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  1. What is the characteristic of developmental socialization in an adolescent?
    1. Not attracted to peer groups; prefers time alone
    2. Spends more time with Siblings than peers
    3. Prefers to spend all time with members of immediate family
    4. Uses peer groups as a standard against which to compare self
    4. Uses peer groups as a standard against which to compare self

    Peer groups, or other adolescents, are very important in the developmental phase of the adolescent. Solitary time (play) is usually found in the younger child, as is the time spent with family.
  2. The nurse is taking the history from a client with congestive heart failure caused by hypertension. The nurse identifies what data as supportive of the client's medical dianosis?
    1. Dysnea after walking 1 block
    2. Weight loss of 15 lbs over last 3 months
    3. Lower extremity edema in the evenings
    4. Dizziness and fainting when rising too quickly
    1. Dysnea after walking 1 block

    Dyspnea on exertion is a classic sign of left ventricular problems, regardless of the precipitating cause. Lower extremity edema is also characteristic but not as much as the dyspnea.
  3. A client comes to the emergency department with a deep penetrating wound he receives in his garden. What is the best nursing action?
    1. Rinse the wound with antibiotic solution
    2. Administer gamma globulin intramuscularly
    3. Anticipate notifying poison control for plant toxicity
    4. Determine when client receives last tetanus immunization
    1. Rinse the wound with antibiotic solution

    Deep penetrating wounds that are contaminated by soil, dust, or excreta containing Clostridium tetani are the cause of tetanus, or lockjaw. First, the wound should be thoroughly cleansed, then the nurse should determine when the client received his last tetanus immunization. As a rule, clients will receive a tetanus booster as a safeguard.
  4. An older adult client has peripheral vascualr disease, and the nurse is advised that the client also experiences intermittent claudication. What are the characteristics of intermittent claudication?
    1. Pain in the client's hands will be aggravated by smoking and cold temperatures
    2. Pain occurs in the lower part of the extremity when the client is sitting down
    3. Presence of pain on ambulation and the need for analgesics prior to walking
    4. Presence of pain on ambulation, but pain is relived by sitting down
    4. Presence of pain on ambulation, but pain is relived by sitting down

    Intermittent claudication is the term used to describe pain in the legs that is relieved by resting the muscle, which is characteristic of peripheral vascular disease (PVD). The other options are not applicable to intermittent claudication. Option 1 is often noted in Raynaud's disease. Option 2 can occur due to stasis of blood leading to congestion and pain in the lower extremities – a venous problem, not arterial as in PVD. Although there is pain on ambulation with intermittent claudication, there is no need for analgesics prior to walking, as stopping the activity is the only way to relieve the pain.
  5. An older client has been experiencing confusion. The nurse is trying to determine wheter the confusion is related to depression or dementia. In evaluating the client, what specific nursing assessment finding(s) would be helpful in making this distinction?
    1. Determining whether confusion worsens in the evening
    2. Assessing early morning agitation, hyperactivity and insomnia
    3. Notifying when signs of anger, hostility, and loss of control occur
    4. Assessing for presence of orientation and reality distortions
    1. Determining whether confusion worsens in the evening

    Confusion can occur in both dementia and depression. However, with dementia, symptoms of confusion are usually worse at night. This may be referred to as "sundowning syndrome" in clients with Alzheimer's disease.
  6. After administering diurectcs to a client with ascites, which of the following nursing actions is most important?
    1. Measure serum potassium level for hyperkalemia
    2. Assess the client for hypervolemia
    3. Weigh the client weekly
    4. Document accurate daily intake and output
    4. Document accurate daily intake and output

    Accurate intake and output measurements are essential for clients receiving diuretics. Hypokalemia, not hyperkalemia, is a frequent occurrence with diuretic therapy, and hypovolemia is a much greater risk with an increased urine output. Clients should be weighed daily.
  7. What is a priority nurisng problem in the care plan for manic client with bipolar disorder?
    1. Altered nutrition
    2. Impaired social interaction
    3. Diversional activity deficit
    4. Altered sexual patters
    1. Altered nutrition

    Frequently, clients in a manic phase of bipolar disorder have extreme hyperactivity and do not take care of themselves. Consequently, their basic needs of nutrition, rest, and hygiene are often not met. Physiological needs come before psychosocial needs; therefore the priority is altered nutrition.
  8. A client has a diagnosis of glaucoma. Which of the following medications are contraindicated?
    1. Atropine sulfate (Atropisol)
    2. Pilocarpine (Pilocar)
    3. Meperidine (Demerol)
    4. Fentanyl (Duragesic)
    1. Atropine sulfate (Atropisol)

    Mydriatic medications, such as atropine (Atropisol), are contraindicated in the care of the glaucoma client. Pilocarpine (Pilocar) is a miotic and is used to reduce intraocular pressure. Demerol and Duragesic can be administered to a glaucoma client.
  9. Different medication preparations of drugs are absorbed in the body at different rates of time. Which preparation of a drug absorbs more rapidly?
    1. Ointment applied to the skin
    2. Liquid medicine given orally
    3. Oral gelatin capsules
    4. Enteric-coated tablets
    2. Liquid medicine given orally

    Liquid oral medications are already in solution and are thus absorbed more rapidly.
  10. Aftr delivery, a neonate is transferred to the nursery. The nurse is planning interventions to prevent hypothermia. What is the common source of radiant heat loss?
    1. Low room humidity
    2. Cold weight scale
    3. Cool bassinet walls
    4. Variable room temperature
    3. Cool bassinet walls

    The nurse understands that the common sources of radiant heat loss include cool bassinets and bassinets placed close to windows or areas of drafts. Low room humidity promotes evaporative heat loss. When the infant's skin has direct contact with a cooler object, such as a cold weight scale, conductive heat loss may occur. Convective heat loss occurs with a cool room temperature.
  11. An 8-year-old child is admitted with a greenstick fracture of the ulna. The nurse explains to the parents the characteristics of a greenstrick facture. What would the nurse include in this explanation?
    1. The bone is broken across the epiphyseal plate
    2. There is a splintering of the bone on one side
    3. There is a separation of the bone at the facture site
    4. The boen is broken into several fragments
    2. There is a splintering of the bone on one side

    Greenstick fracture occurs most often in children as a result of the flexibility of the bone. The bone bends and splinters on one side; there is no separation or fragmentation of the bone.
  12. A client is taking rantidine (Zantac) for treatment of his peptic ulcer disease. What would be important for the nurse to teach the client regarding the administration of this medication?
    1. It should not be taken within an hour of taking a magnesium antacid
    2. It should be taken with food
    3. It should be taken only when gastric symptoms are present
    4. NSAIDs may be taken for gastric discomfort
    1. It should not be taken within an hour of taking a magnesium antacid

    Antacids containing magnesium and aluminum will decrease the effectiveness of this medication. For best results, it should be taken after meals and at bedtime. For best results, it should be taken on a regular basis and NSAIDs should not be taken by a client with peptic ulcer disease.
  13. The nurse would question which medication order for a client who is receiving heparin?
    1. Cortison
    2. Aspirn
    3. Glipizide (Glucotrol)
    4. Digoxin (Lanoxin)
    2. Aspirn

    • Aspirin is contraindicated because it inhibits platelet aggregation, thus increasing clotting times that have already been compromised by the heparin. In addition, aspirin's tendency to cause gastrointestinal irritability could precipitate a gastric bleed.
  14. A client is 24 hours postoperative for gastrectomy. There is an order to clamp the nasogastric tube for 4 hours. About 2 hurs after clamping, the client begins to complain of nausea. What is the best nursing action?
    1. Aspirate the stomach contents to prevent problems with vomiting
    2. Unclamp the nasogastric tube and connect it back the previous level of suction
    3. Call the physician and advise regarding the client's nausea
    4. Administer the antiemetic that is ordered on an as-needed basis
    2. Unclamp the nasogastric tube and connect it back the previous level of suction

    The nausea may lead to vomiting and should be addressed early. Opening the tube to drainage and suction will assist in preventing vomiting and possible aspiration of gastric contents.
  15. A client is admitted to the nursing unit after a motor vehicle accident in which he sustained a head injury and now has slow cerebrospinal fluid (CSF) leak. What would be important nursing intervention for this client?
    1. Frequent assessment and gentle cleaning of the nose and ears.
    2. Maintain client in a prone position to prevent aspiration.
    3. Maintain complete bed rest and low-Fowler's position.
    4. Gently suction the nasopharynx area to promote pulmonary hygiene
    3. Maintain complete bed rest and low-Fowler's position.

    When a client has a CSF leak, he should be maintained on bed rest and in low or semi-Fowler's position until advised otherwise. The client is at increased risk for infection (meningitis). The ears and nose should not be cleaned, and spinal fluid should be allowed to drain and gently wiped away if from the nose or the outer ear. The client should not be suctioned or encouraged to cough vigorously.
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2012-11-20 16:01:20

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