1.

Answer: D
Because the clients gag reflex is absent, elevating the head of the bed to 30 degrees helps
minimize the clients risk of aspiration. Checking the stools, performing ROM exercises, and
keeping the skin clean and dry are important, but preventing aspiration through positioning is the
priority.
2. Answer: A
Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the
bag or unclamping it is the only appropriate method for relieving gas.
3. Answer: A
because celiac disease destroys the absorbing surface of the intestine, fat isnt absorbed but is
passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclerae
result from elevated bilirubin levels. Clay-colored stools are seen with biliary disease when bile
flow is blocked. Celiac disease doesnt cause a widened pulse pressure.
4. Answer: D
Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which
changes blood vessel permeability and allows plasma to move into interstitial tissue, causing
edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium intake
doesnt affect the glomerular filtration rate. Potassium absorption is improved only by increasing
the glomerular filtration rate; it isnt affected by sodium intake.
5. Answer: D
The portion of the cerebrum that controls speech and hearing is the temporal lobe. Injury to the
frontal lobe causes personality changes, difficulty speaking, and disturbance in memory,
reasoning, and concentration. Injury to the parietal lobe causes sensory alterations and problems
with spatial relationships. Damage to the occipital lobe causes vision disturbances.
6. Answer: D
Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after
brain surgery. Cushings syndrome is excessive glucocorticoid secretion resulting in sodium and
water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and
polyphagia. Adrenal crisis is undersecretion of glucocorticoids resulting in profound
hypoglycemia, hypovolemia, and hypotension.
7.Answer: C
The client should report the presence of foulsmelling or cloudy urine. Unless contraindicated, the
client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-
like debris is normal because of residual stone products. Hematuria is common after lithotripsy.
8.Answer: A
A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and
deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid
volume than from decreased cardiac output because his blood pressure is normal. Although the
clients serum glucose is elevated, food isnt a priority because fluids and insulin should be
administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced Nutrition:
Less then body requirements isnt appropriate. A temperature of 100.6 F isnt life threatening,
eliminating ineffective thermoregulation as the top priority.
9. Answer: C
Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2
to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15
to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
10. Answer: A
CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate
cerebral perfusion to take place, the minimum goal is 70 mmHg. The MAP is derived using the
following formula:
MAP = ((diastolic blood pressure x 2) + systolic blood pressure) / 3
MAP = ((60 x2) + 90) / 3
MAP = 70 mmHg
To find the CPP, subtract the clients ICP from the MAP; in this case , 70 mmHg 18 mmHg =
52 mmHg.
11. Answer: B
Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. Nipple
retraction not eversionmay be a sign of cancer. A mobile mass that is soft and easily
delineated is most often a fluid-filled benigned cyst. Axillary lymph nodes may or may not be
palpable on initial detection of a cancerous mass.
12.Answer: D
An enterostomal nurse therapist is a registered nurse who has received advance education in an
accredited program to care for clients with stomas. The enterostomal nurse therapist can assist
with selection of an appropriate stoma site, teach about stoma care, and provide emotional
support.
13.Answer: A
Ottorrhea and rhinorrhea are classic signs of basilar skull fracture. Injury to the dura commonly
occurs with this fracture, resulting in cerebrospinal fluid (CSF) leaking through the ears and
nose. Any fluid suspected of being CSF should be checked for glucose or have a halo test done.
14. Answer: D
Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be
taught how to perform testicular self-examination before age 20, preferably when he enters his
teens.
15. Answer: B
Before weaning a client from mechanical ventilation, its most important to have a baseline ABG
levels. During the weaning process, ABG levels will be checked to assess how the client is
tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume
intake and output is always important when a client is being mechanically ventilated. Prior
attempts at weaning and ECG results are documented on the clients record, and the nurse can
refer to them before the weaning process begins.
16. Answer: B
According to the ACS guidelines, Women older than age 40 should perform breast
selfexamination monthly (not annually). The hormonal receptor assay is done on a known
breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.
17.Answer: C
Increased pressure within the portal veins causes them to bulge, leading to rupture and bleeding
into the lower esophagus. Bleeding associated with esophageal varices doesnt stem from
esophageal perforation, pulmonary hypertension, or peptic ulcers.
18. Answer: B
Complex intra-articular fractures are repaired with external fixators because they have a better
long-term outcome than those treated with casting. This is especially true in a young client. The
incidence of complications, such as pin tract infections and neuritis, is 20% to 60%. Clients must
be taught how to do pin care and assess for development of neurovascular complications.
19.Answer: C
In a client with chronic renal failure, unrestricted intake of sodium, protein, potassium, and fluids
may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as
amino acids and ammonia. Therefore, the client must limit his intake of sodium, meat (high in
Protein), bananas (high in potassium), and fluid because the kidneys cant secrete adequate urine.
20.Answer: D
The client isnt withdrawn or showing other signs of anxiety or depression. Therefore, the nurse
can probably safely approach her about talking with others who have had similar experiences,
either through Reach for Recovery or another formal support group. The nurse may educate the
clients spouse or partner to listen to concerns, but the nurse shouldnt tell the clients spouse
what to do. The client must consult with her physician and make her own decisions
about further treatment. The client needs to express her sadness, frustration, and fear. She cant
be expected to be cheerful at all times.
21. Answer: C
HCG is one of the tumor markers for testicular cancer. The HCG level wont identify the site of
an infection or evaluate prostatic function or testosterone level.
22.Answer: B
Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry
cough, and postural hypotension are adverse reactions to captopril, but the dont indicate that
therapy isnt effective.
23. Answer: A
Tenting of chest skin when pinched indicates decreased skin elasticity due to dehydration. Hand
veins fill slowly with dehydration, not rapidly. A pulse that isnt easily obliterated and neck vein
distention indicate fluid overload, not dehydration.
24. Answer: B
The client should be encouraged to increase his activity level. Maintaining an ideal weight;
following a low-cholesterol, low-sodium diet; and avoiding stress are all important factors in
decreasing the risk of atherosclerosis.
25. Answer: B
Because thrombocytopenia impairs blood clotting, the nurse should assess the client regularly for
signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should
avoid administering aspirin because it can increase the risk of bleeding. Frequent rest periods are
indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for
clients who have highly contagious or virulent infections that are spread by air or physical
contact.
26. Answer: B
SaO2 is the degree to which hemoglobin is saturated with oxygen. It doesnt indicate the clients
overall Hgb adequacy. Thus, an individual with a subnormal Hgb level could have normal SaO2
and still be short of breath. In this case, the nurse could assume that the client has a Hematologic
problem. Poor peripheral perfusion would cause subnormal SaO2. There isnt enough data to
assume that the clients problem is psychosomatic. If the problem were
left-sided heart failure, the client would exhibit pulmonary crackles.
27. Answer: A
Addisonian crisis results in Hyperkalemia; therefore, administering potassium chloride is
contraindicated. Because the client will be hyponatremic, normal saline solution is indicated.
Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex
hormones.
28. Answer: D
Leukemia is manifested by an abnormal overpopulation of immature leukocytes in the bone
marrow.
29. Answer: C
A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick,
allowing microorganisms to contaminate the field. The outside of containers, such as sterile
saline bottles, arent sterile. The containers should be opened before sterile gloves are put on and
the solution poured over the sterile dressings placed in a sterile basin. Wounds should be cleaned
from the most contaminated area to the least contaminated areafor example, from the center
outward. The outer inch of a sterile field shouldnt be considered sterile.
30.Answer: C
Caffeine is a stimulant, which can exacerbate palpitations and should be avoided by a client with
symptomatic mitral valve prolapse. High fluid intake helps maintain adequate preload and
cardiac output. Aerobic exercise helps in increase cardiac output and decrease heart rate. Protein-
rich foods arent restricted but high calorie foods are.
31. Answer: A
Excessive of aldosterone in the adrenal cortex is responsible for the clients hypertension. This
hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of
potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel
metabolism. The adrenal medulla secretes the cathecolaminesepinephrine and norepinephrine.
The parathyroids secrete parathyroid hormone.
32. Answer: D
A heart valve prosthesis, such as a mitral valve replacement, is a major risk factor for infective
endocarditis. Other risk factors include a history of heart disease (especially mitral valve
prolapse), chronic debilitating disease, IV drug abuse, and immunosuppression. Although
diabetes mellitus may predispose a person to cardiovascular disease, it isnt a major risk factor
for infective endocarditis, nor is an appendectomy or pernicious anemia.
33. Answer: A
The client has signs and symptoms of diabetes insipidus, probably caused by the failure of her
renal tubules to respond to antidiuretic hormone as a consequence of pyelonephritis. The
hypernatremia is secondary to her water loss. Imbalanced nutrition related to hypermetabolic
state or catabolic effect of insulin deficiency is an inappropriate nursing diagnosis for the client.
34. Answer: C
When performing a nutritional assessment, one of the first things the nurse should do is to assess
what the client typically eats. The client shouldnt be permitted to eat as desired. Weighing the
client daily, placing her on I & O status, and drawing blood to determine electrolyte level arent
part of a nutritional assessment.
35. Ans. C
Regular follow-up care for the client with Graves disease is critical because most cases
eventually result in hypothyroidism. Annual thyroid-stimulating hormone tests and the clients
ability to recognize signs and symptoms of thyroid dysfunction will help detect thyroid
abnormalities early. Intake and output is important for clients with fluid and electrolyte
imbalances but not thyroid disorders. DDAVP is used to treat diabetes insipidus. While exercise
to improve cardiovascular fitness is important, for this client the importance of regular follow-up
is most critical.
36. Answer: D
Anxiety related to the threat of death is an appropriate nursing diagnosis because the clients
anxiety can adversely affect hear rate and rhythm by stimulating the autonomic nervous system.
Also, because the client required resuscitation, the threat of death is a real and immediate
concern. Unless anxiety is dealt with first, the clients emotional state will impede learning.
Client teaching should be limited to clear concise explanations that reduce anxiety and promote
cooperation. An anxious client has difficulty learning, so the deficient knowledge would
continue despite attempts teaching. Impaired physical mobility and social isolation are
necessitated by the clients critical condition; therefore, they arent considered problems
warranting nursing diagnoses.
37. Answer: A
Because tuberculosis is transmitted by droplet nuclei from the respiratory tract, the nurse should
put on a mask when entering the clients room. Having the client wear a mask at all the times
would hinder sputum expectoration and make the mask moist from respirations. If no contact
with the clients blood or body fluids is anticipated, the nurse need not wear a gown or gloves
when providing direct care. A client with tuberculosis should be in a room with laminar air flow,
and the door should be closed at all times.
38. Answer: C
The nurse can gently irrigate the tube but must take care not to reposition it. Repositioning can
cause bleeding. Suction should be applied continuously, not every hour. The NG tube shouldnt
be clamped postoperatively because secretions and gas will accumulate, stressing the suture line.
39. Answer: A
Regardless of the clients medical history, rapid fluid resuscitation is critical for maintaining
cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement.
A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to
follow over the next 24 hours. Various fluids can be used, depending on the degree of
hypovolemia. Commonly prescribed fluids include dextran (in case of hypovolemic shock),
isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline
solution.
40.Answer: D
Glipizide may cause adverse skin reactions, such as pruritus, and photosensitivity. It doesnt
cause headache, constipation, or hypotension.
41. Answer: B
When clients are on mechanical ventilation, the artificial airway impairs the gag and cough
reflexes that help keep organisms out of the lower respiratory tract. The artificial airway also
prevents the upper respiratory system from humidifying and heating air to enhance mucociliary
clearance. Manipulations of the artificial airway sometimes allow secretions into the lower
airways. Whit standard procedures the other choices wouldnt be at high risk.
42. Answer: C
In chronic bronchitis, the diaphragmatic is flat and weak. Diaphragmatic breathing helps to
strengthen the diaphragm and maximizes ventilation. Exhalation should longer than inhalation to
prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through
pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping.
Diaphragmatic breathingnot chest breathingincreases lung expansion.
43. Answer: A
Verbalizing the observed behavior is a therapeutic communication technique in which the nurse
acknowledges what the client is feeling. Offering to listen to the client express her anger can help
the nurse and the client understand its cause and begin to deal with it. Although stress can
exacerbate the symptoms of SLE, telling the client to calm down doesnt acknowledge her
feelings. Offering to get the nursing supervisor also doesnt acknowledge the clients feelings.
Ignoring the clients feelings suggest that the nurse has no interest in what the client has said.
44. Answer: A
Daily walks relieve symptoms of intermittent claudication, although the exact mechanism is
unclear. Anaerobic exercise may exacerbate these symptoms. Clients with chronic arterial
occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should
limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known
cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration,
so this client should eat foods that raise HDL levels.
45. Answer: A
Gastric decompression is typically low pressure and intermittent. High pressure and continuous
gastric suctioning predisposes the gastric mucosa to injury and ulceration.
46. Answer: A
In osteoarthritis, stiffness is common in large, weight bearing joints such as the hips. This joint
stiffness alters functional ability and range of motion, placing the client at risk for falling and
injury. Therefore, client safety is in jeopardy. Osteoporosis doesnt affect urinary elimination,
breathing, or nutrition.
47. Answer: A
PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vit D to its
active form: 1 , 25 dihydroxy vitamin D. PTH doesnt have a role in the metabolism of Vit E.
48. Answer: C
The presence of unsecured area rugs poses a hazard in all homes, particularly in one with a
resident at high risk for falls.
49. Answer: B
Autonomy ascribes the right of the individual to make his own decisions. In this case, the client
is capable of making his own decision and the nurse should support his autonomy. Beneficence
and justice arent the principles that directly relate to the situation. Advocacy is the nurses role
in supporting the principle of autonomy.
50. Answer: D
Because respirations are depressed in myxedema coma, maintaining a patent airway is the most
critical nursing intervention. Ventilatory support is usually needed. Thyroid replacement will be
administered IV. Although myxedema coma is associated with severe hypothermia, a warming
blanket shouldnt be used because it may cause vasodilation and shock. Gradual warming
blankets would be appropriate. Intake and output are very important but arent critical
interventions at this time.
51. Answer: A
Glipizide begins to act in 15 to 30 minutes. The other options are incorrect.
52.Answer: A
Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration
may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial
oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction
secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels,
easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive
oxygen administration. In a client with COPD, high oxygen concentrations decrease the
ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations dont
cause metabolic acidosis.
53. Answer: C
Continuous subcutaneous insulin regimen uses a basal rate and boluses of short-acting insulin.
Multiple daily injection therapy uses a combination of short-acting and intermediate or long-
acting insulins.
54. Answer: B
Holding a cane on the uninvolved side distributes weight away from the involved side. Holding
the cane close to the body prevents leaning. Use of a cane wont maintain stride length or prevent
edema.
55. Answer: D
High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With leftsided
heart failure, pulmonary edema can develop causing pulmonary crackles. In leftsided heart
failure, hypotension may result and urine output will decline. Dry mucous membranes arent
directly associated with elevated pulmonary artery wedge pressures.
56.Answer: B
Its mandatory in most settings to have a physicians order before restraining a client. A client
should never be left alone while the nurse summons assistance. All staff members require annual
instruction on the use of restraints, and the nurse should be familiar with the facilitys policy.
57. Answer: A
The client who has undergone a thyroidectomy is t risk for developing hypocalcemia from
inadvertent removal or damage to the parathyroid gland. The client with hypocalcemia will
exhibit a positive Chvosteks sign (facial muscle contraction when the facial nerve in front of the
ear is tapped) and a positive Trousseaus sign (carpal spasm when a blood pressure cuff is
inflated for few minutes). These signs arent present with hypercalcemia, hypokalemia, or
Hyperkalemia.
58. Answer: C
Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract,
the relative acidity of the upper GI tract predominates leading to metabolic acidosis. Diarrhea
doesnt lead to respiratory acid-base imbalances, such as respiratory acidosis and respiratory
alkalosis. Loss of acid, which occurs with severe vomiting, may lead to metabolic alkalosis.
59. Answer: B
The head of the bed must be elevated while the client is eating. The client should be placed in a
recumbent positionnot a supine position when lying down to reduce the risk of aspiration.
Encourage the client to wear properly fitted dentures to enhance his chewing ability. Thickened
liquids, not thin liquids, decrease aspiration risk.
60.Answer: A
Endotracheal suctioning secretions as well as gases from the airway and lowers the arterial
oxygen saturation (SaO2) level. Coughing and incentive spirometry improve oxygenation and
should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a
cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldnt be
affected.
61. Answer: D
With a superficial partial thickness burn such as a solar burn (sunburn), the nurses main concern
is pain management. Fluid resuscitation and infection become concerns if the burn extends to the
dermal and subcutaneous skin layers. Body image disturbance is a concern that has a lower
priority than pain management.
62. Answer: D
Crackles result from air moving through airways that contain fluid. Heard during inspiration and
expiration, crackles are discrete sounds that vary in pitch and intensity. Theyre classified as fine,
medium, or coarse. Pleural friction rubs have a distinctive grating sound. As the name indicates,
these breath sounds result when inflamed pleurae rub together. Continuous, highpitched, musical
squeaks, called wheezes, result when air moves rapidly through airways narrowed by asthma or
infection or when an airway is partially obstructed by a tumor or foreign body. Wheezes, like
gurgles, occur on expiration and sometimes on inspiration. Loud, coarse, low-pitched sounds
resembling snoring are called gurgles. These sounds develop when thick secretions partially
obstruct airflow through the large upper airways.
63. Ans. D
Individuals who are tuberculin skin test converters should begin a 6-month regimen of an
antitubercular drug such as INH, and they should never have another skin test. After an
individual has a positive tuberculin skin test, subsequent skin tests will cause severe skin
reactions but wont provide new information about the clients TB status. The client doesnt have
active TB, so cant transmit, or spread, the bacteria. Therefore, she shouldnt be quarantined or
asked for information about recent contacts.
64. Answer: C
Disturbed body image is a negative perception of the self that makes healthful functioning more
difficult. The defining characteristics for this nursing diagnosis include undergoing a change in
body structure or function, hiding or overexposing a body part, not looking at a body part, and
responding verbally or nonverbally to the actual or perceived change in structure or function.
This client may have any of the other diagnoses, but the signs and symptoms described in he case
most closely match the defining characteristics for disturbed body image.
65. Answer: B
Because the pregnant uterus exerts a lot of pressure on the urinary bladder, the bladder repair
may need to be repeated. These clients dont necessarily have to have a cesarean delivery if they
become pregnant, and this procedure doesnt render them sterile. This procedure is completed in
one surgery.
66. Answer: A
Eccrine glands are associated with body temperature regulation. Sebaceous glands lubricate the
skin and hairs, and apocrine glands are involved in bacteria decomposition. Endocrine glands
secrete hormones responsible for the regulation of body processes, such as metabolism and
glucose regulation.
67.Answer: B
The light-colored spots attached to the hair shafts are nits, which are the eggs of head lice. They
cant be brushed off the hair shaft like dandruff. Scabies is a contagious dermatitis caused by the
itch mite, Sacoptes scabiei, which lives just beneath the skin. Tinea capitis, or ringworm, causes
patchy hair loss and circular lesions with healing centers. Impetigo is an infection caused by
Staphylococcus or Sterptococcus, manifested by vesicles or pustules that form a thick, honey-
colored crust.
68. Answer: C
Severe pressure-like pain out of proportion to visible signs distinguishes necrotizing fasciitis
from cellulites. Erythema, leukocytosis, and swelling are present in both cellulites and
necrotizing fasciitis.
69. Answer: A
Contact dermatitis is caused by exposure to a physical or chemical allergen, such as cleaning
products, skin care products, and latex gloves. Initial symptoms of itching, erythema, and raised
papules occur at the site of the exposure and can begin within 1 hour of exposure. Allergic
reactions tend to be red and not scaly or flaky. Weeping, crusting lesions are also uncommon
unless the reaction is quite severe or has been present for a long time. Excoriation is more
common in skin disorders associated with a moist environment.
70.Answer: D
Hoarseness indicate injury to the respiratory system and could indicate the need for immediate
intubation. Thirst following burns is expected because of the massive fluid shifts and resultant
loss leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The
clients output is adequate.
71. Answer: C
Third-degree burn may appear white, red, or black and are dry and leathery with no blisters.
There may be little pain because nerve endings have been destroyed. First-degree burns are
superficial and involve the epidermis only. There is local pain and redness but no blistering.
Second-degree burn appear red and moist with blister formation and are painful. Fourth-degree
burns involve underlying muscle and bone tissue.
72. Answer: C
A universal concern I the care of donor sites for burn care is to keep the site away from sources
of pressure. Ventilation of the site and keeping the site fully covered are practices in some
institutions but arent hallmarks of donor site care. Placing the site in a position of dependence
isnt a justified aspect of donor site care.
73. Answer: A
Anyone with psoriasis vulgaris who reports joint pain should be evaluated for psoriaic arthritis.
Approximately 15% to 20% of individuals with psoriasis will also develop psoriatic arthritis,
which can be painful and cause deformity. It would be incorrect to assume that his pain is caused
by early rheumatoid arthritis or his vocation without asking more questions or performing
diagnostic studies. Carpal tunnel syndrome causes sensory and motor changes in the fingers
rather than localized pain in the joints.
74. Answer: B
To avoid burning and sloughing, the client must protect the graft from sunlight. The other three
interventions are all helpful to the client and his recovery but are less important.
75.Answer: C
Because the itching and rash are localized, an environmental cause in the workplace should be
suspected. With the advent of universal precautions, many nurses are experiencing allergies to
latex gloves. Allergies to medications, laundry detergents, or bath soaps or a dermatologic
reaction to stress usually elicit a more generalized or widespread rash.
76.Answer: A
Hives and urticaria are two names for the same skin lesion. Toxin is a poison. A tubercle is a tiny
round nodule produced by the tuberculosis bacillus. A virus is an infectious parasite.
77. Answer: A
A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and
scars also are secondary lesions in skin disorders, they dont accompany psoriasis.
78. Answer: C
A turning schedule with a signing sheet will help ensure that the client gets turned and thus, help
prevent pressure ulcers. Turning should occur every 1-2 hoursnot every 8 hoursfor clients
who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but
should avoid vigorous massage, which could damage capillaries. When moving the client, the
nurse should lift rather than slide the client to void shearing.
79.Answer: A
To prevent disruption of the artificial skins adherence to the wound bed, the client should
restrict range of motion of the involved limb. Protein intake and fluid intake are important for
healing and regeneration and shouldnt be restricted. Going outdoors is acceptable as long as the
left arm is protected from direct sunlight.
80.Answer: C
According to the Rule of Nines, the posterior and anterior trunk, and legs each make up 18% of
the total body surface. The head, neck, and arms each make up 9% of total body durface, and the
perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm
(9%), totaling 27%.
81.Answer: A
A wet-to-dry saline dressing should always keep the wound moist. Tight packing or dry packing
can cause tissue damage and pain. A dry gauze not a plastic-sheet-type dressingshould
cover the wet dressing.
82. Answer: A
When someone in a group of persons sharing a home contracts scabies, each individual in the
same home needs prompt treatment whether hes symptomatic or not. Towels and linens should
be washed in hot water. Scabies can be transmitted from one person to another before symptoms
develop
83.Answer: A
In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure
that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they
will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine
output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is
more than adequate. Weight gain from fluid resuscitation isnt a goal. In fact, a 4 lb weight gain
in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may
demonstrate secondary benefits of fluid resuscitation but arent primary indicators.
84. Answer: B
The ESR test is performed to detect inflammatory processes in the body. Its a nonspecific test,
so the health care professional must view results in conjunction with physical signs and
symptoms. Platelet count, electrolytes, BUN, and creatinine levels arent usually affected by the
inflammatory process.
85.Answer: B
In Parkinsons crisis, dopamine-related symptoms are severely exacerbated, virtually
immobilizing the client. A client who is confined to bed during a crisis is at risk for aspiration
and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of
these concerns, ineffective airway clearance is the priority diagnosis for this client. Although
imbalanced nutrition:less than body requirements, impaired urinary elimination and risk for
injury also are appropriate diagnoses for this client, they arent immediately lifethreatening and
thus are less urgent.
86.Answer: A
As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or
more, the frequency of catheterization should be increased. Indwelling catheterization is less
preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid
restrictions arent indicated for this case; the problem isnt overhydration, rather its urine
retention. A condom catheter doesnt help empty the bladder of a client with urine retention.
87.Answer: D
The normal pressure is 70 to 200 mm H2O are considered abnormal. The presence of glucose is
an expected finding in CSF, and RBCs typically occur in the first specimen tube from the trauma
caused by the procedure.
88. Answer: A
The nurse should instill the eyedrop into the conjunctival sac where absorption can best take
place. The pupil permits light to enter the eye. The sclera maintains the eyes shape and size. The
vitreous humor maintains the retinas placement and the shape of the eye.
89.Answer: C
According to family theory, any change in a family member, such as illness, produces role
changes in all family members and affects the entire family, even if the client eventually recovers
completely.
90.Answer: B
To help prevent airway obstruction and reduce the risk of aspiration, the nurse should position a
client with hemiparesis on the affected side. Although performing ROM exercises, providing
pillows for support, and applying antiembolism stockings can be appropriate for a client with
CVA, the first concern is to maintain a patent airway.
91. Answer: C
TIA may be a warning that the client will experience a CVA, or stroke, in the near future. TIA
aymptoms last no longer than 24 hours and clients usually have complete recovery after TIA.
The most common symptom of TIA is sudden, painless loss of vision lasting up to 24 hours.
92. Answer: C
Bending to pick up something from the floor would increase intraocular pressure, as would
bending to tie his shoes. The client needs to wear eye protection to bed to prevent accidental
injury during sleep.
93. Answer: B
Concussions are considered minor with no structural signs of injury. A contusion is bruising of
the brain tissue with small hemorrhages in the tissue. Coup and contrecoup are type of injuries in
which the damaged area on the brain forms directly below that site of impact (coup) or at the
site opposite the injury (contrecoup) due to movement of the brain within the skull.
94. Answer: B
The third cranial nerve (oculomotor) is responsible for pupil constriction. When there is damage
to the nerve, the pupils remain dilated and dont respond to light. Glaucoma, lumbar spine injury,
and Bells palsy wont affect pupil constriction.
95.Answer: C
When the mechanical stressors of weight bearing are absent, diffuse osteoporosis can occur.
Therefore, if the client does weight-bearing exercises, disuse complications can be prevented.
Maintaining protein and vitamins levels is important, but neither will prevent osteoporosis. ROM
exercises will help prevent muscle atrophy and contractures.
96. Answer: B
This client requires droplet precautions because the organism can be transmitted through
airborne droplets when the client coughs, sneezes, or doesnt cover his mouth. Airborne
precautions would be instituted for a client infected with tuberculosis. Standard precautions
would be instituted for a client when contact with body substances is likely. Contact precautions
would be instituted for a client infected with an organism that is transmitted through skin-to-skin
contact.
97. Answer: D
With a brain injury such as an epidural hematoma (a diagnosis that is most likely based on this
clients symptoms), the initial sign of increasing ICP is a change in the level of consciousness.
As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing
patterns, and posturing will
occur.
98.Answer: A
In the scenario, airway and breathing are established so the nurses next priority should be
circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding;
therefore, the nurse should assess the site. Neurologic assessment is a secondary concern to
airway, breathing and circulation. The nurse doesnt have enough data to warrant putting the
client in Trendelenburgs position.
99. Answer: C
Establishing and maintaining a routine is essential to decreasing extraneous stimuli. The client
should participate in daily care as much as possible. Attempting to reason with such clients isnt
successful, because they cant participate in abstract thinking.
100. Answer: B
For clients with increased intracranial pressure (ICP), the head of the bed is elevated to promote
venous outflow. Trendelenburgs position is contraindicated because it can raise ICP. Flat or
neutral positioning is indicated when elevating the head of the bed would increase the risk of
neck injury or airway obstruction. Sidelying isnt specifically a therapeutic treatment for
increased ICP.