-like appearance. D. Stage IV pressure ulcers are identified by full-thickness skin loss with extensive destruction to tissues, or damage to muscle, bone and supporting structures.

To help a woman recognize the BEST time for conceiving, a nurse would instruct the woman to monitor for which of the following manifestations of ovulation? Drop in body temperature lasting several days Increase in amount of cervical mucus that is clear and stretches Abdominal bloating that occurs suddenly Breast tenderness accompanied by slight nipple discharge

Increase in amount of cervical mucus that is clear and stretches Explanation: Client Need: Health Promotion and Maintenance Rationale: B. At the time of ovulation the amount of vaginal mucus increases, and appears thin, watery and clear. Basal body temperature increases 0.3 to 0.6 °C approximately 24 to 48 hours after ovulation. A. Basal body temperature increases rather than decreases at the time of ovulation. C. Mittelschmerz and midcycle spotting, rather than sudden abdominal bloating, may occur at ovulation. D. Nipple discharge is not a sign of ovulation.

Which of the following measures should a nurse PRIORITIZE when planning care for a patient who has undergone a cardiac catheterization via femoral approach? Increasing fluid intake. Keeping the affected leg flexed. Assessing the patient's apical pulse. Monitoring the patient's serum glucose level.

Increasing fluid intake Explanation: Client Need: Safe Effective Care Environment Rationale: A. The nurse should encourage fluid intake for the adequate fluid replacement and renal elimination of the nephrotoxic contrast dye. B. The patient should not have the head of the bed elevated more than 30 degrees and should avoid flexing the femoral area to prevent clot formation. C. The patient's femoral pulse on the operative side is monitored every 15 minutes for one hour. While vital signs are monitored, the apical rate is not required in post- procedure care. D. The Patient's serum glucose level does not have to be monitored as part of post-procedure care.

Which of the following actions by the nurse would be APPROPRIATE when caring for a patient who has syndrome of inappropriate antidiuretic hormone (SIADH)? Straining the patient's urine Increasing the patient's fluid intake Monitoring the patient's blood glucose level Increasing the patient's sodium intake

Increasing the patient's sodium intake Explanation: Client Need: Physiological Integrity Rationale: D. Manifestations of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) include hyponatremia. The patient's diet should be supplemented with sodium. A. Straining of urine is done for patients suspected of having renal calculi, not for patients with SIADH. B. The patient with SIADH experiences fluid overload. Initially fluids may be restricted to 100-1000 ml/day. C. The blood glucose level does not require monitoring in patients with SIADH, since SIADH is not a disorder of glucose metabolism.

Following amniocentesis a nurse would instruct the patient to report which of the following findings? Dependent edema of the lower extremities Odorless white vaginal discharge Intermittent abdominal pain Frequent urination

Intermittent abdominal pain Explanation: Client Need: Health Promotion and Maintenance Rationale: C. After amniocentesis the woman is monitored for uterine contractions and fetal heart rate. There is also a risk infection of the amniotic fluid following amniocentesis. A. Many pregnant women have dependent edema in the lower extremities. It is not associated with amniocentesis. B. Odorless, white vaginal discharge is usually not of concern and is not associated with amniocentesis. D. Frequent urination is a common complaint for pregnant women and is not associated with amniocentesis.

When planning care for a patient who has a diagnosis of increased intracranial pressure, a nurse should give PRIORITY to which of the following measures? Limiting environment stimuli Increasing fluid intake Suctioning nasotracheally every hour Keeping the patient in a recumbent position

Limiting environment stimuli Explanation: Client Need: Physiological Integrity Rationale: A. The nurse should orient the patient to the surroundings as needed and provide a quiet environment. B. Fluid administration for patients with increased intracranial pressure is controversial. Administer fluid exactly as prescribed and never infuse more than the prescribed amount. C. The nurse should not suction via the nose because drainage may indicate a cerebrospinal fluid leak. Suctioning every hour will increase intracranial pressure. D. It is important to prevent venous obstruction. The head of the bed should be raised 30 degrees.

Which of the following should a nurse include in the care plan of a patient who has a diagnosis of major depressive episode? Maintaining a safe environment. Providing challenging activities. Decreasing environmental stimulation. Increasing time spent alone.

Maintaining a safe environment Explanation: Client Need: Psychosocial Integrity Rationale: A. Patient safety always takes priority. Depressed patients are often suicidal and need to know that the environment is safe for them. B. The depressed patient does not have the energy to participate in challenging activities. C. Environment stimuli should not be increased or decreased but should be appropriate to the patient. D. The patient should be encouraged to participate in appropriate activities rather than remain socially isolated.

Which of the following topics would be given PRIORITY in the teaching plan for a woman who is attending childbirth classes at 10 weeKs of pregnancy? Breastfeeding techniques Relaxation methods for labor Management of pregnancy discomforts Routine infant care measures

Management of pregnancy discomforts Explanation: Client Need: Health Promotion and Maintenance Rationale: C. During the first trimester the pregnant woman needs information related to her physiologic and psychosocial care. An expected outcome is that the woman will use the knowledge given her regarding nutritional needs sexual needs, activities of daily living, discomforts of pregnancy and self-care. A. Breastfeeding teaching will be done closer to term and reinforced by lactation consultants in the postpartum period. B. Relaxation for labor will be taught closer to the woman's date. D. Infant care will be discussed closer to delivery and reinforced on the mother-infant unit after delivery.

A patient who has pneumonia manifesting with a productive cough is admitted to the hospital. Which of the following actions should a nurse carry out FIRST? Obtain a sputum specimen. Obtain a portable chest x-ray. Administer cefoxitin sodium (Mefoxin) 500 mg every 8h intravenously. Administer guaifenesin with codeine (Robitussin) 30 ml, Po, q 4h p.r.n.

Obtain a sputum specimen Explanation: Client Need: Physiological Integrity Rationale: A. Pneumonia is an inflammatory process of the bronchioles and alveolar spaces in the lung usually caused by an infection. A productive cough is very common. Color and consistency of sputum will vary depending on the type of pneumonia present. The nurse should collect a sputum specimen first so that the underlying pathology can be identified. B. Pneumonia appears on chest x-ray as an area of increased density. Since the patient has already been diagnosed with pneumonia, a chest x-ray would not be indicated. C. The key to effective treatment of pneumonia with antibiotics is identification of the organism causing the pneumonia. Antibiotics should not be started until sputum cultures are obtained. D. Robitussin, an expectorant, is indicated in the treatment of a dry, nonproductive cough. This patient's cough is already productive.

When considering the nutritional needs of a patient who has a diagnosis of bipolar disorder, manic type, a nurse should plan to: offer finger foods. serve food in sealed containers. engage the patient in food preparation. seat the patient with other lively patient in the dining room.

Offer fingers foods Explanation: Client Need: Psychosocial Integrity Rationale: A. The manic patient has poor attention span and concentration. The patient would have difficulty sitting through a meal without becoming distracted or frustrated. Finger foods can be easily handled and are portable. They also can be left in places accessible to the patient. B. Sealed containers may be frustrating for the manic patient to open since the patient has difficulty focusing on a task. C. Expecting a manic patient to focus on a complicated task, such as food preparation, would be unrealistic. D. Lively interactions would intensity the manifestations of mania. Manic patients do best in a calm environment where communication is clear and concise.

Which of the following nursing diagnoses is a PRIORITY for a patient with gout? Pain Fatigue Risk for infection Risk for peripheral neurovascular dysfunction

Pain Explanation: Client Need: Physiological Integrity Rationale: A. Gout is an acute inflammatory condition associated with ineffective metabolism of pureness. Ureic acid deposits accumulate primarily in the joints of the great toe causing pain, edema and inflammation. The nursing diagnosis applicable to a patient with gout should address the pain and limitation for motion. B. fatigue is not symptomatic of gout. C. Interventions are aimed at reducing inflammation and pain. Risk for infection is not a nursing diagnosis associated with gout. D. Gout is a metabolic, rather than a neurovascular, disorder

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 Delayed 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 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 for Health Statistics' growth charts use the 5th 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 of tooth eruption shows considerable variation among children, but the order of their appearance is fairly regular and predictable. The first primary teeth to erupt are the lower central incisors, which appear at approximately six to eight months of age.

Which of the following conditions would a nurse expect during the assessment of a patient who has right-sided heart failure? Shortness of breath Peripheral edema Decreased urinary output Paroxysmal nocturnal dyspnea

Peripheral edema Explanation: Client Need: Physiological Integrity Rationale: B. Congestive heart failure occurs when the heart is no longer able to pump enough blood to meet the demands of the body. In right - sided heart failure, increased volume and pressure in the systemic veins cause peripheral edema. This is related to an inability of the heart to pump blood forward into the lungs. A and D. Pulmonary congestion occurs with left- sided heart failure when the heart is unable to pump blood out to the system. Increased pressure in the left side of the heart causes back- up of fluid into the pulmonary system, resulting in pulmonary congestion. Manifestations of this congestion are shortness of breath and paroxysmal nocturnal dyspnea. C. Decreased urinary output is seen in left-sided heart failure. The heart is unable to pump blood forward and cardiac output is decreased. This, in turn, results in decreased kidney perfusion and, ultimately, decreased urinary output.

A six-month-old infant recently began cereal feeding. Which of the following manifestations would support a nursing diagnosis of ineffective infant feeding pattern? Frequent loose stools Increased abdominal girth Persistent tongue thrusting Lengthened time between meals

Persistent tongue thrusting Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Developmentally, infants are not ready for solid food. The extrusion (protrusion) reflex is strong and often causes food to be pushed out of the mouth Infants instinctively suck when given food. Between four and six months of age the extrusion reflex fades. A. Acute diarrhea, a sudden increase in frequency and change in consistency of stools, is often cause by an infectious agent in the gastrointestinal tract. The increased frequency and severity of diarrheal disease in infants is related to age-specific alterations is susceptibility to pathogens. B. Abdominal circumference or girth is measured just above the level of the umbilicus. In the event of abdominal distention, serial measurements are taken to determine changes in the girth. Abdominal distention can be caused by a variety of gastrointestinal disorders. D. The amount of formula per feeding and the number of feedings per day vary among infants, but a general guideline for a six-month-old is six ounces per feedings. Infants have an average of 4.7 feedings per day. Those on demand feedings usually determine their own feedings schedule. When introducing solid food, the cereal should be offered before the entire milk feeding is given.

Which of the following goals would be given PRIORITY in the care plan of a two-year-old child who has acute gastroenteritis? Promote hydration Reduce lethargy Preserve skin integrity Maintain comfort

Promote hydration Explanation: Client Need: Physiological Integrity Rationale: A. Therapeutic management of acute diarrhea disease (acute gastroenteritis) is directed at correcting the fluid and electrolyte imbalance and preventing or treating malnutrition. Major goals are assessment of fluid and electrolyte imbalance, re-hydration, maintenance fluid therapy and reintroduction of an adequate diet. B. Lethargy, defined as abnormal drowsiness or stupor, can be caused by high fevers, dehydration and electrolyte imbalances. While the child with acute gastroenteritis may become lethargic, the correction of the fluid and electrolyte imbalance is the priority. C. A patient goal should be to promote skin integrity, since frequent stools will cause irritation to the skin. However, this should not be the priority goal. D. A patient goal should be to promote comfort and relieve stress; however, the primary goal for this patient is hydration.

A nurse would encourage a woman to increase which of the following nutrients in her diet throughout pregnancy? Protein Simple carbohydrates Potassium Vitamin A

Protein Explanation: Client Need: Health Promotion and Maintenance Rationale: A. Protein intake should increase from 50 to 60 grams during pregnancy for the synthesis of the products of conception. B. Most carbohydrates should be complex, rather than simple, carbohydrates. They should come from nutritious foods and not sweets. C. Potassium is not needed in extra amounts during pregnancy. D. Excess amounts of vitamin A may be harmful to mother and fetus, even having teratogenic effects. Deficiencies in vitamin A are rare in pregnancy.

When addressing the concerns of a primipara who is eight weeks pregnant, a nurse would provide the woman with which of the following information? Dysuria is a normal finding in pregnancy. Vaginal spotting is common throughout pregnancy. A 10 lb (4.5 kg) weight gain is anticipated during the first trimester of pregnancy. Quickening can be expected to occur between 16 and 20 weeks of pregnancy.

Quickening can be expected to occur between 16 and 20 weeks of pregnancy. Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Quickening is the first fetal movement felt by the pregnant woman, usually between 16 and 18 weeks gestation. A. The bladder's capacity is greatly reduced in the first and second trimesters. B. Vaginal spotting is not common throughout pregnancy. C. A weight gain of two to four pounds is expected the first trimester.

When assessing a patient who underwent a colostomy several months ago, a nurse would expect the stoma to appear: dry. red. edematous. retracted.

Red Explanation: Client Need: Physiological Integrity Rationale: B. The patient's colostomy stoma should be deep pink to red in color, shiny and moist like the mucous membrane inside the mouth. A. The stoma should be most rather than dry C. The edema present in the immediate postoperative period should disappear gradually over four to six weeks. D. Stomal retraction can develop at any time either because of poor surgical technique or significant weight gain. Stomal retraction makes pouching, and hence maintenance, of the peristomal skin difficult, and in some cases surgical revision may be necessary.

A patient who is receiving total parenteral nutrition has an elevated blood glucose level and has an order of intravenous insulin. Which of the following types of insulin should a nurse prepare? Isophane insulin (NPH) Regular insulin (Humulin R) Insulin zinc suspension (Lente) Semi-lente insulin (Semitard)

Regular insulin (Humulin R) Explanation: Client Need: Physiological Integrity Rationale: B. Total parenteral nutrition (TPN) is the infusion of nutrients through a central venous catheter. The hyperalimentation solution contains 200 /o glucose or higher (hypertonic), amino acids, water, vitamins and minerals. It is used for patients unable t eat or digest food in the gastrointestinal tract. Insulin injection (Regular) can be administered via the subcutaneous or intravenous route. Regular insulin has a quick onset and is used to treat the hyperglycemia associated with parenteral nutrition. Intravenously it begins acting within 10 minutes. A. Isophane insulin (NPH) can be administered via the subcutaneous or intramuscular route. The onset of action is on to two hours. NPH would not be used intravenously. C. Insulin zinc suspension (Lente) can be administered via the subcutaneous or intramuscular rout. The onset of action is one to two hours. It should not be used intravenously. D. Semi-lente insulin can be administered via the subcutaneous & intramuscular route. The onset of action is one and half hours. It would not be used intravenously.

A patient had a transurethral resection of the prostrate (TURP) two hours ago. Which of the following measures should a nurse include in the care plan? Administering oxygen by nasal cannula Changing the dressing every two hours Regulating the flow rate of the irrigation solution Assessing for the return of the gag reflex

Regulating the flow rate of the irrigation solution Explanation: Client Need: Physiological Integrity Rationale: C. A transurethral resection of the prostate is a treatment for benign prostatic hypertrophy (BPH), Prostatic tissue is removed via the urethra. After a transurethral resection, the bladder may be continuously irrigated to removed clotted blood and ensure drainage of urine. A. The patient who has undergone a transurethral resection does not require the administration of oxygen unless underlying disease warrants its use. B. Since prostate tissue is removed via the urethra, no dressing is required. D. A short-acting general anesthetic is used during a transurethral resection. Checking the gag reflex is not necessary.

A 10-year-old boy who is in the terminal stages of Duchenne muscular dystrophy is being cared for at home. When evaluating for major complications of the disease, a nurse would give PRIORITY to assess 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 major complications of Duchenne 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.

A patient has a nasogastric tube which is draining large amounts 1/1 point of fluid. Which of the following nursing diagnoses would the nurse PRIORITIZE? Diarrhea Risk for infection Ineffective thermoregulation Risk for fluid volume deficit

Risk for fluid volume deficit Explanation: Client Need: Physiological Integrity Rationale: D. The patient with a nasogastric tube should be monitored closely for signs of dehydration and electrolyte imbalance. Other nursing diagnoses appropriate for this patient include altered nutrition and pain related to abdominal distention and increased peristalsis. A, B and C. The diagnoses of diarrhea, risk for infection and ineffective thermoregulation are not identified for the patient with a nasogastric tube draining large amounts of fluid.

To which of the following nursing diagnoses would a nurse PRIORITIZE in the care of a patient who has an acute attack of Meniere's disease? Energy disturbance Activity intolerance Risk for injury Risk for infection

Risk for injury Explanation: Client Need: Physiological Integrity Rationale: C. The patient with Meniere's disease is at risk for injury due to the vertigo that can occur without warning. Keeping the patient safe during an acute attack is a priority. A. Energy field disturbance is not associated with Meniere's disease. B. Activity intolerance may be present due to the dizziness experienced by the patient. However, risk for injury would be the priority nursing diagnosis because it addresses patient safety. D. Risk for infection is not associated with Meniere's disease.

Which of the following manifestations would a nurse expect to identify when assessing the lower extremities of a patient who has chronic arterial insufficiency? Foot tenderness Peripheral edema Rubor with dependency Increased capillary refill

Rubor with dependency Explanation: Client Need: Physiological Integrity Rationale: C. When the feet of a patient with arterial insufficiency are placed in a dependent position, the skin becomes red. This is known as dependent rubor. A. The pain of arterial insufficiency is described as a cramping, aching pain that develops in the calf or thigh and occasionally the buttocks. It is not described as tenderness of the foot. B. Peripheral edema is not an indication of arterial insufficiency. Peripheral edema accompanies venous insufficiency. D. Reduced capillary refill and reduced arterial blood flow are signs of arterial insufficiency.

Which of the following laboratory values would a nurse closely monitor in a four-year-old child who has acute gastroenteritis? Serum amylase Serum potassium Total bilirubin Hemoglobin level

Serum potassium Explanation: Client Need: Physiological Integrity Rationale: B. The most serious consequences of acute diarrheal disease are dehydration, electrolyte disturbances and malnutrition. Therapeutic management of acute diarrheal disease (acute gastroenteritis) is directed at correcting the fluid and electrolyte imbalance and preventing or treating malnutrition. Since the child with acute diarrheal disease loses potassium, he/she should be evaluated for hypokalemia. A. Measurement of serum amylase activity is an important diagnosis test acute and chronic pancreatitis. C. This test measures the serum level of bilirubin, and degradation product of the pigmented heme portion of hemoglobin. It is used to detect hemolytic disorders and to confirm observed jaundice. D. This test measures the amount of hemoglobin (the main intracellular protein of erythrocytes) in the blood. It functions to carry oxygen to, and remove carbon from, the cells and acts as a buffer in the maintenance of acid-base balance.

Which of the following laboratory results would a nurse check before administering digoxin (Lanoxin)? Urinalysis Urine ketones Blood glucose Serum potassium

Serum potassium Explanation: Client Need: Physiological Integrity Rationale: D. The nurse should monitor the patient's electrolyte status closely, paying particular attention to sodium and potassium levels. Diuretics can deplete serum potassium and enhance the toxic effects of digitalis. A. B and C. Urinalysis, urine ketones and blood glucose are not significant to digitalis administration.

Which of the following symptoms would be MOST significant when assessing a woman who has pregnancy induced hypertension? Severe headache Urine output of 200 ml in the last four hours Dependent edema Patellar reflexes of +2

Severe headache Explanation: Client Need: Health Promotion and Maintenance Rationale: A. Preeclampsia is a pregnancy- specific condition in which hypertension develops after 20 weeks of gestation in a previously normotensive woman. It is leading cause of morbidity and mortality in the mother and infant. Severe headache is an indication of hypertension. B. Urine output equal to, or greater than, 30 ml/hr is normal adult output. Urine output less than 120 ml in four hours is a sign of oliguria, which is seen in severe preeclampsia. C. Dependent edema is a sign of mild preeclampsia D. Normal patellar reflexes are +2

A nurse in assessing a patient who had a tuberculin skin test(PPD) test 48 hours ago. Which of the following findings at the patient's injection site indicate a need for FURTHER investigation? Maculopapular rash of 5 mm Reddened circle of 10 mm Ecchymotic area of 15 mm Skin induration of 18 mm

Skin induration of 18 mm Explanation: Client Need: Health promotion and Maintenance Rationale: D. The nurse should read the test 48-72 hours after the rejection by palpating the area for the presence of indurations, not the erythematic, is measured at its widest A. A maculopapolar rash is not indicative of a positive tuberculin skin test. B. Erythema without induration is not considered significant. C. Ecchymosis should not occur as a result of a PPD test.

Which of the following actions should a nurse include in the care plan of a patient who has bulimia nervosa? Stay with the patient for one hour after meals Decrease environmental stimuli Weigh the patient twice a day Discourage verbalization about out-of-control eating

Stay with the patient for one hour after meals Explanation: Client Need: Psychosocial Integrity Rationale: A. Treatment protocols for a patient with bulimia include determining the conditions for bathroom privileges and the indications for close observation by staff. The patient should be observed by staff meals to make sure that purging does not occur. B, C and D. Decreasing environment stimuli, weighing the patient twice daily and discouraging verbalization about eating are not identified as treatment protocols for the patient with bulimia.

A patient who is admitted to a medical unit for treatment of congestive heart disease is tearful, forgetful and anxious. Which of the following symptoms would indicate that the patient is developing dementia? Sundown phenomenon Altered level of consciousness Sleep disturbance Decreased appetite

Sundown phenomenon Explanation: Client Need: Psychosocial Integrity Rationale: A. Sun downing occurs frequently in patients with dementia and is defined as increased agitation and confusion that occurs in late afternoon. B. Altered level of consciousness would indicate delirium. C. Sleep disturbance is not a symptom of dementia. D. Decreased appetite is not a symptom of dementia, although the patient may not be able to prepare his/her own meals.

A patient is brought to the emergency department after ingesting cocaine. During the patient assessment the nurse would expect to observe which of the following signs? Constricted pupils and lethargy Tachycardia and chest pain Nystagmus and paresthesias Ataxia and bradycardia

Tachycardia and chest pain Explanation: Client Need: Psychosocial Integrity Rationale: B. Tachycardia and chest pain are signs of cocaine use. A. Constricted pupils and lethargy are signs of opiate ingestion. C. Nystagmus and paresthesias are symptoms of PCP (Angel Dust) use. D. Tachycardia, rather than bradycardia, is a sign of cocaine use.

The most beneficial purpose of group therapy is to: control anxiety. teach social skills. deter deviant behavior. establish support systems.

Teach social skills Explanation: Client Need: Psychosocial Integrity Rationale: B. Group members can develop new socializing skills and can learn to correct maladaptive behavior through ongoing group interactions. A. Group therapy is one of several possible modalities used to treat anxiety disorders. It is, however, not the most beneficial purpose of group therapy. C. With the support of the group, the patient may resist deviant behavior. Of the choices given, the main purpose of group therapy is to teach social skills. D. The group may provide support for the patient during therapy. However, developing social skills within the group setting will allow the patient to establish support systems outside the group.

Which of the following patient outcomes would indicate that the manic phase of a bipolar disorder is subsiding? The patient participates in group activity without disruption. The patient has an increased ability to verbalize. The patient assumes leadership in social activities. The patient initiates multiple projects in art therapy.

The patient participates in group activity without disruption. Explanation: Client Need: Psychosocial Integrity Rationale: A. Signs of improved social interaction include non- disruptive participation in activities. B. The patient with mania usually has flight of ideas and rapid, pressured speck. Increased ability to verbalize is not necessarily a sign of improvement. C. The manic patient often tries to lead group activities. This would not be a sign of improvement. D. The ability to stay focused on a single task would indicate improvement in the manic patient.

Which of the following assessment findings would be MOST significant in documenting that surgical repair of an abdominal aortic aneurysm has been effective? Urine output of 30 ml/hr Presence of pretibial edema Clear sclera Presence of a carotid bruit

Urine output of 30 ml/hr Explanation: Client Need: Physiological Integrity Rationale: A. Manifestations of adequate tissue perform following repair of an abdominal aortic aneurysm is evidenced by a normal blood urea nitrogen, a urine output of 25-30 ml/hr, the presence of distal pulses and the absence of abdominal distention or postoperative ileus. B. Pre-tibial edema should not be present post-abdominal aortic aneurysm repair. C and D. Clear sclera and carotid bruit are not evaluative criteria for a patient post-aneurysm repair.

Which of the following techniques would a nurse use when interviewing a 94-year-old patient? Using a low-pitched voice Enunciating each word slowly Varying voice intonations Reinforcing the words with pictures

Using low- pitched voice Explanation: Client Need: Psychosocial Integrity Rationale: A. Elderly hearing loss typically involves diminished hearing of high-pitched sounds. B. Over-enunciating words does not make lip-reading easier and is demeaning to the patient. C. Varying voice intonation includes use of high-pitched tones, which of the patient will have difficulty hearing. D. The hearing loss seen in older adults not require reinforcement of sounds with pictures. This action also would be determining to the patient.

Which of the following snacks would be APPROPRIATE for a patient with hyperlipidemia? A slice of baked apple pie Cheddar cheese and crackers Vanilla yogurt Mixed nuts

Vanilla yogurt Explanation: Client Need: Physiological Integrity Rationale: C. Yogurt containing whole milk has 7 grams of fat. Low- fat yogurt would be an even better choice since patients on a low- fat diet usually may have only 30 grams fat. A. Apple pie contains 18 grams of fat per serving B. A cracker (1) contains 1 grams of fat per serving. Cheese (cheddar), 1 oz contains 9 grams of fat per serving. D. Mixed nuts contain 15 grams of fat per serving

Which of the following conditions would a nurse expect to assess in a patient who has Meniere's disease? Vertigo Diplopia Presbycusis Nystagmus

Vertigo Explanation: Client Need: Physiological Integrity Rationale: A. Meniere's is a chronic disease of the inner ear characterized by recurrent episodes of vertigo, progressive unilateral nerve deafness and tinnitus. The attacks of vertigo, the sense that the outer world is moving around oneself, are sudden and occur without warning. B. Diplopia, or double vision, is not characteristic of Meniere's disease C. Presbycusis, progressive, bilaterally symmetrical perceptive hearing loss occurring with age, is not characteristic of Meniere's disease. D. Nystagmus, involuntary rhythmic movements of the eyes, is seen in patients with neurologic disorders.

A patient who has schizophrenia, paranoid type says to a nurse,"The FBI is out to get me and you're one of them." Which of the following responses by the nurse would be MOST therapeutic? "You seem scared." "What makes you think the FBI is here?" "You should go to your room to rest." "How could an FBI agent get in here?"

You seem scared Explanation: Client Need: Psychosocial Integrity Rationale: A. It is not possible to logically discuss illogical ideas. The nurse should focus on the patient's feeling of anxiety. B. The nurse needs to avoid becoming incorporated into the signs and symptoms of the delusion. C. Paranoid schizophrenic patients are keenly sensitive to rejection. When these patients sense that others are avoiding them, they feel inadequate. D. The nurse should not attempt logical explanations of delusions, since the paranoid patient will only defend the delusions more vigorously.

The nurse is preparing a patient for an intravenous pyelogram (IVP). The patient should be made aware that when the dye is injected during the test, he/she may experience: a feeling of warmth. a metallic taste in the mouth. slight chest pain. shortness of breath.

a feeling of warmth. Explanation: Client Need: Physiological Integrity Rationale: A. The patient should be made aware that as the dye is injected, he/she may experience a feeling of warmth or heat and flushing of the face. B. The patient may experience a salty, rather than metallic, taste in the mouth when the dye is injected. C and D. Chest pain and shortness of breath should not be experience by the patient when the dye is injected.

When performing a physical assessment to a woman who is 20 weeks pregnant, a nurse would expect to palpate the uterine fundus: at the symphysis pubis. midway between the symphysis pubis and the umbilicus. at the umbilicus. midway between the umbilicus and the xiphoid.

at the umbilicus. Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Fundal height at 20 weeks will be at the level of the umbilicus. A. Prior to the first trimester, the fundal height is below the symphysis pubis. At 12 weeks, the fundal height is slightly above the symphysis. B. Fundal height for 16 weeks is between the symphysis pubis and the umbilicus. D. The fundal height is not always accurate after 36 weeks due to variations in fetal size, but it is generally hallway between the umbilicus and the xiphoid process.

A patient is receiving warfarin sodium (Coumadin) therapy. The nurse should be aware that adverse effects associated with Coumadin use include: blurred vision. diffuse red rash. black, tarry stools. ringing in the ears.

black, tarry stools. Explanation: Client Need: Physiological Integrity Rationale: C. Adverse effects of Coumadin therapy include bleeding, which would be noted by black, tarry stools. A and B. Blurred vision and diffuse red rash are not identified as side effects of Coumadin. D. Ringing in the ears is a side effect of acetylsalicylic acid (Aspirin) therapy.

A nurse would explain to the patient who is administered with prednisone (Deltasone) for the treatment of rheumatoid arthritis, that the desired effect is it: enhances the immune system. increases bone density. decreases inflammation. reduces peripheral edema.

decreases inflammation. Explanation: Client Need: Physiological Integrity Rationale: C. Rheumatoid arthritis (RA) is characterized by a chronic inflammation of the synovial membrane of the diarthroidal joints (synovial joints). Chronic inflammation can lead to joint damage and deformity. Medications used to decrease the inflammatory process in rheumatoid arthritis include systemic steroids. A. The nurse should be alert to possibility of Immunosuppression with the use of prednisone. B. A side effect of prednisone use is osteoporosis, a reduction in bone density C. A side effect of prednisone therapy is edema.

The caregiver of a patient who has Alzheimer's disease says to a nurse, "I just can't take it anymore. My mother is out of control." The nurse's BEST response would be to: remind the caregiver of the family's responsibilities. explore alternative care settings for the patient. refer the caregiver for psychological counseling. discuss medication options for the patient.

explore alternative care settings for the patient. Explanation: Client Need: Psychosocial Integrity Rationale: B. An estimated two-thirds of patients with Alzheimer's disease live at home with the family as primary care providers. Research has pointed to the extensive burden this place on the family. In the final stages of Alzheimer's many families are forced to choose nursing home placement because of the burden of care. A. Reminding the caregiver of family responsibilities would not encourage the caregiver to discuss his/her feelings and concerns. C. Counseling is not indicated at this point in time. The nurse should allow time for the family to express its concerns and provide information on community resources. D. Medications options may be discussed but intervention should focus on relief for the caregivers.

An eight-year-old boy who has hemophilia A falls in the classroom, injuring his ankle. He is brought to the school nurse clinic. Immediate actions for first-aid 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.

A parent tells a nurse, "My three-month-old infant recently passed several stools that resembles clumpy red jelly." Based on this information, the nurse should suspect that the infant has developed: celiac disease. biliary atresia. intussusception. ulcerative colitis.

intussusception. Explanation: Client Need: Physiological Integrity Rationale: C. Intussusception is an invagination or telescoping of one portion of the intestine onto another. Initially, the has an episode of acute, colicky abdominal pain and the abdomen becomes tender and distended. The classic currant jelly-like stool occurs later in the disease of intussusceptions. A. Symptoms of celiac disease most often appear between ages one and five years. Stools often are described as watery, pale diarrhea with an offensive odor. Vomiting, anemia and constipation also can occur. B. In biliary atresia stools become progressively more alcoholic or gray, indicating absence of bile pigment. D. The manifestations of ulcerative colitis may be mild, moderate or severe based on the extent of mucosal inflammation and systemic. Most patients exhibit bloody diarrhea or occult fecal blood.

To meet the safety needs of a patient who has received thrombolytic therapy, the nurse should: institute reverse isolation. maintain complete bedrest. limit intramuscular injections. supply a firm-bristled toothbrush.

limit intramuscular injections. Explanation: Client Need: Physiological Integrity Rationale: C. The major complication of thrombolytic therapy is bleeding. The patient is receiving an agent that causes clot dissolution, which may cause the patient to go into a lytic state. Minor bleeding is expected in this patient. The nurse must pay particular attention to signs to bleeding such as a drop in blood pressure and oozing of blood from intravenous, injection and catheter sites. A. The patient does not have to be on reverse isolation is indicated for the patient with an extremely low white blood cell count. B. Complete bedrest is not necessary for the patient on thrombolytic therapy C. A Soft- bristled tooth brush should be used to prevent irritation and bleeding of the gums.

A two-month-old infant is brought to the emergency department because of projectile vomiting. The emesis contains formula and is bile-stained. The nurse should assess the infant for signs of: viral gastroenteritis. gastroesophageal reflux. pyloric stenosis. Meckel's diverticulum.

pyloric stenosis. Explanation: Client Need: Physiological Integrity Rationale: C. Pyloric stenosis is the narrowing of the sphincter leading from the stomach to the small intestine. With pyloric stenosis vomiting usually starts during the second or third week of life, but may not appear until the infant is several months old. The vomiting usually becomes forceful and projectile. The emesis contains milk or formula and is not bile stained. Initially, the infant may be hungry and irritable; later, the infant becomes lethargic, dehydrated and malnourished. A. The child with acute diarrhea (gastroenteritis) has a sudden increase in frequency, and a change in consistency, of stools. It is often caused by an infectious agent in the gastrointestinal tract. B. Gastrosophageal reflux is defined as the passive transfer of gastric contents into the esophagus. Regurgitation or emesis, rather than projectile vomiting, is the most common clinical manifestation. Recurrent reflux of gastric contents can lead to esophagitis, which can cause bleeding from the esophageal mucosa. D. The most common clinical manifestations of Meckel's diverticulum include painless, rectal bleeding, abdominal pain and signs of intestinal obstruction.

A patient has a chest tube water-seal drainage that is connected to suction. A nurse observers that there is continuous bubbling in the suction control chamber. This finding most likely indicates that: there is a leak in the tubing. the system is functioning properly. the tube needs to be repositioned. additional suction should be applied to the system.

the system is functioning properly. Explanation: Client Need: Physiological Integrity Rationale: B. Chest tubes to water-seal drainage are used to promote lung re-expansion through the removal of air and fluid, and to prevent lung collapse from air entering the chest cavity. When suction is added to an underwater drainage system, gentle bubbling in the suction control chamber should be noted. A. When vigorous bubbling is noted, an air leak may be present. C. Continuous bubbling in the suction control chamber is normal and does not indicate that the tube needs to be repositioned. D. Increasing the suction source can cause more bubbling, but does not increase the effectiveness of suctioning because the outside air offsets air removal.