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NEW QUESTION # 140
A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
- A. Delusions
- B. Echolalia
- C. Hallucinations
- D. Flight of ideas
Answer: D
Explanation:
Explanation
(A) Rapidly moving from one topic to another without following any logical sequence is called flight of ideas.
(B) False beliefs are delusions. (C) False sensory perceptions are hallucinations ("hearing voices"). (D) Repeating words is called echolalia.
NEW QUESTION # 141
Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:
- A. Patent ductus arteriosus
- B. Ventricular septal defect
- C. Tetralogy of Fallot
- D. Transposition of the great arteries
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood the reach the systemic circulation. (B) A VSD alone creates a left-to-right shunt.
The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the systemic circulation. (C) In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. (D) Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.
NEW QUESTION # 142
A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate?
- A. Administer a stat dose of lithium as necessary.
- B. Recognize this as an expected response to lithium.
- C. Give an oral dose of lithium antidote.
- D. Request an order for a stat blood lithium level.
Answer: D
Explanation:
Section: Questions Set A
Explanation:
(A) These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal. (B) These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote.
NEW QUESTION # 143
The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
- A. Infuse volume at 22 mL/hr.
- B. Infuse volume at 30 mL/hr.
- C. Infuse volume at 44 mL/hr.
- D. Infuse volume at 10 mL/hr.
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is:
Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min)Desired Time to Infuse in Minutes Rate = (10 + 12)22 X 60 30 = 44 mL/hr. (B, C, D) These values are incorrect.
NEW QUESTION # 144
A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:
- A. Is usually not necessary after the first year following transplantation
- B. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids
- C. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually resolve themselves
- D. Is available at discount pharmacies for a reduced price
Answer: B
Explanation:
Explanation
(A) Cyclosporine is the immunosuppressive drug of choice. It provides immunosuppression but does not lower the white blood cell count; therefore, the client is less susceptible to infection. (B) Cyclosporine is available at discount pharmacies. The cost may be absorbed by health insurance, or Medicare, if the client is eligible.
However, this statement does not address the entire problem verbalized by the client. (C) Immunosuppressive agents will be taken for the client's entire life because rejection can occur at any time. (D) These side effects do not necessarily resolve in time; however, the client may adapt.
NEW QUESTION # 145
Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?
- A. Administration of hypo-osmolar fluids
- B. Increased core body temperature
- C. Decreased PaCO2
- D. Decreased serum osmolality
Answer: C
Explanation:
(A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known.
NEW QUESTION # 146
A client has been diagnosed with congestive heart failure. His fluid intake and output are strictly regulated.
For lunch, he drank 8 oz of milk, 4 oz of tea, and 6 oz of coffee. His intake would be recorded as:
- A. 655 mL
- B. 600 mL
- C. 500 mL
- D. 540 mL
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A, C, D) This answer is a miscalculation. (B) 1 oz = 30 mL; therefore, 18 oz x.
NEW QUESTION # 147
During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:
- A. Immobilizing the joints in functional position using splints, rolls, and pillows
- B. Applying warm water bottle or heating pads over involved joints
- C. Massaging the joints briskly with lotion or liniment after bath
- D. Putting all joints through full range-of-motion twice daily
Answer: A
Explanation:
(A) Any movement of the joint causes severe pain. (B) Touching or moving the joint causes severe pain. (C) Immobilization in a functional position allows the joint to rest and heal. (D) Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.
NEW QUESTION # 148
A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:
- A. Myxedema
- B. Respiratory obstruction
- C. Hypercalcemia
- D. Fistula formation
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal compression from hemorrhage is a major complication after a thyroidectomy. (B) Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a major complication, not hypercalcemia. (C) Fistula formation is not a major complication associated with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess production of thyroid hormone.
NEW QUESTION # 149
Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:
- A. The violent behavior subsides, and the client agrees to behave
- B. A therapeutic alliance has been established, and violent behavior subsides
- C. The nurse deems that removal of restraints is necessary
- D. The physician orders it
Answer: B
Explanation:
(A) The physicianmayorder release of restraints, but prior to that, the client must meet criteria for release. (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only "agrees to behave" after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.
NEW QUESTION # 150
A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:
- A. Elevated temperature and general malaise
- B. Marked engorgement and breast pain
- C. Cracked nipple with complaints of soreness
- D. Marked engorgement, elevated temperature, chills, and breast pain with an area that is red and hardened
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Mastitis is a bacterial inflammation of the breast tissue found primarily in breast-feeding mothers. The bacteria usually enter the breast through a cracked nipple, or the infection results from stasis of milk behind a blocked duct. (B) With breast engorgement during breast-feeding, there may be marked breast pain. This is not necessarily a sign of infection. (C) Women may become ill during breast-feeding with other bacterial or viral infections that are not related to mastitis. (D) Improper care of the nipples or improper positioning of the infant during breastfeeding may result in cracked or sore nipples.
NEW QUESTION # 151
Which of the following nursing orders has the highest priority for a child with epiglottitis?
- A. Intake and output
- B. Specific gravity every shift
- C. Tracheostomy set at bedside
- D. Vital signs every shift
Answer: C
Explanation:
(A) Because of the possibility of fever or respiratory failure, vital signs should be done more often than every eight hours. (B) If the epiglottitis worsens, the edema and laryngospasm may close the airway and an emergency tracheostomy may be necessary. (C) Although intake and output are a part of the nursing care of a child with epiglottitis, it is not as important as the safety measure of keeping the tracheostomy set at the bedside. (D) Specific gravity will indicate hydration status, but it is not as important as keeping the tracheostomy set at the bedside.
NEW QUESTION # 152
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. Self-discipline is required to control caloric intake throughout the pregnancy
- B. Immediate treatment of mild PIH includes the administration of a variety of medications
- C. The client may not recognize the early symptoms of PIH
- D. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
Answer: C
Explanation:
(A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH.
NEW QUESTION # 153
When planning care for the passive-aggressive client, the nurse includes the following goal:
- A. Allow the client to use humor, because this may be the only way this client can express self.
- B. Allow the client to give excuses if he forgets to give staff information.
- C. Allow the client to have time away from therapeutic responsibilities.
- D. Allow the client to express anger by using "I" messages, such as "I was angry when . . .," etc.
Answer: D
Explanation:
(A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of "I" messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. (C) Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.
NEW QUESTION # 154
A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?
- A. Give her a big hug and tell her that she is a big girl now and that she will do just fine.
- B. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.
- C. Explain what will take place and what she will see, feel, and hear.
- D. Remind her that she has had this procedure before and that it is nothing to be afraid of.
Answer: C
Explanation:
Explanation
(A) Even though the child has had the procedure before, she will probably need additional explanations and emotional support. (B) The fact that the child has had the procedure before and possibly found it painful or uncomfortable may increase, not relieve, her stress. (C) This intervention does nothing to reassure the child and may well prevent her from expressing her feelings. (D) This does not prepare the child for the test and burdens her with the expectation that she act bigger and braver than she is.
NEW QUESTION # 155
A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:
- A. Place the client on a pad count
- B. Have the client void and then re-evaluate the fundus
- C. Notify the physician
- D. Massage the uterus and re-evaluate in 30 minutes
Answer: B
Explanation:
Section: Questions Set B
Explanation:
(A) The nurse should initiate actions to remove the most frequent cause of uterine displacement, which involves emptying the bladder. Notifying the physician is an inappropriate nursing action. (B) The pad count gives an estimate of blood loss, which is likely to increase with a boggy uterus; but this action does not remove the most frequent cause of uterine displacement, which is a full bladder. (C) Massage may firm the uterus temporarily, but if a full bladder is not emptied, the uterus will remain displaced and is likely to relax again. (D) The most common cause of uterine displacement is a full bladder.
NEW QUESTION # 156
A 32-year-old female client is being treated for Guillain- Barre syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?
- A. Facial paralysis
- B. Complaints of shortness of breath
- C. Loss of superficial and deep tendon reflexes
- D. Complaints of a headache
Answer: B
Explanation:
Explanation
(A) Headaches are not associated with Guillain-Barre syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. (D) Facial paralysis is expected and is not considered abnormal.
NEW QUESTION # 157
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be:
- A. Bright red with streaks
- B. Green colored
- C. Pink-tinged and frothy
- D. Rust colored
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such as Klebsiellapneumonia. (B) Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. (C) Green-colored sputum is more characteristic of Pseudomonasthan of gram-positive bacterial pneumonia. (D) Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.
NEW QUESTION # 158
The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?
- A. Ability to focus and concentrate thoughts
- B. Memory
- C. Judgment
- D. Abstract thinking
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. (B) This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. (C) This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. (D) This answer is incorrect. In testingmemory, the nurse would attempt to get the client either to recall recent events or to think about past events.
NEW QUESTION # 159
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