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A 30-year-old client has just been admitted to the psychiatric unit with the diagnosis of manic episode

. The client manifests an excess of energy, and it is difficult for her to sit still. The most useful activity for this client that the nurse might suggest would be to   A) Empty wastebaskets on the unit. B) Engage in occupational therapy and group exercises. C) Play volleyball outside. D) Deliver linen to the rooms.

Answer: D D) This activity would channel her energy, but not increase the external stimuli as the group activities would do. Competitive activities are nontherapeutic because they are so stimulating.

The best rationale for the nurse introducing her- or himself to a blind client and telling him exactly what will be administered is to   A) Illustrate the principle of open communication. B) Encourage and utilize clear communication. C) Follow steps for beginning a nurse-client relationship. D) Decrease the client's anxiety and fear of the unknown.  

.Answer: D D) Blind clients become anxious when they hear someone enter the room without talking.

The priority rationale for checking a client's platelet count following heparin therapy is to   A) Check the client's level of anticoagulation. D) Monitor the client's heparin absorption.   . B) Detect heparin-induced thrombocytopenia C) Determine if the client requires an anticoagulant alternative.

the client has this condition and it contraindicates the continued use of heparin.Answer: B B) Up to 10 percent of clients receiving heparin therapy develop heparininduced thrombocytopenia. He may then require an alternate medication. If the platelet count drops below 10. .000/cu mm or 40 percent below the pretreatment level.

The nurse will be able to recognize that this state is resolving when   A) His legs move.A young client is in spinal shock and will be for a few weeks after being struck by a car. . B) Hyperreflexia occurs. D) He regains sensations but not motion in his upper extremities. C) His vital signs stabilize.

.Answer: B B) Reflex activity begins to return below the level of injury because of automatic activity inherent in nervous tissue.

which clinical manifestations could indicate that a complication has occurred and the physician should be notified?   A) Increased pulse and pallor. B) Increased temperature and blood pressure. . D) Serosanguineous drainage from the puncture site. C) Hypotension and hypothermia.Immediately following a thoracentesis.

Answer: A A) Increased pulse and pallor are symptoms associated with shock. A compromised venous return may occur if there is a mediastinal shift as a result of excessive fluid removal. Usually no more than one liter of fluid is removed at one time to prevent this from occurring. .

B) Limit suction time to 30 seconds.The nurse has orders to suction a 50-yearold client. D) Suction no more than three consecutive times before administering oxygen. One nursing action necessary to prevent hypoxia during the procedure is to   A) Ensure that the catheter is no more than three-quarters the diameter of the nares. C) Hyperinflate the lungs with 100 percent oxygen prior to and following suctioning. at intervals of three minutes.   .

Answer: D D) Preoxygenation of the lungs prevents hypoxia during the suctioning procedure in a client requiring frequent treatments. (B) suctioning should be limited to 5-10 seconds at one time. . (A) The catheter should be one-half the diameter of the nares. and (D) should be to allow the client to breathe normally or administer oxygen between periods of suctioning.

percussion sounds. is admitted to the hospital for a possible low intestinal obstruction. R 18. C) Absence of bowel sounds. His preoperative work-up indicates vital signs of BP 100/70. high-pitched sounds.4 degrees F. D) Tympanic. . age 60.A client. and temperature of 96. the nurse would expect to find   A) Gurgling bowel sounds. Listening to bowel sounds. P 88. B) Hyperactive.

Answer: B B) The nurse will note high-pitched sounds with an obstruction. Gastric distention will have tympanic sounds. Paralytic ileus has no bowel sounds or gurgling. .

. D) Prepare for delivery of the placenta. B) Wrap the baby tightly to keep it warm. C) Place the baby on the mother's abdomen to maintain warmth.The first nursing action immediately after a precipitous birth in the emergency room is to   A) Remove any mucous from the baby's mouth to clear the airway.

This action facilitates contraction of the uterus and provides warmth for the baby. . place the infant head-down on his mother's abdomen. After delivery and clearing the infant's airway. Keeping the baby warm is also a very important nursing intervention.Answer: A A) The first priority is to determine that the infant's airway is clear. but not the first action to be done.

D) A child with a fever and upper respiratory disorder. While working in the hospital. is in her first trimester of pregnancy. the nurse knows that her friend should avoid   A) A client who has just been diagnosed with lupus erythematosus. C) Any client with an infection. who is also a nurse.   .An RN's friend. B) A 3-month-old infant with a generalized rash.

may result in a child with congenital malformations of the heart. eye and ear.Answer: B B) German measles or rubella. if contracted in the first trimester of pregnancy. as well as mental retardation. .

If this test is "reactive. showing an increased fetal heart rate (FHR) with fetal movement. B) The test was normal. D) Ultrasound is indicated to determine .A common test used to determine fetal status in the presence of pre-eclampsia is the Nonstress Test (NST). showing no change in FHR with fetal movement. C) The test was normal. indicating a need for an immediate Oxytocin Challenge Test (OCT)." the nurse knows that it means   A) The test was abnormal.

. Increased FHR with movement indicates normal reaction and adequate CNS integration.Answer: C C) Reactive = good outcome.

.The nurse is assigned a client who has just had a nasogastric tube inserted postoperatively. the nurse will check for   A) Infection. During the evaluation of his status. C) Electrolyte imbalance. D) Gastric distention. B) Ulcerative colitis.

Answer: C C) Nasogastric intubation can lead to the complication of electrolyte imbalance because of removing the gastric contents by suctioning. can lead to serious electrolyte imbalance. if not replaced via IV fluids. Large amounts of sodium and potassium are lost through the suctioning and. .

. The nurse will recommend to the client that   A) He begin on a drug protocol. C) He take the Tine test. B) The Mantoux test be repeated. The results are 6 mm induration.A client who has been near a family member with suspected tuberculosis has the Mantoux test. D) He do nothing because it is not 10 mm induration.

a repeat test should be done. . The Tine test is not recommended for diagnosis and. a drug protocol will be administered. When a definitive diagnosis of TB is made. if positive.Answer: B B) If the reaction (area of induration) is between 5 and 9 mm. If the induration is 10 mm or more. it indicates that the client has had contact with the tubercle bacillus. the Mantoux will be done.

The most important measure to include in the nursing management for a child with cystic fibrosis would be to   A) Promote optimal nutrition with a highprotein. especially fruit juices. C) Administer pancreatic enzymes before each meal. B) Administer only water-soluble vitamins. D) Encourage lots of fluids. low-fat diet.   .

Answer: C C) Pancreatic enzymes should be administered before each meal in order to facilitate digestive processes in the child with cystic fibrosis. but without the pancreatic enzymes the nutrients will not be assimilated. The diet is important. .

A male client is being discharged from the hospital following a short hospitalization for angina. He will be sent home on the drug propranolol hydrochloride (Inderal)." C) "I will need to take additional potassium supplements." ." D) "I will need to have laboratory tests done every month." B) "I will monitor my blood pressure before each dose of the drug. Which of the following statements would indicate to the nurse that he understands the actions of the drug?   A) "I will not discontinue the drug suddenly.

Answer: A A) Discontinuing the drug suddenly may result in an exacerbation of the angina and myocardial infarction. Laboratory tests are not drawn routinely and potassium supplements are not necessary with this drug. .

Monitoring his EKG. . C) Ventricular arrhythmias. the nurse will observe for   A) Complete heart block. B) Peaked T waves. D) Flattened T waves.A client has the diagnosis of acute renal failure. The nurse assesses him for hyperkalemia.

Answer: B B) When the serum potassium exceeds 5. Enhanced automaticity does not occur. T waves become tall. nor does heart block as a result of hyperkalemia.5 mEq/l. . narrow and pointed.

. is legally responsible for reporting child abuse. not the nurse. the legal responsibility of the staff who evaluated the case is that   A) The nurse is legally responsible for reporting a suspected child abuse. C) The doctor.If it is suspected that a child is abused. B) Both the doctor and the nurse are legally responsible for reporting child abuse. D) Neither the doctor nor the nurse is legally responsible for reporting child abuse.

Answer: B B) Both the nurse and doctor, independently, are legally responsible to report a suspected battered child to the proper authorities.

A 42-year-old client is admitted with suspected cholelithiasis. Making an assessment of the client, the nurse should be alert to her complaints of   A) Fatty food intolerance several hours after eating. B) Chronic pain in her lower right abdomen. C) Chronic pain in her lower left abdomen. D) Fatty food intolerance while eating.

Answer: A A) Pain is probably due to contraction of the gallbladder. The gallbladder empties when fat is present in the stomach and symptoms usually occur several hours after eating. Pain would likely be present in the region of the gallbladder.

C) Vomiting. . D) Decreased food intake. The nurse knows that this condition occurs in pancreatitis due to   A) Elevated amylase.A client with acute interstitial pancreatitis has laboratory values that show mild hypocalcemia. B) Poorly digested fats.

. Because calcium ions are bound to the fats. hypocalcemia can occur.Answer: B B) Fats are incompletely metabolized in pancreatitis.

D) Was well prepared by his parents for the separation and hospitalization.   . During painful hospital procedures. C) Has given up fighting and has become despondent and hopeless. the nurse would interpret this behavior as evidence that he   A) Does not feel well. Based on knowledge of growth and development. the nurse observes that the child becomes very quiet and never cries.A 3-year-old's parents are unable to "room in" because of other responsibilities at home. B) Has been taught not to misbehave in front of strangers.

Answer: C C) A toddler who passively accepts aggressive. painful intrusions into his or her life has usually given up any sense of hope and is suffering from separation anxiety. . He is depressed and requires specialized care from the staff and parents.

A client's demand pacemaker is programmed for a ventricular rate of 72. C) Report this finding immediately. D) Do nothing more at this time. The nursing action is to   A) Obtain a cardiogram. it is 84 and regular.   . When the nurse takes the client's apical pulse. B) Place the client on bedrest.

Answer: D D) A demand pacemaker stimulates cardiac contraction when the heart rate falls below the preset rate. . no action is called for at this time. therefore. A regular rate that is above the demand rate and below 100 indicates that the client's heart is beating independently at a normal sinus rate.

. B) Tell the nurse that she had always learned to announce herself when entering the room of a blind person. The appropriate intervention is to   A) Do nothing.The nurse observes another nurse enter the room of a blind client without announcing herself. D) Inform the head nurse so that he can intervene. C) Tell the client she is sorry the other nurse may have frightened her. as there is no intervention required.

explaining how she herself learned to approach a blind client is a way of teaching the other nurse a new approach.Answer: B B) Because the nurse's behavior is not therapeutic and may cause the client to be frightened. .

The critical nursing assessment immediately following the test is to assess for   A) Vital signs to compare with baseline signs.A male client has just returned from a bronchoscopy procedure to diagnose possible bronchogenic carcinoma. C) The client's ability to deep breathe and cough. B) The client's face and neck for edema. . D) Signs of dyspnea or wheezing.

Vital signs are always important to monitor. not just edema. but at this time the most crucial assessment is to monitor for respiratory problems. His face and neck should be assessed for subcutaneous crepitus. Clients are instructed to refrain from coughing which could result in hemorrhaging. .Answer: D D) Dyspnea and wheezing are signs of laryngeal edema or bronchospasm which can result in respiratory distress and must be reported to the physician immediately.

because it provides the most rapid insulin absorption.In teaching a newly diagnosed diabetic client about insulin self-injection. C) Abdomen. . the nurse teaches that the injection site currently believed to be the best. B) Thighs. is the   A) Arms. D) Buttocks.

rather than among the other available anatomic sites. therefore. The current thinking..e. arms. is that insulin injections should be rotated among sites on the abdomen alone (with the exception of 1 inch around the umbilicus).Answer: C C) Studies have shown that insulin is most rapidly and consistently absorbed from the subcutaneous tissue of the abdomen. . thighs and buttocks. i.

B) Twitching. high-pitched cry. .As part of a newborn assessment. no cry. C) Stuporlike behavior. D) Weak. soft cry. respiratory distress. shrill or intermittent cry. the nurse knows that signs of hypoglycemia in the infant include   A) Hyperactivity.

Answer: B B) Infants with signs and symptoms of hypoglycemia usually have a shrill or intermittent cry and may have hypertonicity. . Answer (A) refers to an infant born to a drug-addicted mother.

C) Monitoring an IV infusion. D) When suctioning clients.In which situation would gloves not be necessary when caring for an AIDS client?   A) When in contact with urine. . B) Changing an ostomy pouch.

Starting an IV would require gloves. a closed system.Answer: C C) The first three situations could result in transmission of the HIV virus. would not. . but monitoring an infusion.

bradycardia. vomiting.A 39-year-old client has been admitted to the hospital with clinical manifestations indicating acute renal failure. nausea. dyspnea. A precipitating factor seems to be a viral infection of the upper respiratory tract. the nurse would expect to observe   A) Anuria. Considering the diagnosis while completing a physical assessment. neck vein distention. B) Urine output of 400 mL/day. hypokalemia. tachypnea. D) Hypomagnesemia. C) Urine specific gravity of 1. decreased creatinine levels.010.   . weakness.

Resultant blood samples will indicate higher levels of creatinine. When the end products of metabolism cannot be excreted in sufficient amounts. the intravascular compartment becomes overloaded with fluids causing tachycardia and neck vein distention. they will accumulate in the body. not lower levels. .Answer: B B) These signs are indicative of fluid overload due to decreased ability to excrete urine. When fluid overload occurs due to decreased urine output. potassium and magnesium.

. D) Abdominal surgery.A 6-month-old child with cystic fibrosis is brought to the hospital with sudden onset vomiting and abdominal distention. The nurse will anticipate that the child will first be prepared for   A) Total parenteral nutrition (TPN) supplement. Intussusception is the admitting diagnosis. C) Nasogastric (NG) tube insertion. B) Barium enema x-ray.

Answer: B B) A barium enema is the first treatment of choice because this procedure frequently reduces the bowel and cures the intussusception (telescoping bowel). surgery for bowel reduction will be done. If this procedure does not work. The child will probably not require TPN or an NG tube. .

The nursing care plan will be based on knowledge that   A) It is necessary to limit visitors until his condition has improved.A client with a myocardial infarction is transferred to the transitional care unit as his condition improves. . D) It is important to eliminate stress as much as possible in his daily routine. C) The client must begin to accept that changes in lifestyle will be needed. B) It is therapeutic to give him explanations of his illness as soon as possible.

rather than limiting them. This may include his having visitors immediately.Answer: D D) The first priority will be to minimize stress by orienting the daily routines to his needs. .

C) Check for sensation in the lower extremities. the most important postoperative assessment is to   A) Auscultate lung sounds. B) Check the client's temperature for signs of infection.When a male client returns from the recovery room following a lumbar laminectomy. D) Observe the dressing for any drainage. .

the most important intervention is to check for sensation. however.Answer: C C) All of the interventions are important and will be carried out during the postoperative period. . The ability to wiggle toes and move his feet indicate there is not a complication from the surgical site.

the client complains of feeling light-headed and the pulse rate is 44. B) Call the physician.After removing the fecal impaction. C) Begin CPR. The priority intervention is to   A) Place in shock position. D) Monitor vital signs. .

then the physician is called for orders.Answer: A A) The client requires treatment for shock. . Vital signs are monitored after placing the client in the shock position.

B) Empathy. . D) Encouragement. C) Sympathy.The nursing behavior of sitting down at the client's bedside to talk with the client will convey a sense of   A) Communication.

It assists the client to verbalize feelings. openness to listen. and empathy. .Answer: B B) Nonverbal action conveys acceptance.

Which nursing diagnosis should receive the highest priority in a client with acute renal failure?   A) Altered nutrition: less than body requirements related to anorexia. D) Risk for trauma related to decreased alertness.   . C) Fluid volume excess related to oliguria. B) Activity intolerance related to fatigue and muscle cramps.

. and cerebral edema. hypertension. The increase in fluid volume may produce life-threatening effects such as heart failure. The other nursing diagnoses would have lower priority.Answer: C C) The oliguria associated with acute renal failure results in fluid volume excess.

To assess for desired therapeutic effect. D) Serum chloride.A client with cystic fibrosis is receiving dornase-alfa (Pulmozyme). the nurse would monitor the client's   A) Weight. . C) Lung sounds. B) Cardiac rhythm.

therefore. monitored closely as an indicator of the therapeutic effect of this drug. Pulmonary function is improved and the incidence of respiratory tract infections is lessened. Lung sounds reflect the presence or absence of lung congestion which may indicate infection and are. .Answer: C C) Dornase-alfa reduces the viscosity of the sputum in clients with cystic fibrosis.

A client is brought to the hospital by her husband who says she is highly anxious and spends half the morning doing rituals. C) Mornings are better for group therapy because clients have the rest of the day to work through problems that come up during the sessions. the client will join a daily group therapy session at 10:30 in the morning. B) Most groups are planned for the morning when physicians are on the unit. D) The client will have just completed her ritualistic activity. The rationale for choosing this time of day is   A) Anxious clients are more relaxed in the morning. . As part of her treatment plan.

particularly therapy.Answer: D D) It is best to plan any activity. to follow the compulsive activity because anxiety is lowest at this time. .

C) Double the rate of drops/minute for one hour to make up for the loss. The appropriate action would be to   A) Increase the flow so that the loss is made up over the remaining hours in the shift.Following gall bladder surgery. she observes that the IV is one hour behind. D) Speed up the IV to make up for the loss . B) Continue the IV flow at the same rate. a client has orders for an IV of D5W to run 100 ml/hour. When the nurse checks at the beginning of the evening shift.

.Answer: A A) The IV needs to be infused equally over the time ordered. it should be recalculated. When the IV is behind. The calculation is completed by taking the amount of solution remaining to be infused and dividing by the remaining hours.

D) May be given even after sensitization occurs. . B) Should be given to an unsensitized mother after each pregnancy or abortion. The nurse's knowledge of RhoGAM is that it   A) Must be given on the sixth day postdelivery. C) May be given to the infant in the uterus.The development of anti-Rh antibodies within the mother could have been prevented with the administration of RhoGAM for previous pregnancies.

because fetal blood may enter the mother's circulation and set up a sensitization process.Answer: B B) RhoGAM should be given after each pregnancy including an abortion. .

The nurse will know that a client with chronic renal failure adheres to dietary phosphorus modification when he   A) Increases milk products. C) Decreases whole grain products. B) Increases red meats. . D) Decreases red vegetables.

Answer: C C) Whole grain breads and cereals provide high sources of phosphate. meat. Calcium antacids are often given to bind phosphate in the GI tract. Hyperphosphatemia results from decreased renal clearance. poultry. Other sources include milk. and legumes. fish. .

the nurse will know he understands if he says that he will avoid   A) Pasta. B) Raw apples. C) French bread.When evaluating the client's understanding of a low potassium diet. D) Dry cereal. .

Answer: B B) Raw apples are high in potassium. while white-enriched and French bread. and pasta are foods low in potassium. . dry cereal.

a craniotomy has been scheduled. Analyzing the client's immediate postoperative needs.After an automobile accident in which the client sustained a head injury. B) Keeping his temperature below 97 degrees F to decrease metabolic needs. C) Obtaining serial blood and urine samples. . D) Placing him in supine position. the nursing care plan includes   A) Maintaining fluid and electrolyte balance by administering at least 3000 mL D5 Lactated Ringer's every 24 hours.

the client would probably shiver. At 97 degrees F. Fluids are kept at a minimum to prevent overhydration. The temperature should be kept normal to avoid increasing metabolic needs. which can lead to cerebral edema. causing not only increased intracranial pressure but also increased metabolic rate.Answer: C C) Serial blood and urine samples are collected because sodium regulation disturbances frequently accompany head injury. .

" C) "No.As the nurse is diluting an NG feeding for a CVA client. isn't she?" The best nursing response at this time is   A) "Why do you ask? Does she appear different to you?" B) "The doctor could better tell you that. She is just about the same. "She's getting better."   ." D) "Her condition is stable and she is very ill. but only time will tell. her husband says.

. thus are nontherapeutic.Answer: A A) The appropriate response is an assessment question to determine whether the husband has observed a change. All the other responses close off communication.

Which assessment finding indicates that the fistula is patent?   A) Normal capillary refill distal to the fistula.A client has an arteriovenous fistula as an access site for hemodialysis. B) Palpation of a pulse distal to the fistula. D) Auscultation of a bruit over the . C) Absence of edema or redness over the fistula.

Answer: D D) The flow of blood through a patent arteriovenous fistula produces turbulence manifested by a bruit audible when the fistula is auscultated. .

immediately postoperatively the nurse will formulate a goal that states   A) Turn on operative side only immediately postoperatively.Following a client's total hip replacement. . C) Head of bed elevated to 45-degree angle. B) Operative leg maintained in abduction. D) Buck's traction until hip can be put through range of motion.

Physicians now order that the client may be turned on either side postop. . Buck's traction is no longer used following total hip replacement. This position prevents dislocation of the new hip until range of motion can be instituted.Answer: B B) The leg must be kept in abduction.

age 32. He has been experiencing abdominal pain for several months and his physician suspects a duodenal ulcer. B) Intermittent with no correlation between food intake and when the pain occurs. is married and has no children. the nurse will chart that the pain is   A) Constant over the epigastric area when eating.A client. D) Experienced about 2 to 3 hours after . C) Experienced about 30 minutes after eating regardless of the diet. Assessing the symptoms described by the client.

.Answer: D D) Pain is reduced upon eating when the client has a duodenal ulcer. the pain recurs. When the duodenum is empty. about 2 to 3 hours after eating.

. D) A mask with reservoir bag.A client with COPD has orders for oxygen administration. B) An oxygen catheter. The method that delivers the appropriate liter flow and concentration of oxygen would be   A) A venturi mask. C) Nasal prongs.

A liter flow of 8 to 10 will provide an FIO2 of 70 to 100%.Answer: A A) The venturi mask delivers a fixed FIO2. . oxygen is taken in from the bag. The reservoir bag contains the highest level of oxygen. The COPD client must have an accurate and predictable FIO2 and a low liter flow (less than 6 l/minute) to prevent hypoxemia. As the client inhales. usually 24 to 35% at a liter flow of 2 to 8 l.

. B) Levothyroxine (Synthroid). C) Digoxin (Lanoxin). D) Ibuprofen (Motrin).A hypothyroid client has orders for all of the following medications. The nurse would evaluate the client most closely following administration of which medication?   A) Meperidine (Demerol).

Answer: A A) Hypothyroidism reduces the metabolic rate and prolongs the sedative effects of medications. such as meperidine. . The client must be closely monitored for signs of oversedation and respiratory depression. are especially dangerous and should be given in smaller doses. Narcotics.

The nurse is assigned to a client with a central vein IV infusing hyperalimentation solution. . The most important nursing intervention is   A) Checking urine specific gravity. D) Maintaining the exact amount of solution administered hourly by adjusting the flow rate. C) Changing the IV filter and tubing with each bottle change. sugar. and acetone every 4 hours. B) Preparing the next bottle of solution prior to use.

Insulin may have to be administered according to rainbow coverage. . Notify physician for urine glucose over 2+ and positive acetone.Answer: A A) Checking the urine for glucose and acetone is essential to prevent a hyperosmolar condition.

you will not gain too much." B) "If you are careful about the foods you eat." The most appropriate response is   A) "Why don't you have your husband come to the clinic next time.The nurse is counseling a woman who has just learned she is pregnant. She says she does not want to gain too much weight because her husband likes her "thin." C) "It's best for the baby if you don't try to stay too thin." D) "Let's talk about the importance of good nutrition and weight gain in pregnancy." . especially those high in calories. and we can all talk about nutrition.

Answer: D D) Adequate nutrition and weight gain in pregnancy are directly related to decreased mortality and morbidity in the newborn. . Helping the client understand the role of nutrition and weight gain will help her then explore the best way to talk to her husband about his concerns.

Adequate nutrition is essential during early pregnancy for optimum fetal development. would recommend a daily diet that would include   A) 1500 calories B) One fruit or vegetable high in vitamin C. C) Low roughage foods. in counseling a client. The nurse.   . D) A low sodium diet.

Pregnancy requires the addition of 300 calories a day over regular caloric intake. and 1500 calories a day would be inadequate. Research indicates that sodium is essential during pregnancy. . The recommended calories for someone age 28 are 2300 a day. and should include a total of four fruits and vegetables.Answer: B B) The diet must include at least one fruit or vegetable high in vitamin C.

Indications of progression of pre-eclampsia to a more severe state would be the presence of   A) Severe hypertension. The nursing care plan will include assessment for further signs of this condition. glycosuria. epigastric pain. polyuria. convulsions. B) Hypertension.   . C) Hyperreflexia. D) Hypertension. oliguria. diuresis. weight loss.A client in her 37th week of pregnancy is showing early signs of pre-eclampsia. polyuria.

Answer: C C) Hyperreflexia occurs with increased CNS irritation. . Epigastric pain is usually due to edema or bleeding into the liver capsule and oliguria. Other signs include edema and hypertension.

The first intervention is to   A) Withhold the next dose.When a client with a diagnosis of manic episode returns to the clinic to have lithium blood levels checked. C) Instruct her to watch for signs of toxicity. D) Notify the physician. B) Suggest she drink more fluid. her lithium level is only slightly higher than the previous week but she complains of blurred vision and ataxia. .

Answer: A A) These are symptoms of toxicity and the nurse must withhold the next dose. The nurse would then notify the physician. The client needs to maintain a normal fluid level to prevent toxicity, but this may not be the cause of her symptoms.

A nursing intervention to increase the nutritional status of a client on chemotherapy is to   A) Encourage the intake of fluids with meals. B) Provide the highest amount of protein with the morning meal. C) Provide three meals a day and high protein supplement fluids at least twice a day. D) Use high protein supplement fluids as the major source of protein during the chemotherapy.

Answer: B B) The highest amount of protein should be ingested in the morning because this is usually when the appetite is better. The client should consume at least one-third of the daily protein requirement with this meal. It is best to offer frequent small meals or snacks throughout the day to promote adequate protein consumption. Fluids should be taken between rather than with meals to prevent the client from

A schizophrenic client has been taking Thorazine for 2 days and is beginning to develop extrapyramidal effects. The nurse would expect the physician to order   A) Xanax. B) Cogentin. C) L-dopa. D) The drug to be discontinued.

Answer: B B) Cogentin is an antiparkinson drug and will reduce these side effects. Xanax is an antianxiety drug. L-dopa is given to clients with Parkinson's disease but is not useful for dystonic effects; answer (D) is not the treatment of choice, because the client needs Thorazine to control her symptoms.

D) A box of jacks. C) Play -doh.The toy most suitable to provide for a 21 1/2 year old hospitalized for diarrhea is   A) A stuffed animal. . B) A mobile.

Answer: A A) A stuffed animal would not be harmful and it would be comforting. . Play-doh is more appropriate for older children. they will go immediately into the infant's mouth. Jacks are not safe for an infant.

D) The cast being too tight.   . B) Uneven cast drying. The nurse reports to the physician the signs of   A) Infection. While caring for the client. the nurse identifies a "hot spot" or area on the cast that feels warm.A young male client has had a cast placed on his right leg. C) Poor circulation.

.Answer: A A) Infection can be identified by "hot spots." or areas on the cast that feel warm to the touch. A hot spot is not evidence of poor circulation or too tight a cast.

B) Compete with others for stimulation.   . C) Get a sense of continuity.The nursing staff should encourage clients with senile dementia to participate in activities that provide him a chance to   A) Learn something new. D) Complete a task and feel successful.

His diagnosis indicates he will have difficulty learning anything new (A) and competition would be too threatening (B). continuity will not be an issue.Answer: D D) It is essential that the client participate in activities that he can complete and that will increase his selfesteem. . If his diagnosis is dementia.

B) Establish equal pressure in the line. D) Assist in catheter insertion.   .Assisting the physician to establish a CVP line in a client. The purpose of this procedure is to   A) Decrease intrathoracic pressure. C) Prevent an air embolism. the nurse instructs the client to exhale against a closed glottis (perform Valsalva's maneuver).

nose and mouth closed--produces increased intrathoracic pressure and lessens the chance of an air embolism as the CVP catheter is inserted. .Answer: C C) Valsalva's maneuver--the attempt to forcibly exhale with the glottis.

B) Ventricular tachycardia.The nurse is monitoring the following cardiac rhythms on the central cardiac monitoring console on the unit. D) Atrial fibrillation. C) Sinus arrhythmia. . Which client would the nurse assess first?   A) Complete heart block.

Answer: B B) Ventricular tachycardia is a lifethreatening arrhythmia because it severely limits cardiac output and can degenerate quickly into ventricular fibrillation. Although atrial fibrillation and complete heart block can limit cardiac output. . they are not as immediately life-threatening as is ventricular tachycardia. Sinus arrhythmia is not life-threatening.

The intervention most important as a part of the preparation for this procedure is   A) Giving the client a high-fat meal. C) Administering an enema. B) Assessing for shellfish allergy.The physician has ordered a cholecystogram for a client. D) Allowing a light breakfast. .

but they are not the most important. Answers (C) and (D) might be carried out.Answer: B B) If the client is allergic to shellfish. . he most likely will be allergic to the dye used for the cholecystogram.

D) Restrict intake of high sodium foods. Which nursing intervention should be implemented?   A) Assess blood glucose by finger-stick AC and HS. B) Give the medication with meals. C) Monitor apical pulse rate and rhythm.A client is receiving the drug flecainide (Tambocor). .

Answer: C C) Flecainide is an antiarrhythmic used for the treatment of certain lifethreatening arrhythmias. . The apical pulse is monitored to evaluate the therapeutic response to the drug and to detect any new arrhythmias which may represent a side effect or toxic effect of this potent drug.

When a child has had one poison ingestion. B) Never give medications to others in front of the child. D) If poisoning occurs. the most important information to tell the mother is to   A) Keep purses out of the child's reach. statistically he is nine times more likely to have another poisoning episode within the year. C) Keep all cabinets locked at all times. To prevent further poisoning incidents.   . do as the label on the bottle recommends.

The child's mother should be given the telephone number of a poison control center.Answer: C C) Answers (A) and (B) are also necessary information but keeping cabinets locked is critical. Not all labels include sufficient information. .

25 mg PO daily with Valium and Compazine ordered prn. The initial nursing intervention will be to   A) Administer the Compazine ordered prn for nausea. B) Call the physician because the client is probably having an allergic reaction to Digoxin. D) Hold the drug as the client is probably Digoxintoxic. C) Administer the Valium ordered prn for anxiety.   . The Digoxin dose is 0. The monitor reveals she is now in a slow atrial fibrillation with a pulse rate of 72.A client complains of nausea and loss of appetite.

Neither Valium nor Compazine is indicated until the source of the nausea is determined. The drug should not be given until the cause of the client's nausea is determined. .Answer: D D) One of the first signs of Digoxin toxicity is nausea.

D) Decreased respiratory rate. Two weeks later. the nurse will assess a   A) Lowered blood pressure.25 mg daily. B) Decreased pulse rate. C) Decreased urine output. she comes to the clinic for a check-up.   . If the medication is effective.A female client is placed on digoxin (Lanoxin) 0.

.Answer: B B) The pulse rate should decrease with digoxin due to strengthened myocardial contraction. Urine output should increase. Blood pressure and respirations will be unaffected.

The nurse would begin this assessment by   A) Taking his axillary temperature. D) Taking his apical pulse. A priority assessment on admission is to obtain his vital signs. B) Counting his respirations. The nurse enters the room and finds him sleeping. C) Taking his rectal temperature. .[Chapter 1] Topic: Physiological Integrity A 6-week-old infant with a diagnosis of a fever of unknown origin is admitted to the unit.

if awake) his respiratory and apical rate will increase. apical pulse next. and rectal temperature last.Answer: B B) Counting respirations before disturbing the child will give the most accurate number. As soon as a child is touched (or even approached. . Take respirations first.

  .As the nurse is changing an abdominal dressing. The priority intervention is to   A) Obtain vital signs. D) Apply butterfly tape to the wound edges. B) Keep the client in a supine position. C) Apply an abdominal binder to the incision. the client suddenly coughs and an evisceration of the wound occurs.

thus the supine position is required. .Answer: B B) The client's wound opens and the bowel contents protrude when an evisceration occurs. the bowel contents should be prevented from protruding any further. In addition. Intra-abdominal pressure changes creating a shock state.

  . The nurse would set the IV controller to deliver   A) 48 mL per hour. Available is a bag containing 25. D) 12 mL per hour. B) 24 mL per hour. C) 82 mL per hour.000 units of Heparin in 500 mL of D5W.A client is to receive IV heparin at a rate of 1200 units per hour.

1200 divided by 25.000 multiplied by 500 equals 24 mL. .Answer: B B) This computation can be done using the formula of D divided by H multiplied by V.

C) Neologism. "My blue sky moves to arm." This statement is most clearly an example of   A) Hallucinatory experience. When the nurse is sitting with the client. . Her initial diagnosis is schizophrenia-undifferentiated type. she says slowly.A client has been admitted to an inpatient psychiatric unit. B) Associative looseness.

Flight of ideas is found with manic disorders. and neologisms (made up words). This is manifested by words that don't make sense. word salad.Answer: B B) Schizophrenics often evidence loose associations or disordered thoughts. .

According to standard orders. the nurse will probably add which specific supplement to the IV glucose?   A) Calcium gluconate. thiamine. C) Vitamin C.A client in acute intoxication or DTs is admitted to the emergency room. . D) Magnesium sulfate. B) Vitamin B.

. specifically thiamine.Answer: B B) The most critical supplement is vitamin B. although often a B complex (mixture that contains all B vitamins) is given. This vitamin deficiency is at least partially responsible for causing the client to develop Delirium Tremens. None of the other answers is relevant.

.Paralytic ileus is a frequent complication of postoperative abdominal surgery. D) Insert a rectal tube. According to the physician's orders and the nurse's assessment. C) Listen for bowel sounds. B) Insert a nasogastric tube. a planned intervention would be to   A) Administer PO fluids only.

.Answer: C C) The client will not be fed until bowel sounds are present. and flatus is passed. abdominal distention relieved. Answer (C) would be the first intervention followed by (B) and (D) if necessary.

While assessing a client in skeletal traction. D) Notify the physician. . the nurse observes the distal extremity to be pale with slow capillary refill and palpated at a 1+ pulse. C) Observe for ecchymosis or signs of infection. B) Remove the traction. The initial intervention is to   A) Assess the client every 15 minutes for changes.

Answer: D D) There is a circulatory compromise and thus the physician needs to be notified immediately. except removing traction. The other actions. will be carried out later. .

When a client has the diagnosis of schizophrenia. . C) Spastic movements of the eyelids. D) Oral movements and drooling. B) Drowsiness and lethargy. the most conspicuous signs of tardive dyskinesia are A) Muscular spasms of the extremities.

a condition associated with long-term use of antipsychotic drugs. shuffling gait.Answer: D D) Drooling. and general dystonic symptoms are characteristic of tardive dyskinesia. This is usually a permanent form of an extrapyramidal effect. Muscular spasms most often occur with dystonia. . a side effect that occurs early in the use of antipsychotics.

. C) Immediately after feedings. B) Between feedings. the nurse would expect her to say that the baby vomits   A) When new foods are introduced.When taking the history from the mother of a baby who has pyloric stenosis. D) Continuously.

. therefore.Answer: C C) Stenosis of the pyloric sphincter impedes gastric emptying. feedings are vomited when the stomach is full.

D) Pale color to skin. . B) Generalized edema. C) Diarrhea.Following abdominal surgery it is important that the nurse assess the client for negative nitrogen balance. The clinical manifestation most indicative of negative nitrogen balance is   A) Dehydration.

. there is a change in the body's osmotic pressure resulting in the oozing of fluids out of the vascular space.Answer: B B) When there is insufficient nitrogen for synthesis. This phenomena results in the formation of edema in the abdomen and flanks.

The RN responsible for administering a thiazide medication to a client evaluates his recent lab reports. B) Withhold the drug and report both lab results to the physician. The correct intervention is to   A) Administer the thiazide drug. D) Withhold the drug and report K+ level to the physician. C) Notify the physician.   . which are K+ 3.0 and NA+ 140.

5 to 5.Answer: D D) The appropriate intervention is to withhold the thiazide medication until the nurse receives further orders and report K+ level to the physician.5 mEq/l. Normal K+ is 3. His NA+ level is normal (range 135 to 145 mEq/l). .