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NEW QUESTION # 143
The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client's diet?
- A. Fresh fruits
- B. Cream cheese
- C. Yeast bread
- D. Aged cheese
Answer: D
Explanation:
Explanation
(A) Cream cheese does not contain tyramine, which might cause a hypertensive crisis. (B) Fresh fruits do not contain tyramine, which might cause a hypertensive crisis. (C) Aged or matured cheese combined with a monoamine oxidase predisposes the client to a hypertensive crisis. (D) Bread products raised with yeast do not contain tyramine.
NEW QUESTION # 144
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. "If I have any side effects from my medicines, I will take an extra dose of Cogentin."
- B. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now."
- C. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."
- D. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway."
Answer: C
Explanation:
Explanation
(A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance.
NEW QUESTION # 145
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.
The nurse's first intervention should be to:
- A. Prepare for the delivery because the client is probably in transition
- B. Notify the attending physician
- C. Check FHT
- D. Turn off the IV oxytocin
Answer: D
Explanation:
Explanation
(A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
NEW QUESTION # 146
Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?
- A. Decreased anteroposterior chest diameter
- B. Increased heart sounds
- C. Distant breath sounds
- D. Collapsed neck veins
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema.
NEW QUESTION # 147
Hematotympanum and otorrhea are associated with which of the following head injuries?
- A. Frontal lobe fracture
- B. Subdural hematoma
- C. Basilar skull fracture
- D. Epidural hematoma
Answer: C
Explanation:
Section: Questions Set A
Explanation:
(A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage.
NEW QUESTION # 148
A 37-year-old client has been taking antipsychotic medication for the past 10 days. The nurse observes her walking with a shuffling gait and postural rigidity and notes a masklike expression on her face. Which side effect is this client exhibiting?
- A. Dystonia
- B. Akathesia
- C. Parkinsonism
- D. Tardive dyskinesia
Answer: C
Explanation:
(A) This answer is incorrect. Dystonia refers to severe, painful muscle contractions. (B) This answer is correct. Parkinsonism commonly occurs approximately 1-2 weeks after initiation of antipsychotic drug therapy. Traditional signs are masklike facies, postural rigidity, shuffling gait, and resting tremor. (C) This answer is incorrect. Tardive dyskinesia is characterized by involuntary muscle movements of the face, jaw, and tongue. (D) This answer is incorrect. Akathesia is motor restlessness.
NEW QUESTION # 149
The family member of a child scheduled for heart surgery states, "I just don't understand this open-heart or closed-heart business. I'm so confused! Can you help me understand it?" The nurse explains that patent ductus arteriosus repair is:
- A. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.
- B. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed.
- C. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.
- D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.
Answer: C
Explanation:
Explanation
(A) Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine. (B) Patent ductus arteriosus is a ductus arteriosus that does not close shortlyafter birth but remains patent. Repair is a closed-heart procedure involving ligation of the patent ductus arteriosus. (C) Coronary artery bypass graft surgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts. (D) Percutaneous transluminal coronary angioplasty is a closedheart procedure that improves coronary blood flow by increasing the lumen size of narrowed vessels.
NEW QUESTION # 150
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
- A. Examine painful areas first to get them "over with."
- B. Have the mother leave the room with one child, and examine the other child privately.
- C. Examine the 4 year old first.
- D. Provide time for play and becoming acquainted.
Answer: D
Explanation:
Explanation
(A) The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. (B) Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. (C) Children generally cooperate best when their mother remains with them. (D) Painful areas are best examined last and will permit maximum accuracy of assessment.
NEW QUESTION # 151
A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?
- A. Papilledema
- B. Hearing test
- C. Strabismus
- D. Gait
Answer: C
Explanation:
Section: Questions Set C
Explanation:
(A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or amblyopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment.
NEW QUESTION # 152
A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:
- A. "I may also have to have a radical neck dissection done."
- B. "The quality of my voice will be excellent after surgery."
- C. "I know I will need special swallowing training after my surgery."
- D. "I will have very little difficulty swallowing after surgery."
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) A client with a supraglottic (horizontal partial) laryngectomy would require special swallowing training, not a vertical partial laryngectomy. (B) The quality of the client's voice will be altered but adequate for communication. (C) The client will have minimal difficulty swallowing. (D) A radical neck dissection may be done with a total laryngectomy, but not with a partial laryngectomy.
NEW QUESTION # 153
A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?
- A. D50W by IV push
- B. NPH insulin SC
- C. Regular insulin by IV infusion
- D. Sweetened grape juice by mouth
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) This action would further increase the client's blood sugar. (B) NPH insulin is an intermediate-acting insulin, with an average of 4-6 hours before onset of action. The client needs insulin that will act immediately. During a ketoacidotic state, the client is dehydrated, so any insulin administered SC will be poorly absorbed. (C) Regular insulin is the fastest acting-insulin; when given IV, it will immediately act to decrease blood sugar. Regular insulin is given to decrease blood glucose levels by promoting metabolism of glucose, inhibiting lipolysis and formation of ketone bodies. (D) This action would further increase the client's blood sugar.
NEW QUESTION # 154
A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect.
Based on his developmental stage, the nurse:
- A. Explains the procedure using simple words and sentences just before the preoperative sedation
- B. Uses pictures to explain the procedure to the child and his parents that evening
- C. Asks the parents to explain the procedure to the child after she explains it to them
- D. Asks the parents to leave the room while the preoperative medication and instructions are given
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. (B) A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddler's need for parental support, body intactness, and short attention span. (C) A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. (D) The parents are the child's support system and need to be there to strengthen the child.
NEW QUESTION # 155
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
- A. Providing him with books, challenging puzzles, and games as diversionary activities
- B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
- C. Having a volunteer come in to sit with the client and to read him stories
- D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently
Answer: B
Explanation:
(A) These activities could be frustrating for the client if he is having difficulty with problem solving and concentration. (B) Selfcare is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility. (C) This may be helpful to the client if he has no visitors, but it does little to help him develop coping skills. (D) This will helpto prevent skin irritation or breakdown related to immobility but will not help to prevent behavioral changes related to immobility.
NEW QUESTION # 156
After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son's circumcision?
- A. "I'll apply alcohol to the area daily to clean it and prevent any infection."
- B. "I'll make sure that I report any drainage around where they operated."
- C. "I'll make sure I soak the gauze with warm water first, before I take it off each time."
- D. "I'll keep a close watch on it for a day or two."
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent trauma to adherent tissues. (B) A yellow exudate often forms normally over the surgical site. Only if it becomes foul- smelling and purulent would it need to be reported. (C) Alcohol should never be used on the site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 7-10 days.
NEW QUESTION # 157
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
- A. Level of consciousness
- B. Blood pressure
- C. Fluid intake
- D. Skin turgor
Answer: A
Explanation:
Explanation
(A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.
NEW QUESTION # 158
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, "Why did this happen to my baby?" is:
- A. "I can see you're upset. Would you like to see and hold your baby?"
- B. "It's God's will. It was probably for the best. There was something probably wrong with your baby."
- C. "You're young. You can have other children later."
- D. "I know your other children will be a great comfort to you."
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father.
Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ("she is bruised") and provide support.
NEW QUESTION # 159
The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
- A. A birth defect
- B. A low birth weight
- C. Nicotine withdrawal
- D. Anemia
Answer: B
Explanation:
Section: Questions Set F
Explanation:
(A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn.
NEW QUESTION # 160
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?
- A. Restrain the child so he will not injure himself.
- B. Move furniture out of the way and place a blanket under his head.
- C. Place a tongue blade in the child's mouth.
- D. Go to the nurses station and call the physician.
Answer: B
Explanation:
Section: Questions Set B
Explanation:
(A) The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. (B) Restraining the child's movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head.
NEW QUESTION # 161
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at 0 station. Based on the vaginal exam, she is in:
- A. Stage 1, active phase
- B. Stage 2, latent phase
- C. Stage 1, latent phase
- D. Stage 3, transition phase
Answer: C
Explanation:
Section: Questions Set E
Explanation:
(A) The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. (B) The first stage of labor begins with regular uterine contractions and continues until the woman is
10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is < 4 cm dilated so she is in the latent phase of the first stage of labor. (C) The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. (D) The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-
3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.
NEW QUESTION # 162
A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:
- A. Respiratory alkalosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Metabolic acidosis
Answer: C
Explanation:
Explanation
(A) Respiratory acidosis is the result of problematic ventilation. Plasma pH decreases, while plasma PCO2 and plasma HCO3 increase. (B) Respiratory alkalosis results from increased respiratory rate and depth. Plasma pH increases, while plasma PCO2 and plasma HCO3 decrease. (C) Metabolic acidosis occurs when there is strong acid gain in the body. Plasma pH, PCO2, and HCO3 decrease. (D) Increased risk for metabolic alkalosis is due to a loss of hydrogen ions; depletion of potassium, sodium, and chloride when vomiting occurs. Plasma pH and plasma PCO2 increase; plasma HCO3 may decrease and then increase to compensate.
NEW QUESTION # 163
A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?
- A. He is asleep 30 minutes after receiving the IV morphine.
- B. He is euphoric for about an hour after each injection.
- C. The client requests pain medicine every 4 hours.
- D. He asks for pain medication although his blood pressure and pulse rate are normal.
Answer: B
Explanation:
(A) Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. (B) Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. (C) A person may be in pain even with normal vital signs. (D) A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain.
NEW QUESTION # 164
A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued?
- A. Garamycin (Gentamicin)
- B. Prednisone
- C. Timolol maleate (Blocadren)
- D. Phenytoin (Dilantin)
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Prednisone is not linked with hematological side effects. (B) Timolol, a β-adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplastic anemia is chloramphenicol (Chlormycetin).
NEW QUESTION # 165
The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:
- A. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
- B. Take all vital signs, and report to the physician
- C. Discontinue the IV
- D. Stop the medication, and begin a normal saline infusion
Answer: D
Explanation:
(A)
The IV line should not be discontinued because other IV medications will be needed.
(B)
Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.
NEW QUESTION # 166
MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:
- A. Magnesium oxide
- B. Calcium gluconate
- C. Calcium hydroxide
- D. Naloxone (Narcan)
Answer: B
Explanation:
Explanation
(A, B) These drugs are not antidotes for MgSO4. (C) This drug is the standard antidote and should always be readily available when MgSO4is being administered. (D) This drug is an antidote for narcotics, not MgSO4.
NEW QUESTION # 167
A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:
- A. "I may also have to have a radical neck dissection done."
- B. "The quality of my voice will be excellent after surgery."
- C. "I know I will need special swallowing training after my surgery."
- D. "I will have very little difficulty swallowing after surgery."
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) A client with a supraglottic (horizontal partial) laryngectomy would require special swallowing training, not a vertical partial laryngectomy. (B) The quality of the client's voice will be altered but adequate for communication. (C) The client will have minimal difficulty swallowing. (D) A radical neck dissection may be done with a total laryngectomy, but not with a partial laryngectomy.
NEW QUESTION # 168
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