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NEW QUESTION # 150
A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance.
Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:
- A. Secondary infection resulting from poor oral hygiene
- B. Loss of ability to speak and communicate effectively
- C. Drooling
- D. Aspiration and weight loss
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
NEW QUESTION # 151
The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:
- A. Maintain her interest in school
- B. Maintain contact with her parents
- C. Provide a nutritious diet
- D. Provide for physical and psychological rest
Answer: D
Explanation:
(A)
This goal is helpful, but rest is essential during the acute phase. (B) Rest is essential for healing to occur and for pain to be relieved. (C) This goal is important, but rest is essential.
(D)
This goal should be part of the plan of care, but it is not the priority during the acute phase.
NEW QUESTION # 152
A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:
- A. "I should contact my physician if I have headaches after I take this medicine."
- B. "I should call the doctor if three doses of the medicine do not relieve my pain."
- C. "I should keep the tablets in the refrigerator."
- D. "I should take these with water but not with milk."
Answer: B
Explanation:
Explanation
(A) Headaches may occur after taking nitroglycerin because of vasodilation. (B) The tablets do not need to be refrigerated. The client should carry them with her. (C) The client should contact the physician if repeated doses of nitroglycerin do not relieve the discomfort. (D) Nitroglycerin tablets should be dissolved under the tongue, not swallowed.
NEW QUESTION # 153
Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:
- A. Both parents must be carriers for a child to have the disease
- B. Both parents must have the disease for a child to have the disease
- C. Fathers carry the gene and pass it to their daughters
- D. Mothers carry the gene and pass it to their sons
Answer: A
Explanation:
(A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child.
NEW QUESTION # 154
An 82-year-old former restaurant owner walks to the nursing station and states, "I have to go. The restaurant opens at 11 am." Which response by the nurse is the most appropriate?
- A. "Go back to your room. You do not own a restaurant."
- B. "You once owned a restaurant. Tell me about it."
- C. "You are in the hospital now. Calm down."
- D. "It is snowing outside. The restaurant is closed."
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) This response cuts off communication with the client. It does not address her feelings. (B) Reality orientation frequently does not work alone. Feelings must be addressed. Telling a client to calm down is frequently ineffective. (C) Reminiscence is used here to reorient and recall past pleasant events. Talking about the restaurant will allay anxiety. (D) This response may confirm to the client that she indeed does still own a restaurant, buying into her confusion. Her feelings and anxiety require nursing intervention.
NEW QUESTION # 155
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
- A. Prevent air from entering the pleural space
- B. Provide a means to measure chest drainage
- C. Prevent fluid from entering the pleural space
- D. Provide an indicator of respiratory effort
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) A chest tube extends from the pleural space to a collection device. The tube is placed below the surface of the saline so that air cannot enter the pleural space. (B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain fluid from the pleural space, but the water seal is not involved in this. (C) Chest drainage should be measured, but the water seal is not involved in this. (D) Fluctuations in the tube in the water-sealed bottle will give an indication of respiratory effort, but that is not the purpose of the water seal.
NEW QUESTION # 156
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
- A. Boardlike, rigid abdomen
- B. Loss of the urge to defecate
- C. Liquid stool
- D. Abdominal pain
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) A boardlike, rigid abdomen would point to a perforated bowel, not a fecal impaction. (B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so. (C) When an impaction is present, only liquid stool will be able to pass around the impacted site. (D) Abdominal pain without distention is not a sign of a fecal impaction.
NEW QUESTION # 157
An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse's understanding of normal fluid requirements for this infant?
- A. 960 mL/day
- B. 680 mL/day
- C. 240 mL/day
- D. 330 mL/day
Answer: B
Explanation:
Section: Questions Set E
Explanation:
(A, C, D) These answers are incorrect. (B) Normal fluid requirement for this pediatric client is based on the fact that 0-10 kg of weight equals 100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL X 6.8
680 mL/day.
NEW QUESTION # 158
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being "on the move," sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?
- A. Introspection related to his present situation
- B. Exaggerated self-importance
- C. Feelings of helplessness and hopelessness
- D. Short, polite responses to interview questions
Answer: B
Explanation:
Explanation
(A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. (B) Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration.
(C) Grandiosity and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.
NEW QUESTION # 159
A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate:
- A. Fetal lung maturity
- B. Cord compression
- C. Placental maturity
- D. Suspected chronic asphyxia
Answer: A
Explanation:
(A) Placental maturity is assessed by a biophysical profile. (B) L/S ratio and presence of phosphatidylglycerol are not used to determine fetal asphyxia. A biophysical profile score of6 may indicate this condition. (C) Cord compression is not reflected by the L/S ratio or presence of phosphatidylglycerol. Variable decelerations observed through electronic fetal monitoring could reflect umbilical cord compression. (D) An L/S ratio>2 and the presence of phosphatidylglycerol in amniotic fluid indicate fetal lung maturity.
NEW QUESTION # 160
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
- A. Counseling a client with post-traumatic stress disorder
- B. Referring a client who has been on a detoxification unit to a rehabilitation center
- C. Teaching fifth-grade children the harmful effects of substance abuse
- D. Crisis intervention with an intoxicated teenager whose mother just committed suicide
Answer: C
Explanation:
Explanation
(A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
NEW QUESTION # 161
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
- A. Turner's sign
- B. Murphy's sign
- C. Rebound tenderness
- D. Cullen's sign
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. (B) This sign indicates areas of inflammation within the peritoneum, such as with appendicitis.
It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. (C) This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. (D) This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.
NEW QUESTION # 162
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. Stop the medication, and begin a normal saline infusion
- B. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
- C. Discontinue the IV
- D. Take all vital signs, and report to the physician
Answer: A
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 # 163
Assessment of a newborn for Apgar scoring includes observation for:
- A. Heart rate
- B. Respiratory rate
- C. Babinski's reflex
- D. Pupil response
Answer: A
Explanation:
Explanation
(A) Pupil response should be assessed but is not part of Apgar scoring. (B) Respiratory effort is an essential part of Apgar scoring, not respiratory rate. (C) Heart rate is the most critical component of Apgar scoring. (D) Assessment of Babinski's reflex is not a component of Apgar scoring.
NEW QUESTION # 164
A first-trimester primigravida is diagnosed with anemia.
The nurse should suspect that this anemia is a result of:
- A. Mother's decreased blood volume
- B. Increase in iron absorption
- C. Fetal blood volume increase
- D. Mother's increased blood volume
Answer: D
Explanation:
(A) Maternal blood volume increases at the end of the first trimester leading to a dilutional anemia. (B) Maternal blood volume increases. (C) Fetal blood volume is minimal in the first trimester. (D) Increased iron absorption would facilitate the manufacturing of erythrocytes and decrease anemia.
NEW QUESTION # 165
A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:
- A. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures
- B. Febrile seizures do not usually recur
- C. Febrile seizures are associated with diseases of the central nervous system
- D. Sustained temperature elevation over 103F is generally related to febrile seizures
Answer: A
Explanation:
Section: Questions Set A
Explanation:
(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system.
NEW QUESTION # 166
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:
- A. Monitor for visual disturbances, a side effect of digoxin
- B. Take the apical pulse for a full minute
- C. Not give the digoxin if the pulse is_60
- D. Not give the digoxin if the pulse is_100
Answer: B
Explanation:
Explanation
(A) Digoxin should not be given to adults with an apical pulse < 60 bpm. (B) Digoxin should be given to children with an apical pulse > 100 bpm. With a pulse < 100 bpm, the medication should be withheld and the physician notified. (C) Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. (D) Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.
NEW QUESTION # 167
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. Immediate treatment of mild PIH includes the administration of a variety of medications
- B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
- C. The client may not recognize the early symptoms of PIH
- D. Self-discipline is required to control caloric intake throughout the pregnancy
Answer: C
Explanation:
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 # 168
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